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National Sexual Health Survey (NSHS)

NSHS is national telephone survey of adults 18 years and older residing in the 48 contiguous states. Measures were developed to assess a wide range of HIV-related and human sexuality topics including, but not limited to, the following: condom attitudes, condom slips and breaks, HIV-related caregiving, HIV testing and home testing use, STD histories, perceived risk for HIV and other STDs and optimistic bias assessments, extramarital sex, sexual development, sexual abuse and rape, and sexual dysfunctions. The survey also employed various psychological scales (sensation-seeking, machismo) and collected family assessments and history, health information and demographics, and a detailed assessment of sexual activities with each of the respondent’s sexual partners in the past year up to a total of 10 partners. In addition, demographic, geographic, and HIV/STD risk characteristics of sexual partners were determined. Instruments:

Supporting documentation:

Scoring: Included Reliability and/or validity: Catania JA, Coates TJ, Stall R, Turner HA, Peterson J, Hearst N, Dolcini MM, Hudes E, Gagnon J, Wiley J, Groves R (1992). Prevalence of AIDS-related risk factors and condom use in the United States. Science, 258, 1101–1106.

Resource

India HIV-Related Stigma Scales

Instrument: India HIV-related stigma scales Scoring: Included in article. Reliability or validity: Steward WT, Herek GM, Ramakrishna J, Bharat S, Chandy S, Wrubel J, Ekstrand ML. HIV-related stigma: Adapting a theoretical framework for use in India. Social Science & Medicine 67 (2008) 1225–1235.

Resource

Hepatitis C

Can hepatitis C (HCV) transmission be prevented?

Prepared by Alice Asher RN, MS, CNS and Kimberly Page PhD MPH Fact Sheet: 46 September 2010

What is the hepatitis C virus (HCV)?

Hepatitis C virus is blood borne virus affects the liver. It is principally acquired and transmitted by blood-to-blood contact, most commonly among injection drug users (IDU). Other common infectious viruses that affect the liver are Hepatitis A and B which have other routes of infection. Unlike hepatitis A and B, there is no vaccine for HCV. About 3.2 – 4 million Americans are estimated to be infected with HCV.1 In the US, 8,000 to 10,000 deaths per year are attributed to HCV-associated liver disease and that is expected to triple in the next 10-20 years.

Who’s at risk for HCV?

The population at highest risk for HCV are people who inject drugs; principally through sharing of syringes directly or through sharing of drug preparation equipment. Among newly reported HCV cases with known risk factors, 50%-60% are attributable to injecting drugs. However, this may be underestimated due to underreporting both due to the illicit nature of IDU and lack of HCV surveillance in high risk groups.2 HCV is usually acquired rapidly after a person first starts injecting drugs. As a result, prevalence of HCV among IDU is very high, ranging from 40-90%, depending on a person’s age and number of years injecting.3 Persons who received blood transfusions or an organ transplant before 1992 and hemophiliacs who received clotting factor concentrates before 1987 are also at risk for HCV. At moderate risk are persons receiving continual care (hemodialysis) for kidney failure. Others at risk include healthcare workers exposed to needlesticks with HCV+ blood.and, rarely, infants born to infected mothers. Sexual transmission of HCV is uncommon, although recent studies of HIV+ gay men show that it does occur.4Rough sex, fisting, sex with multiple partners and having a sexually transmitted disease (STD) or HIV appear to increase a person’s risk of HCV.5 This is likely due to blood contact during sex.

What does HCV infection look like?

HCV infection can range of in severity from a mild illness lasting a few weeks to a serious, lifelong illness that damages the liver.5 The majority of people infected with HCV do not experience symptoms related to their infection. Because of this, testing is the only way to confirm HCV infection. The first period after HCV infection is referred to as the “acute” period. Acute HCV infection generally lasts about 6 months after someone is infected with the virus. About 25% of people who become infected with HCV will spontaneously clear the virus on their own in the first 6 months. Studies have shown that women are more likely to spontaneously clear the virus than men. Even for those who have cleared HCV, re-infection can occur. While many who become re-infected will clear the virus again, this is not guaranteed, and a subsequent infection may become chronic. Those who do not clear or resolve their HCV infection are considered chronically infected. Most people with chronic infection remain asymptomatic for 20-30 years, and some will never develop symptoms of advanced disease. However, 60-70% of people with chronic HCV ultimately will develop some degree of liver disease.5 People with chronic infection whose liver disease has started to progress often report increasing levels of fatigue and stomach pain. The symptoms of chronic HCV are often are vague and unspecific and may go undiagnosed. This again underlines the importance of testing for anyone at risk of HCV. Chronic HCV infection causes liver damage that can turn into cirrhosis (scarring of the liver) and liver cancer.5 Up to 20% of chronically infected individuals will develop cirrhosis and 5% will develop liver cancer. Alcohol and drugsincluding marijuana and even tobaccocan speed up the rate of liver damage significantly.

Can HCV be treated?

The short answer is yes, there is a treatment for HCV, but currently available treatments will not work for everybody. Before starting a treatment regimen, it is important to stabilize any mental or other health problems. Undergoing antiviral treatment for HCV is a long, difficult and expensive process, so determining whether treatment is the right choice is a decision that should be made between a patient and a care provider. There are two approved antiviral medications used for the treatment of HCV: pegylated interferon alpha (often referred to as “peg”) and ribavirin. Peg interferon is taken by injection once a week. Ribavirin is an oral tablet that is taken daily. When taken together, the medications are effective in clearing the HCV virus 40-80% of the time, depending on the genotype of the virus.7 Hepatitis C has 6 chemical types (1-6), called genotypes, and they differ in how they respond to treatment. People of color, especially African-Americans and Latinos, have lower response rates to treatment, compared to other groups.7 New drugs are being developed that may be more effective than currently available treatments and may be available in the very near future. Treatment during the acute phase of infection is significantly more likely to be effective8, so identifying HCV early can be beneficial. While herbal remedies are popular among people living with HCV, none have been proven effective at clearing the HCV virus or in improving liver health.9 HCV treatment can be successful for active drug users. Nonetheless, daily drug and alcohol use can adversely affect treatment eligibility and completion. Engaging in drug or alcohol treatment programs while being treated for HCV can be helpful.

