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HIV 101

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Tricia Smallwood

on 9 August 2016

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Transcript of HIV 101

HIV/
Basic Facts, History, & Statistics
Testing, Basic Treatment Information
& the Latest Developments
Tricia A. Smallwood, MPH

image source: http://www.tonymillsmd.com/category/news/hiv/
Image: ISTOCKPHOTO/ERAXION
Basic Facts
HIV is the retrovirus that causes AIDS
The HIV virus attacks, infects and destroys CD4/Tcell Cells.
CD4[Tcells] are white blood cells, which are an important part of the human immune system.
In fact, your CD4[TCells] act as your immune systems alarm system sending out signals to prompt an immune response when an intruder(virus/bacteria) is detected.
*http://www.aids.gov/hiv-aids-basics/just-diagnosed-with-hiv-aids/understand-your-test-results/cd4-count/
AIDS = Acquired Immune Defiency Syndrome
HIV = Human Immuno-defiency Virus
source: http://www.thebody.com/content/art13708.html
source: http://www.thebody.com/content/art13708.html
source: http://www.thebody.com/content/art13708.html
source: http://www.thebody.com/content/art13708.html
source: http://www.thebody.com/content/art13708.html
source: http://www.thebody.com/content/art13708.html
{ HIV }
[ How HIV works in your body ]
The Virus
{ Transmission }
FOUR bodily fluids:
HIV is NOT transmitted by: sweat, saliva* or tears and CAN NOT enter the body through intact skin
MODES of Transmission:

Blood
Semen
Vaginal secretion
Breast milk
Contact w. Infected Blood
Sharing Needles/Cotton/Spoons
Vaginal Sex
Anal Sex
Oral sex (lower risk)
Mother to Child
In the event of HIV transmission
Often referred to as CD4 cells, T-helper cells or T4 cells. They are called helper cells because one of their main roles is to send signals to other types of immune cells, including CD8 killer cells.
CD4 cells send the signal and CD8 cells destroy and kill the infection or virus. '

If CD4 cells become depleted, for example in untreated HIV infection, the body is left vulnerable to a wide range of infections that it would otherwise have been able to fight.


HIV attacks the body's CD4 Cells
http://en.wikipedia.org/wiki/CD4
The first 6-12 weeks of HIV infection is called the WINDOW PERIOD.*
[ HIV Window Period & Life cycle ]
The Acute Primary Infection, 6-12 weeks, is considered the "Window Period" of the HIV infection because during this time the immune system has not responded adequately enough for HIV Rapid Anti-body tests to detect HIV in an HIV infected individual.
(e.g an HIV+ person will test negative within this period)

most infectious
1983
1984
1991-1992
1987
1981
ATZ approved by the FDA
The first cases of rare pneumonia (PCP) and unusually aggressive cancer, Kaposi’s Sarcoma (usually occurring in older people), among other opportunistic infections reported among young/previously healthy gay men in New York and California.*


Congress holds hearings to discuss "G.R.I.D": Gay Related Immune Deficiency
Other 'slang' terms Identified what was HIV/AIDS as the "gay cancer"

U.S. CDC uses the term AIDS: Acquired Immune Deficiency Syndrome
IDed populations at risk: homosexual men, intravenous drug abusers, Haitian origin and hemophilia A.

First cases of a "new-fatal wasting disease" reported in Uganda. Doctors and community call it "SLIM". It will later be identified as the first reported cases of AIDS in Africa.

First community based AIDS service providers started by the gay communities of New York and San Francisco.
A Brief History of HIV/AIDS
June - July
*Scientists believe HIV presented itself years before the 1st case was made public.
The US public Health Service recommends preventing HIV transmission through sexual contact & blood transfusions
females of male partners are added to groups at risk.
Dr. Robert Gallo discovers a retrovirus that causes AIDS. It is later named Human Immunodeficiency Virus (HIV).
Reagan finally addresses AIDS in first public speech.
Federal funds are banned from being used for AIDS prevention education. Termed the "no homo" policy.
AIDS Coalition To Unleash Power (ACT UP) is founded by the New York gay community to advocate for AZT affordability as well as protest the CDC and FDAs apparent lack of action in the face of the AIDS epidemic.
HIV positive foreigners are no longer allowed entry into the US
15 years since the start of the HIV/AIDS Epidemic the first protease inhibitors are approved by the FDA. The era of HAART begins.
1995
2003
President G.W. Bush announces PEPFAR
(President's Emergency Plan for AIDS Relief )

source: http://kff.org/hivaids/timeline/global-hivaids-timeline/
Period of Silence
1970
"While rare, sporadic case reports of AIDS and sero-archaeological studies have documented human infections with HIV prior to 1970, available data suggest that the current pandemic started in the mid- to late 1970s.