How does HCV affect HIV?

About one-quarter of all people in the US living with HIV are also infected with HCV. Persons who are both HIV+ and HCV+ (coinfected), can experience a much faster progression of liver disease and have higher HCV viral loads and higher rates of cirrhosis than do people who have HCV but not HIV.10 Liver damage from HCV infection also can increase the toxicity of medications used to treat HIV. As persons living with HIV who are on effective medications lead longer lives, liver disease has become the leading cause of non-AIDS-related deaths among HIV+ persons, due to HCV and HBV infection.11 Treatment for HCV infection in an HIV+ person can be effective. Side effects and drug interactions, however, can be hard to manage. It is important the coinfected person be on well-managed HIV treatment before starting treatment for HCV.

How can HCV be prevented?

HCV prevention can take many forms.12 Currently, targeted prevention strategies and harm reduction programs, including increased availability of clean syringes and increased access to drug treatment programs have the greatest potential to slow transmission of HCV. Educating those at risk, especially about the risks associated with shared injecting and ancillary equipment is very important. Encouraging the use of condoms, lubrication and gloves during high-risk sexual practices also can help reduce HCV transmission. Behavioral risk reduction prevention programs have had mixed results in decreasing risks associated with HCV transmission. Two peer-led interventions were effective in reducing injection risk behaviors in HIV negative and positive IDUs. The Study to Reduce Intravenous Exposures (STRIVE) and Drug Users Intervention Trials (DUIT) both provided information, enhanced risk-reduction skills, and motivated behavior change through peer education training. Although participants in these programs reported decreases in sharing syringes and drug preparation equipment,13,14 rates of new HCV infections among HCV negative participants in the DUIT Study did not decrease (neither did HIV infections). The UFO Study conducts HCV-related research and provides hepatitis, HIV and STD prevention services including testing, counseling, support and education tailored to young adult IDUs under age 30 in San Francisco, CA. Young injection drug users comprise a group for whom few health-related resources or programs are targeted.15 For persons who are infected with HCV or at risk of becoming infected with HCV, it is important to get regular healthcare. A healthcare provider can help monitor HCV infection and liver health and make important decisions about prevention and treatment. Support and education groups are valuable in learning more about HCV infection and about the experience of living with HCV, treating HCV and preventing HCV transmission to others. People infected with HCV should be screened and vaccinated for HBV and should be strongly encouraged to stop or decrease alcohol use.

What needs to be done?

Over the next 15 years, the global costs associated with HCV infection are projected to increase from $30 billion to $85 billion.16 Development of an HCV vaccine will significantly decrease rates of new HCV infections. Research is needed on the development of a vaccine and effective models for delivery. Increasing access to HCV testing and screening, HCV treatment, drug treatment, clean syringes and effective behavioral interventions is crucial.

Says who?

1. Armstrong GL, Wasley A, Simard EP, et al. The prevalence of hepatitis C virus infection in the United States, 1999 through 2002. Annals of Internal Medicine. 2006;144:705-714. 2. Hagan H, Snyder N, Hough E, et al. Case-reporting of acute hepatitis B and C among injection drug users. Journal of Urban Health. 2002;79:579-585. 3. Hagan H, Pouget ER, Des Jarlais DC, et al. Meta-regression of hepatitis C virus infection in relation to time since onset of illicit drug injection: the influence of time and place. American Journal of Epidemiology. 2008;168:1099-1109. 4. Urbanus AT, van de Laar TJ, Stolte IG, et al. Hepatitis C virus infections among HIV-infected men who have sex with men: an expanding epidemic. AIDS. 2009;23:F1-7. 5. Hepatitis C Fact Sheet. Prepared by the Centers for Disease Control and Prevention. 6. Page K, Hahn JA, Evans J, et al. Acute hepatitis C virus infection in young adult injection drug users: a prospective study of incident infection, resolution, and reinfection. Journal of Infectious Diseases. 2009;200:1216-1226. 7. Ghany MG, Strader DB, Thomas DL, et al. Diagnosis, management, and treatment of Hepatitis C: An update. Hepatology. 2009;49:1335-1374. 8. Kamal SM. Acute hepatitis C: a systematic review. American Journal of Gastroenterology. 2008;103:1283-1297 9. Liu JP, Manheimer E, Tsutani K, et al. Medicinal herbs for hepatitis C virus infection. Cochrane Database of Systematic Reviews. 2001;4. 10. Verucchi G, Calza L, Manfredi R, et al. Human immunodeficiency virus and hepatitis C virus coinfection: epidemiology, natural history, therapeutic options and clinical management. Infection. 2004;32:33-46. 11. Tuma P, Jarrin I, Del Amo J, et al. Survival of HIV-infected patients with compensated liver cirrhosis. AIDS. 2010;24:745-753. 12. Page-Shafer K, Hahn J, Lum PJ. Preventing hepatitis C virus infection in injection drug users: risk reduction is not enough. AIDS. 2007;21:1967-1969. 13. Latka MH, Hagan H, Kapadia F, et al. A randomized intervention trial to reduce the lending of used injection equipment among injection drug users infected with hepatitis C. American Journal of Public Health. 2008;98:853-861. 14. Garfein RS, Golub ET, Greenberg AE, et al. A peer-education intervention to reduce injection risk behaviors for HIV and hepatitis C virus infection in young injection drug users. AIDS. 2007;21:1923-1932. 15. Lum PJ, Ochoa KC, Hahn JA, et al. Hepatitis B virus immunization among young injection drug users in San Francisco, Calif: the UFO Study. American Journal of Public Health. 2003;93:919-23. 16. Shah BB, Wong JB. The economics of hepatitis C virus. Clinics in Liver Disease. 2006;10:717-34.

Special thanks to the following reviewers of this Fact Sheet: Laura Mae Alpert, Orlando Chavez, Myrna Cozen, Richard Garfein, Holly Hagan, Judy Hahn, Emalie Huriaux, Steve Livingston, Megan Mahoney, Brian McMahon, Jay Ryan, Jim Stillwell, Leslie Tobler, Anouk Urbanus. Reproduction of this text is encouraged; however, copies may not be sold, and the University of California San Francisco should be cited as the source. Fact Sheets are also available in Spanish. To receive Fact Sheets via e-mail, send an e-mail to [email protected] with the message “subscribe CAPSFS first name last name.” ©September 2010, University of CA. Comments and questions about this Fact Sheet may be e-mailed to [email protected].

Resource

Mother-to-child transmission (MTCT)

Is Mother-to-Child HIV Transmission Preventable?

Prepared by Sarah A. Gutin, MPH* *CAPS, Community Health Systems- School of Nursing, UCSF Fact Sheet #34ER – September 2015 Special thanks to the following reviewers of this Fact Sheet: Yvette Cuca, Carol Dawson Rose, Shannon Weber In 2012, there were 2.3 million new HIV infections globally [1]. A large proportion of people newly diagnosed with HIV worldwide are in their reproductive years and these men and women are likely to want children in the future [2-4]. Addressing the sexual and reproductive health and rights of this population is critical to addressing the spread of HIV because HIV infection in childbearing women is the main cause of HIV infection in children [5]. Treatment for those who are already infected is also central to stopping the spread of HIV to infants and to uninfected sexual partners.

How does transmission occur?

Perinatal transmission of HIV, also called vertical transmission, occurs when HIV is passed from an HIV-positive woman to her baby during pregnancy, labor and delivery or breastfeeding. For an HIV-positive woman not taking HIV medications, the chance of passing the virus to her child ranges from about 15 to 45% during pregnancy, labor and delivery. If she breastfeeds her infant, there is an additional 35 to 40% chance of transmission [6].

Is the risk of perinatal transmission always the same?

No. Global societal and economic inequities create a wide gap between women in developing nations and women in developed nations with regard to HIV prevention, voluntary counseling and testing and access to drugs which treat HIV infection and can prevent perinatal transmission. Developed countries- In many developed countries, pediatric HIV has been virtually eliminated [7]. In the US in 1994, the Public Health Service recommended HIV counseling and voluntary testing and AZT therapy for all pregnant women after the clinical trial known as “076” showed that AZT reduced rates of MTCT by two-thirds. Since then, a combination of interventions that includes treatment with ART to control the virus and make it undetectable, cesarean delivery, and avoidance of breastfeeding has helped further reduce perinatal transmission in the US, from an estimated 1,500 cases in 1992 to an estimated 162 perinatal infections in 2010 [8]. Although the estimated number of perinatal HIV infections in the US continues to decline, women of color, especially black/African American women are disproportionately affected by HIV infection and as a result, perinatal HIV infection is highest among blacks/African Americans (63%), followed by Hispanics/Latinas (22%) [8]. Although effective interventions have led to a significant reduction in the number of perinatal infections in the US, perinatal transmission still occurs. To close the final gap, the CDC has proposed a new framework to eliminate mother-to-child HIV transmission (EMCT) in the US [8]. This framework focuses on key areas including: comprehensive reproductive health care (that includes both family planning (FP) and preconception care) and comprehensive case-finding of pregnancies in HIV-infected women that is conducted through comprehensive clinical care and case management services for women and infants; case review and community action; continuous quality research in prevention and long-term monitoring of HIV-exposed infants; and thorough data reporting for HIV surveillance at the state and local health department levels [8 9]. Developing countries- Unfortunately, perinatal transmission of HIV continues to plague many developing countries despite recent prevention acceleration. In 2008, an estimated 1.4 million pregnant women in low and middle-income countries were living with HIV, of whom about 90% were in sub-Saharan African countries [7]. In 2012, UNAIDS reported that approximately 210,000 children became HIV infected [1].

Can perinatal transmission of HIV be reduced?

Yes. Perinatal transmission encompasses a variety of highly effective interventions that have huge potential to improve maternal and child health. Advances in treatment and new classes of drugs have provided the opportunity to greatly reduce rates of perinatal transmission worldwide. Also, perinatal transmission can be reduced by preventing unintended pregnancies. Preventing unintended pregnancies is one of the most effective ways to prevent HIV infection in infants and stop spread of the epidemic to children [10]. For that reason, preventing unintended pregnancies among women living with HIV and offering family planning to delay, space or end childbearing is one of the four WHO pillars in the comprehensive approach to preventing perinatal transmission [7]. However, we have still not addressed the root cause of perinatal transmission, mainly heterosexual HIV transmission. The best way to prevent perinatal HIV transmission is to prevent HIV transmission in the mother and father. In order to reduce perinatal transmission, all pregnant women should have access to free or low-cost prenatal care and voluntary HIV testing and counseling. If a pregnant woman is HIV-positive, she should have access to lifelong ART to treat HIV and improve her own health and to decrease the chances of HIV infection in her infant. In June 2013, the WHO published updated guidelines on the diagnosis of HIV, the care of people living with HIV(PLHIV) and the use of ART for treating and preventing HIV infection [1]. In the US, the Department of Health and Human Services recommends that all HIV-infected pregnant women should be given ART during pregnancy to prevent perinatal transmission of HIV, regardless of whether ART is indicated for the woman’s own health [11]. Perinatal transmission can be reduced to less than 2% if a woman is on ART, has a low or undetectable viral load, follows the recommended treatment regimen and does not breastfeed [7 8]. Careful management during labor and delivery can also help reduce perinatal transmission, for example by avoiding unnecessary instrumentation and not prematurely rupturing membranes [12]. Also, although universal prenatal HIV testing is the standard in the US, if prenatal care has not been provided, the patient has HIV, or her HIV status is undocumented, it is critical for hospitals to determine a laboring patient’s HIV status upon admission. Even without the use of ART during the pregnancy, the use of ART during labor and for the infant can reduce the risk of perinatal transmission to between 6 to 13% [13]. It is therefore recommended that rapid HIV testing be performed in Labor and Delivery units on pregnant women with no HIV test during their pregnancy or with risk factors for infection since their last test [14]. In developing countries, perinatal transmission has been a priority since 1998, following the success of short-course zidovudine and single-dose nevirapine clinical trials [7]. In recent years, single-dose nevirapine as the primary antiretroviral medicine option for HIV-positive pregnant women to prevent transmission to their infants has been phased out, in favor of more effective and simplified triple ART regimens [1]. The WHO now recommends that all pregnant and breastfeeding women with HIV, regardless of CD4 count or clinical stage, should initiate a triple ART regimen which should be maintained for the duration of perinatal transmission risk, which includes pregnancy, delivery and throughout the breastfeeding period (this is known as Option B). In countries were more than one percent of the population has HIV (these are known as generalized epidemics) and where there is often limited access to tests that indicate the severity of HIV illness (such as CD4 testing), limited partner testing, long duration of breastfeeding and high rates of fertility, the WHO recommends that women meeting treatment eligibility criteria should continue lifelong ART (this strategy is referred to as Option B+) [12]. There are many benefits to lifelong treatment for all pregnant and breastfeeding women and these include increased coverage of those needing ART for their own health, a reduction in the number of women stopping and starting ART during repeat pregnancies, early protection against perinatal transmission in future pregnancies, reduced risk of infecting a partner who is HIV-negative and decreased risk of medication failure or the development of resistance [12]. The ultimate goal is to find the most effective and sustainable regimens for HIV treatment and the prevention of perinatal transmission worldwide. Economics, politics, poor infrastructure, access to healthcare and medications, stigma and cultural norms all pose significant challenges to providing this standard of care everywhere and not all PLHIV have equal access to treatment.