By 1980, HIV had spread to at least five continents (North America, South America, Europe, Africa and Australia). During this period of silence, spread was unchecked by awareness or any preventive action and approximately 100,000-300,000 persons may have been infected."-Jonathan Mann



source: http://www.avert.org/history-aids-1986.htm#footnote1_pf7j81o

http://www.avert.org/history-aids-1986.htm#footnote1_pf7j81o
The first HIV-1 rapid test is licensed by the FDA
AIDS becomes the NUMBER ONE cause of death for US men ages 25 to 44.
5 year, 15 billion dollar initiative that will address HIV, TB and malaria in countries worldwide.
PEPFAR makes up 48.7% of all International HIV funding
President Obama reestablished and increased PEPFAR funding.
1) An HIV infected individual
WILL NOT

test positive ...therefore, may not know they are HIV+

2) An infected individual is most infectious at this time due his/her HIGH viral load.
WHY THE WINDOW PERIOD IS
CRITICAL TO DIAGNOSIS & TRANSMISSION
1982
HIV LIFE CYCLE
For more information about HIV politics and activism of the 1980s-early 1990s check out the Oscar nominated documentary: How to Survive a Plague
Three Clinical Stages*
ACUTE INFECTION*

*People may progress through these stages at different rates, depending on a variety of factors.
What it feels like:

“Acute retroviral syndrome” (ARS) or “primary HIV infection"
2-4 weeks after transmission many
(NOT ALL)

have intense flue like symptoms.
this is your body's natural reaction to the HIV infection
Clinical Latency Stage
WITHOUT treatment there is an average of 10 years spent in the clinically latent stage.*
*some progress faster through this stage
AIDS
Acute Infection is during the
WINDOW PERIOD
The final stage of HIV infection.
AIDS is diagnosed when the HIV+ person has a CD4 count below 200 cells/mm.
In someone with a healthy immune system, CD4 counts are between 500 and 1,600 cells/mm
The persons immune system is now compromised to the degree that they are now vulnerable to life threatening

opportunistic infections.
Examples of OIs: certain types of cancers (e.g. the Kaposi's sarcoma discovered early in the epidemic), oral thrush, TB, pneumonia, HEP C, Toxo (brain infection) etc.
Wasting, the extreme decrease in fat & muscle tissue due to disease, typically occurs as well
WITH long term adherence to proper HIV treatment and medical supervision: HIV can be managed & suppressed.
*won't test postive on HIV Rapid antibody test.
HIV+ person is still infectious during this stage
HIV is still active.
But it is
NOT
reproducing at the same rate as it did during the acute stage.
HIV+ individuals may not have any symptoms during this time
MOST INFECTIOUS STAGE
}
HIV
A.R.T.
&
What is ART
ART = AntiRetroviral Therapy.
ART typically consists of
"at least three antiretroviral (ARV) drugs to maximally suppress the HIV virus and stop the progression of HIV disease."

ART has made it possible for HIV+ individuals to
MANAGE
their HIV long term.
A 20 yr old who is put on ART early in his/her infection now has the life expectancy of living till his/her early 70s. *
ART's availability worldwide, specific to third world country's has lowered world wide death rates.
source: http://www.who.int/hiv/topics/treatment/en/
*studies show previous injection drug use and initiation of ART done when patient is clinically diagnosed w. AIDS lowers life expectancy.
"The
Lazarus
Effect"
Coined to describe the amazing response that people suffering with HIV/AIDS have to ART medication. The most stunning examples have come out of Africa, a continent that bares a disproportionate amount of the world's HIV burden, people tend to wait longer to receive treatment due to: stigma and health care access.
pre-ART
3 months on ART
5 years later
PEP
&
PrE
P
ARVs can also be used in HIV prevention
PEP is an emergency prophylaxis that MUST be taken within
72 hours
of a possible exposure in order to prevent HIV transmission.
PEP consists of 2-3 ARV medications and should be taken for

28 days

The more hours between exposure and the 72 hour limit the less effect PEP is (e.g. much like Plan B for pregnancy)
You can be prescribed PEP at the emergency room, doctor's office, local HIV clinic and urgent care clinics.
It is NOT 100% effective
& has serious side effects that sometimes effect patient adherence.
PEP
PrE
P