What are the barriers to the prevention of perinatal transmission?

Pregnant women face many difficult decisions, including decisions around HIV testing, treatment options and infant feeding. Understanding the barriers that women face and addressing barriers at various levels can help in realizing the full potential of prevention of perinatal transmission programs. A recent review article found that barriers to the prevention of perinatal transmission often fell into three broad categories that included the individual, their partners and community, and health systems [15]. At the individual level, studies suggest that a lower maternal education level, younger maternal age, and poor knowledge of HIV transmission and ART are associated with not receiving and/or not taking ART in order to treat and prevent the spread of HIV [15]. Additionally, a woman’s male partner(s), extended family, greater community and health care setting all influence her decision and ability to take advantage of prevention of perinatal transmission programs. Many qualitative studies have found that stigma regarding HIV status and fear of disclosure to partners and family members is a major barrier to the uptake of perinatal prevention interventions [15]. Women living with HIV also continue to report that stigma and discrimination, especially in health care settings, continue to be a barrier to accessing adequate information and services [1]. In various studies, PLHIV have reported negative staff attitudes and this has been cited as a barrier to returning to facilities for care [15]. In developing countries, health systems issues are also a barrier to greater prevention uptake. Key barriers that have been identified include a shortage of trained clinic staff, high patient volumes, long wait times, and brief and poor counseling sessions [15]. In addition, a lack of access or shortages of medications, including ART, as well as stock-outs of HIV test kits and condoms have been reported. Poor access to healthcare overall (long distances to facilities) and poor integration of services also contributes to low ART uptake.

What about breastfeeding?

Breastfeeding is usually the healthiest choice for both infants and mothers. However, HIV transmission can occur during breastfeeding, with chances of transmission increasing the longer the infant is breastfed. In the countries with the highest perinatal HIV rates, it is estimated that more than half of the children newly infected with HIV acquire it during the breastfeeding period [1]. However, the risk of transmitting HIV to infants through breastfeeding is low in the presence of ART [12]. Therefore, providing ART to mothers throughout the breastfeeding period is a critical step needed to further reduce rates of perinatal transmission [1]. It is recommended that HIV-positive mothers do not breastfeed when formula feeding is safe, well accepted and readily available. In the US, both the Centers for Disease Control and Prevention and the American Academy of Pediatrics recommends that HIV-infected women refrain from breastfeeding regardless of their ART status to avoid postnatal transmission of HIV to their infants through breast milk [16 17]. However, formula feeding requires clean water for mixing formula. Many women in developing countries do not have access to clean water or sanitation and cannot afford formula, and therefore cannot avoid breastfeeding. In developing countries where breastfeeding is the norm, formula feeding may also alert a woman’s family or community that she is HIV-positive, which may result in stigma or other negative repercussions. Therefore, the WHO recommends that when breastfeeding is unavoidable, mothers should take ART while breastfeeding and that infants should receive 6 weeks of prophylaxis with once-daily nevirapine [12]. The WHO further recommends that mothers known to be infected with HIV (and whose infants are HIV uninfected or of unknown status) should exclusively breastfeed for the first 6 months of life, introducing appropriate complementary foods thereafter, and continue breastfeeding for the first 12 months of life. It is recommended that breastfeeding should only stop when a nutritionally adequate and safe diet without breast-milk can be provided [12]. Access to ARVs during this extended breastfeeding period is critical [12].

What’s being done?

Primary prevention of HIV among men and women of childbearing age: Various tools are now available to prevent HIV infections in men and women of childbearing age. Pre-exposure prophylaxis (PrEP), which is a special course of HIV treatment that aims to prevent people from becoming infected with HIV, has been found to protect against HIV-1 infection in heterosexual men and women and reduce HIV transmission by 67 to 75% [18 19]. PrEP is intended for people at-risk of becoming infected with HIV, for example in the case of couples where one partner is HIV-positive and the other is HIV-negative. In countries with generalized HIV epidemics, voluntary medical male circumcision for HIV-negative male partners in relationships with a positive partner has been shown to reduce the risk of HIV-acquisition in men by between 38% to 66% [20]. Using ART to decrease the chance of HIV transmission, a concept known as treatment as prevention, has also recently been found to be very efficacious, with studies in heterosexual populations showing that adherence to ART is very effective at preventing transmission of HIV to HIV-negative partners [21-23]. Couples-testing with treatment for infected partners in discordant partnerships is also a promising approach. Integrating couples counseling and partner testing into routine clinic and community services can increase the number of couples in which the status of both partners is known and can help identifying sero-discordant couples [24]. Preventing unintended pregnancies and Safer Conception Options: Preventing unintended pregnancies among women living with HIV (WLHIV) is a powerful prevention strategy. One study found that even modest reductions in the numbers of pregnancies among WLHIV could avert HIV-positive births at the same rates as the use of ART for PMTCT [25]. One targeted approach to strengthening FP programs is to integrate FP within HIV services. In Kenya, a recent cluster-randomized trial tried to determine whether integrating FP services into HIV care was associated with increased use of more effective contraceptive methods such as sterilization, IUDs, implants, injectables and oral contraceptives. Women seen at integrated sites were significantly more likely to use more effective methods of FP at the end of the study [26]. This makes the case for integrating FP within HIV care. Reducing the unmet need for FP will reduce new HIV infections among children and improve overall maternal and infant health. For HIV-positive or serodiscordant couples who would like to have children, there are many options available to make conception safer. When offering preconception care, HIV-positive couples will have specific needs, many of which can be addressed during their routine HIV care. When offering preconception counseling for HIV-positive women, the CDC recommends that health care providers should discuss a variety of topics, including: reproductive options and actively assessing women’s pregnancy intentions on an ongoing basis; Counseling on safe sexual practices that prevent HIV transmission to sexual partners, protect women from acquiring sexually transmitted diseases, and reduce the potential to acquire more virulent or resistant strains of HIV; Using ART to attain a stable, maximally suppressed maternal viral load prior to conception to decrease the risk of perinatal transmission and of HIV transmission to an uninfected partner; and encouraging sexual partners to receive counseling and HIV testing and, if infected, to seek appropriate HIV care[11]. For couples who want to conceive, in which one or both are HIV-positive, the positive partner should be on ART and have achieved maximal suppression of HIV infection. ART for the positive partner may not be fully protective against sexual transmission of HIV and so the administration of PrEP for the HIV-negative partner may offer an additional tool to reduce the risk of transmission. For discordant couples, when the positive partner is a woman, the safest conception option is artificial insemination. In discordant couples where the positive partner is male, the safest conception option is the use of donor sperm from an HIV-uninfected male with artificial insemination. When the use of donor sperm is unacceptable, the use of sperm preparation techniques together with either intrauterine insemination or in vitro fertilization is an option [11]. Preventing HIV transmission from WLHIV to infants: Increasing access to ART for WLHIV is critical to saving the lives of women and their children. The number of pregnant WLHIV receiving ART for their own health has increased from 25% in 2009 to 60% in 2012 [1]. One of the greatest success stories has been in Malawi where a policy of providing lifelong ART to all pregnant and breastfeeding women (irrespective of CD4 count or clinical status– a strategy referred to as Option B+) was enacted in 2011. Since then, Malawi increased the estimated coverage of women in need of ART from 13% in 2009 to 86% in 2012. The implementation of Option B+ has resulted in a 748% increase in the number of pregnant and breastfeeding women starting ART, from 1,257 in the second quarter of 2011 to 10,663 in the third quarter of 2012 [27]. As a result of Option B+, the perinatal transmission rate for women on ART is expected to be reduced, from approximately 40% without intervention to less than 5%. By decentralizing treatment services and offering lifelong HIV treatment to all pregnant and breastfeeding women, Malawi has been able to increase ART coverage both during pregnancy and the breastfeeding period [1]. Providing treatment, care and support to WLHIV and their children and families: Increasing access to ART for pregnant women living with HIV for their own health is critical to saving the lives of women and their children. Even developing countries, which at first lagged behind in reducing the number of children newly infected with HIV, have made great gains in recent years. In 2013, UNAIDS reported that in 7 high burden countries where access to treatment has increased, the rates of HIV transmission to children has fallen by 50% or more [1].

What still needs to be done?

HIV is a preventable disease. Perinatal transmission is best prevented by effective, accessible and sustainable HIV prevention, access to HIV testing, early diagnosis and linkage to treatment programs for women, men and their children, access to family planning and abortion services to prevent unintended pregnancies, and access to an ongoing supply of ARVs to improve the health of women and their children. Structural interventions are also needed that increase access to health centers, improve health care infrastructure, provide food supplementation, and HIV treatments. Women are the key to the HIV response and the number of women acquiring HIV has to be reduced. All women have a right to be treated for HIV infection, not simply because they are bearing a child. All women living with HIV who are eligible for ART need to have access to it. Unfortunately, too many women are still lost along the prevention cascade and never get the care or treatment they need and deserve. Providing women with access to high quality healthcare for themselves and their families, whether they are HIV-positive or not, is imperative.

Says who? 1. UNAIDS. AIDS by the numbers. Geneva, Switzerland, 2013. 2. Kanniappan S, Jeyapaul MJ, Kalyanwala S. Desire for motherhood: exploring HIV-positive women’s desires, intentions and decision-making in attaining motherhood. AIDS care 2008;20(6):625-30 doi: 10.1080/09540120701660361[published Online First: Epub Date]|. 3. Beyeza-Kashesya J, Kaharuza F, Mirembe F, et al. The dilemma of safe sex and having children: challenges facing HIV sero-discordant couples in Uganda. African health sciences 2009;9(1):2-12 4. Cooper D, Moodley J, Zweigenthal V, et al. Fertility intentions and reproductive health care needs of people living with HIV in Cape Town, South Africa: implications for integrating reproductive health and HIV care services. AIDS and behavior 2009;13 Suppl 1:38-46 doi: 10.1007/s10461-009-9550-1[published Online First: Epub Date]|. 5. UNAIDS. We Can Prevent mothers fom dying and babies from becoming infected with HIV. Geneva, Switzerland, 2010. 6. De Cock KM, Fowler MG, Mercier E, et al. Prevention of mother-to-child HIV transmission in resource-poor countries: translating research into policy and practice. JAMA : the journal of the American Medical Association 2000;283(9):1175-82 7. WHO. PMTCT Strategic Vision 2010-2015: Preventing mother-to-child transmission of HIV to reach the UNGASS and Millenium Development Goals. Geneva, Switzerland, 2010. 8. CDC. HIV Among Pregnant Women, Infants, and Children in the United States. Atlanta, 2012. 9. Nesheim S, Taylor A, Lampe MA, et al. A framework for elimination of perinatal transmission of HIV in the United States. Pediatrics 2012;130(4):738-44 doi: 10.1542/peds.2012-0194[published Online First: Epub Date]|. 10. Nakayiwa S, Abang B, Packel L, et al. Desire for children and pregnancy risk behavior among HIV-infected men and women in Uganda. AIDS and behavior 2006;10(4 Suppl):S95-104 doi: 10.1007/s10461-006-9126-2[published Online First: Epub Date]|. 11. Department of Health and Human Services Panel on Treatment of HIV-Infected Pregnant Women and Prevention of Perinatal Transmission. Recommendations for Use of Antiretroviral Drugs in Pregnant HIV-1-Infected Women for Maternal Health and Interventions to Reduce Perinatal HIV Transmission in the United States. In: Bureau HA, ed. Washington, DC, 2014. 12. WHO. Consolidated guidelines on the use of antiretroviral drugs for treating and preventing HIV infection: Recommendations for a public health approach. Geneva, Switzerland, 2013. 13. Kourtis AP, Lee FK, Abrams EJ, et al. Mother-to-child transmission of HIV-1: timing and implications for prevention. The Lancet infectious diseases 2006;6(11):726-32 doi: 10.1016/S1473-3099(06)70629-6[published Online First: Epub Date]|. 14. Branson BM, Handsfield HH, Lampe MA, et al. Revised recommendations for HIV testing of adults, adolescents, and pregnant women in health-care settings. MMWR. Recommendations and reports : Morbidity and mortality weekly report. Recommendations and reports / Centers for Disease Control 2006;55(RR-14):1-17; quiz CE1-4 15. Gourlay A, Birdthistle I, Mburu G, et al. Barriers and facilitating factors to the uptake of antiretroviral drugs for prevention of mother-to-child transmission of HIV in sub-Saharan Africa: a systematic review. Journal of the International AIDS Society 2013;16(1):18588 doi: 10.7448/IAS.16.1.18588[published Online First: Epub Date]|. 16. American Academy of Pediatrics Committee on Pediatric A. HIV testing and prophylaxis to prevent mother-to-child transmission in the United States. Pediatrics 2008;122(5):1127-34 doi: 10.1542/peds.2008-2175[published Online First: Epub Date]|. 17. Panel on Treatment of HIV-Infected Pregnant Women and Prevention of Perinatal Transmission. Recommendations for Use of Antiretroviral Drugs in Pregnant HIV-1-Infected Women for Maternal Health and Interventions to Reduce Perinatal HIV Transmission in the United States. Secondary Recommendations for Use of Antiretroviral Drugs in Pregnant HIV-1-Infected Women for Maternal Health and Interventions to Reduce Perinatal HIV Transmission in the United States.  18. Celum C, Baeten JM. Tenofovir-based pre-exposure prophylaxis for HIV prevention: evolving evidence. Current opinion in infectious diseases 2012;25(1):51-7 doi: 10.1097/QCO.0b013e32834ef5ef[published Online First: Epub Date]|. 19. Baeten JM, Donnell D, Ndase P, et al. Antiretroviral prophylaxis for HIV prevention in heterosexual men and women. The New England journal of medicine 2012;367(5):399-410 doi: 10.1056/NEJMoa1108524[published Online First: Epub Date]|. 20. Siegfried N, Muller M, Deeks JJ, et al. Male circumcision for prevention of heterosexual acquisition of HIV in men. The Cochrane database of systematic reviews 2009(2):CD003362 doi: 10.1002/14651858.CD003362.pub2[published Online First: Epub Date]|. 21. Donnell D, Baeten JM, Kiarie J, et al. Heterosexual HIV-1 transmission after initiation of antiretroviral therapy: a prospective cohort analysis. Lancet 2010;375(9731):2092-8 doi: 10.1016/S0140-6736(10)60705-2[published Online First: Epub Date]|. 22. Grant RM, Lama JR, Anderson PL, et al. Preexposure chemoprophylaxis for HIV prevention in men who have sex with men. The New England journal of medicine 2010;363(27):2587-99 doi: 10.1056/NEJMoa1011205[published Online First: Epub Date]|. 23. Cohen MS, Chen YQ, McCauley M, et al. Prevention of HIV-1 infection with early antiretroviral therapy. The New England journal of medicine 2011;365(6):493-505 doi: 10.1056/NEJMoa1105243[published Online First: Epub Date]|. 24. Medley A, Baggaley R, Bachanas P, et al. Maximizing the impact of HIV prevention efforts: Interventions for couples. AIDS care 2013 doi: 10.1080/09540121.2013.793269[published Online First: Epub Date]|. 25. Sweat MD, O’Reilly KR, Schmid GP, et al. Cost-effectiveness of nevirapine to prevent mother-to-child HIV transmission in eight African countries. Aids 2004;18(12):1661-71 26. Grossman D, Onono M, Newmann SJ, et al. Integration of family planning services into HIV care and treatment in Kenya: a cluster-randomized trial. Aids 2013;27 Suppl 1:S77-85 doi: 10.1097/QAD.0000000000000035[published Online First: Epub Date]|. 27. Centers for Disease Control and Prevention. Impact of an innovative approach to prevent mother-to-child transmission of HIV–Malawi, July 2011-September 2012. MMWR. Morbidity and mortality weekly report 2013;62(8):148-51

Resource

Hombres negros

¿Qué necesitan los hombres negros para evitar el VIH?

¿quiénes son los hombres negros?

Los hombres negros y los afroamericanos no se pueden encasillar en una sola categoría “unitalla”. Ellos son padres, hermanos, tíos e hijos en las comunidades negras. Son médicos, abogados, barberos y conductores de autobuses; son cristianos y musulmanes y hablan muchos idiomas. Sin embargo, no toda persona de aspecto negro o afroamericano se identifica con estas etiquetas. En EEUU, los hombres negros son un grupo diverso que abarca, entre otros, a afrocubanos, caribeños, brasileños y africanos.

¿por qué el VIH es una preocupación?

Actualmente, el VIH es una crisis de salud mayúscula entre los hombres negros y afroamericanos de cualquier edad u orientación sexual.1 En el año 2000, el SIDA fue la primera causa de muerte entre los hombres negros de 35-44 años de edad y la tercera causa de muerte de hombres negros entre 25 y 44 años de edad.2 Las tasas del VIH entre afroamericanos jóvenes que tienen sexo con otros hombres (HSH) son más elevadas que entre cualquier otro grupo racial o étnico.2 El VIH/SIDA no es la primera crisis de salud que encaran los hombres negros, ni será la última. Los hombres negros afrontan muchas disparidades médicas y están desproporcionadamente afectados por muchas enfermedades como la hipertensión, el cáncer y las cardiopatías. El VIH plantea otro tipo de desafío debido a su transmisión por medio del contacto sexual y del consumo de drogas, temas difíciles de tocar y cargados de estigma en muchas comunidades.

¿cuáles son los factores de riesgo del VIH?

La primera causa de infección por VIH entre los hombres afroamericanos es el sexo, ya sea con hombres o con mujeres.1 En EE.UU. hemos confundido la conducta sexual con la identificación sexual de los hombres negros.3 Por ejemplo, un hombre negro que tiene sexo con hombres y mujeres puede pertenecer a la clasificación de riesgo de los CDC (centros de control de enfermedades) de “contacto sexual de hombre a hombre;” por los investigadores como “bisexual” o “HSH,” por la prensa como “incógnitos” o que tienen relaciones con otros hombres discretamente (on the down low), por grupos activistas como “amante del mismo sexo” o por sus parejas como “heterosexual.” El consumo de drogas inyectables es la segunda causa de infección por VIH entre hombres negros1. Muchos consumidores de drogas padecen adicción, pobreza, falta de vivienda, estigma, depresión, enfermedad mental y trauma anterior, todas éstas situaciones que favorecen la transmisión del VIH, por ejemplo al compartir equipos de inyección.4

¿qué afecta al riesgo del VIH?

Sabemos que el VIH se transmite entre hombres (sean negros o no) por medio del sexo anal o vaginal sin protección con una persona VIH+ o por usar los equipos de inyección de una persona VIH+. Sabemos mucho menos sobre el efecto de las fuerzas psicosociales, contextuales, políticas e históricas sobre las prácticas de riesgo de los hombres negros. Es necesario resolver los problemas de educación, empleo y encarcelamiento, especialmente entre los hombres marginados económicamente. Los hombres negros y afroamericanos son discriminados en la educación y en el empleo. En la escuela, muchos niños negros son etiquetados como “problemáticos” y son remitidos a clases de “educación especial,” lo cual reduce el número de varones negros que ingresan a la escuela secundaria.5 Consecuentemente, muchos hombres negros no consiguen empleo bien remunerado y quedan sumamente desfavorecidos en nuestra economía tecnológica. La falta de empleo está vinculada con condiciones que pueden aumentar el riesgo del VIH, tales como el consumo de alcohol y drogas, el sexo comercial, la falta de vivienda y el encarcelamiento. Casi la tercera parte de los hombres negros han estado encarcelados como adolescentes o adultos.6 El ciclo de entrar, salir y regresar a la cárcel puede perjudicar la capacidad de los hombres negros de encontrar y mantener tanto empleo como relaciones personales. Entre menos hombres negros haya en la comunidad, menos oportunidades tendrán las parejas negras para la monogamia a largo plazo y mayores serán las posibilidades de tener múltiples parejas, lo que puede aumentar el riesgo de transmitir el VIH/ETS.7 En EE.UU. existe una larga historia de explotación y objetivización sexual del varón negro. Con frecuencia a los hombres negros se les describe según su supuesta afición o proeza sexual en lugar de reconocerlos como seres complejos y multidimensionales con sus fortalezas y debilidades.8

¿cuáles son los factores protectores?

Muchas organizaciones en todo el país promueven la fuerza y la unidad entre hombres negros. Grupos fraternales, barberías y grupos cívicos, como “100 Black Men” y otros, fortalecen a los hombres negros ofreciéndoles modelos positivos a seguir, promoviendo la historia y cultura afroamericana y colaborando con empresas y universidades.9 Los sistemas de apoyo familiares, comunitarios y espirituales son importantes para proteger a los jóvenes negros contra el VIH. Las familias unidas con padres que vigilen a sus hijos y hablen con ellos son la clave para promover conductas saludables.10 Las iglesias negras pueden ofrecer información sobre la prevención del VIH; también pueden poner el ejemplo respondiendo a las necesidades de los consumidores de drogas, homosexuales y personas VIH+ sin estigmatizarlos.11

¿qué se está haciendo al respecto?

Se implementó un programa de prevención el VIH con adolescentes afroamericanos en Filadelfia, PA, que abarcaba tanto la abstinencia sexual como la protección durante las relaciones sexuales. Los participantes de la intervención de abstinencia reportaron menos actos sexuales después de 3 meses, pero no en las encuestas de seguimiento realizadas a los 6 y 12 meses después. Entre los jóvenes con experiencia sexual anterior al programa, aquellos que participaron en la intervención sobre el sexo más seguro reportaron menos actos sexuales que los participantes de la intervención de abstinencia según las encuestas de seguimiento realizadas a los 3, 6 y 12 meses. Ambos métodos redujeron a corto plazo las conductas riesgosas con respecto al VIH, pero es posible que las intervenciones enfocadas en la protección en el sexo tengan efectos más duraderos que las intervenciones sobre la abstinencia, y que también logren mejores resultados entre jóvenes con previa experiencia sexual.12 Desde hace muchos años, “People of Color in Crisis” (POCC) en Brooklyn, NY ofrece actividades de prevención del VIH/SIDA y otras intervenciones para hombres y mujeres negras. “Many Men, Many Voices” es una intervención grupal interactiva y experiencial para hombres homosexuales no caucásicos. Sus facilitadores capacitados dirigen seis sesiones semanales para ayudar a los hombres a sentirse protegidos y aceptados con un apoyo social positivo.13 “Concerned Black Men” (CBM) es una organización de servicio establecida y dirigida por hombres negros con el fin de ofrecer modelos positivos a seguir a los niños negros. CBM tiene 21 sedes a lo largo de EE.UU. que brindan programas de prevención de la violencia, el consumo del alcohol y drogas, del embarazo y de ETS/VIH, al tiempo que promueven la autoestima, resolución de conflictos y plantación para asistir a la universidad.14 El “Down Low Barbershop Project” colabora con barberos y estilistas en comunidades negras para brindar a los hombres negros información sobre el VIH, condones y recomendaciones para pruebas y consejería de VIH gratuitas. Los barberos participan en dos capacitaciones de 8 horas sobre la prevención del VIH y luego reclutan a diez clientes para que asistan a una capacitación de 4 horas. La participación de los propietarios de barberías, barberos y clientes es pagada, y los clientes que asisten reciben un vale para un corte de pelo gratuito. El Down Low Barbershop Project se realiza a través de los programas “Brother to Brother” en Seattle, WA y “Us Helping US” en Washington, DC.15

¿qué queda por hacer?

Las agencias de prevención del VIH deberán reconocer las bases culturales y sociales de la comunidad negra.16 La brecha entre ricos y pobres sigue creciendo y la mayoría de las infecciones por VIH ocurre en comunidades pobres.3 Los programas deben responder a los problemas de empleo, educación, encarcelamiento, adicción y estigma, además de las conductas riesgosas relacionadas con el sexo y con el consumo de drogas. Para contar con un ambiente de confianza que favorezca las conversaciones abiertas sobre temas delicados relacionados con el sexo y con el consumo de drogas, los programas de investigación y de prevención deben llevarse a cabo en ambientes familiares lejos de los clubes, bares y otros lugares donde prevalece el sexo.17 La colaboración con organizaciones culturales, religiosas y cívicas que históricamente han llegado a los hombres negros puede ayudar a reclutar e involucrar a estos hombres.18 Los programas de prevención deben vincularse con programas de tratamiento de drogas, prevención de la violencia, enriquecimiento académico, planificación familiar, fortalecimiento cultural y organizaciones empresariales; todo esto con el fin de apoyar a los hombres negros en general tomando en cuenta la riqueza y la complejidad de la vida moderna del hombre negro.

¿quién lo dice?

1.Centers for Disease Control and Prevention. HIV/AIDS among African Americans. 2003.https://www.cdc.gov/hiv/group/racialethnic/africanamericans/index.html&…; 2. Key Facts: African Americans and HIV/AIDS. Report published by the Kaiser Family Foundation. September 2003.http://www.kff.org/hivaids/hiv6090chartbook.cfm 3. Beatty LA, Wheeler D, Gaiter J. HIV prevention research for African Americans: current and future directions. Journal of Black Psychology. 2004;30:40-58. 4. Galea S, Vlahov D. Social determinants and the health of drug users: socioeconomic status, homelessness and incarceration. Public Health Reports. 2002;117: S135-S145. 5. Davis JE. Early schooling and academic achievement of African American males. Urban Education. 2003;38:515-537. 6. Braithwaite RL, Arriola KR. Male prisoners and HIV prevention: a call for action ignored. American Journal of Public Health. 2003;93:759-763. 7. Adimora A, Schoenbach VJ. Contextual factors and the Black-White disparity in heterosexual HIV transmission. Epidemiology. 2002;13:707-712. 8. Whitehead TL. Urban low-income African American men, HIV/AIDS, and gender identity. Medical Anthropology Quarterly. 1997;11:411-447. 9. Bailey DF, Paisley PO. Developing and nurturing excellence in African American male adolescents. Journal of Counseling and Development. 2004;82:10-17. 10. “This is my reality–the price of sex: an inside look at Black urban youth sexuality and the role of the media.” Report published by Motivational Educational Entertainment. January 2004. https://www.meeproductions.com/ 11. Miller RL. African American churches at the crossroads of AIDS. FOCUS. 2001;10:1-5. 12. Jemmott JB III, Jemmott LS, Fong GT. Abstinence and safer sex HIV risk-reduction interventions for African American adolescents: a randomized controlled trial. Journal of the American Medical Association. 1998;279:1529-1536. 13. People of Color in Crisis (POCC), Brooklyn, NY. http://www.pocc.org/ 14. Concerned Black Men, Washington, DC. http://www.cbmnational.org/ 15. Sanders E. Seattle HIV program enlists barbershops: Black men get a trim and a frank discussion. The Boston Globe. January 1, 2004. The Down Low Barbershop Program: www.brotobro.com, www.ushelpingus.com. 16. Darbes LA, Kennedy GE, Peersman G, et al. Systematic review of HIV behavioral prevention research in African Americans. The Cochrane Review. March 2002. 17. Malebranche DJ. Black men who have sex with men and the HIV epidemic: next steps for public health. American Journal of Public Health. 2003;93:862-865. 18. Summerrise R, Wilson W. “The Black Print” model for recruitment of African-American males. Published by the Chicago, IL, Prevention Planning Group. 2000.

Preparado por Darrell P. Wheeler, PhD, MPH, ACSW; Hunter College, NY Traducción Rocky Schnaath Enero 2005. Hoja Informativa 54S