PrE
P =
PRE
-Exposure Prophylaxis
PrEP is a once daily pill intended for high risk NEGATIVES to REDUCE their risk of being negative.
High Risk Negatives are IDed as:
Men who have sex with Men (MSM)
An HIV- partner in a sero-discordant (HIV-/HIV+) couple
Injection Drugs Users (IDU)
PrEP can only be prescribed by a physician.
Before initiation/during PrEP use clients are tested for HIV routinely to insure if they have not contracted HIV and in the event of transmission PrEP is immediately stopped to prevent drug resistance.
source: http://women.prepfacts.org/
more than 90%
iPREX study results showed that Truvada
among MSM who had the drug in their blood
indicating medication adherence
lowers HIV infection risk by
source
: (photo) stigmaproject.org (statistic) women.prepfacts.org
PrEP is NOT
a Cure for HIV
a Vaccination against HIV
a Morning After Pill*


Protection from other STDs
For those living with HIV
On it’s own, as a treatment regimen for HIV+ individuals
*The medicine takes time (7 days) to start working. It WILL NOT prevent infection if taken right before or right after an exposure to HIV.
The Goal of ART
the goal of ART is to inhibit HIV replication and in doing so: help CD4 cells increase.
Vital to the success of ART
=
ADHERENCE

Failing to take the medication as scheduled and/or missing doses can result in the failure of ART to keep HIV at bay as well as the development of DRUG RESISTANT strains.
ARVs are very time sensitive & HIV replicates and mutates rapidly.
Undetectable
http://www.aidsmap.com/Undetectable-viral-load/page/1320141/
Essentially, undetectable means that a viral load test run on an HIV+ person comes back with no HIV cells detected.
HIV viral load tests can not measure small levels of HIV, therefore undetectable means there is so little HIV it can't be found in one sample of blood.
it does NOT mean there is no HIV elsewhere in the body or that transmission is not possible*
(* studies show it does REDUCE risk of transmission.)
WHERE WE STAND TODAY:
HIV/AIDS Statistics: World, Regional and State
There were an estimated
2.3 million NEW HIV infections globally


Globally, an estimated people were living with HIV in 2012.
35.3 million
Sub-Saharan Africa bares a disportionate amount of the world's HIV /AIDS burden.*
with an estimated
25 million
people living with HIV
source:
unaidsglobalreport2013
Good news: New Infections are showing a 33% decline in the number of new infections from 2001.
Additonally, Deaths are declining among adults and children due to AIDS:
1.2 million of total occurred in Sub-Saharan Africa
20,000 occurred in North America (US & Canada)
http://www.unaids.org/en/resources/infographics/20131120aidsbythenumbers03/
The history of global HIV prevalence
by GapMinder
HIV/AIDS: United States of America
As per the CDC:
More than
1.1 million people in the United States are living with HIV
infection, and almost
1 in 6 (15.8%) are unaware of their infection.
Gay, bisexual, and other men who have sex with men (MSM)
particularly young black/African American (YMSM) are most seriously affected by HIV.
By race, African Americans face the most severe burden of HIV.
There are an
estimated 50,000 new infections
every year.
HIV/AIDS :
OAKAND
HIV & Gender:
Primary Modes of Transmission by Gender

Prevention Tools
Know 'em.
Live 'em.

Prevent it.

What is Risky Sex?
Male Condoms
Female Condoms
LUBE
Syringe Harm Reduction
Vaginal/Anal Health
HIV Prevention tends to lose it's audience's buy in when it talks in terms of absolutism (e.g. NO CONDOM = HIV) What is truly useful to the community is understanding how to asses their level of risk and act appropriately.
To do that they need to understand:
ADVANTAGES
Can be inserted up to 8 hrs before expected/unexpected sexual encounter.
Unlike the male condom, erection is not necessary to keep the condom in place.
Female condoms do not reduce a male partner’s stimulation.
Can be used by people who are known to be sensitive to latex condoms are made of plastic,
DISADVANTAGES
Female condoms make a noticeable sound during sexual intercourse.
It is sometimes difficult to insert or use, and some women can have difficulty on the first attempt at self-insertion.
It can break or leak.
It is much more expensive than a male condom.
When used consistently and correctly condoms are effective prevention against pregnancy, STDs and HIV/AIDS.
Women have to rely on the man’s cooperation.
Men sometimes report "they don't fit me" or simply "i don't like them"
Men/Women stop using due to irritation that can be linked to a latex allergy or allergy to the lube used by the condom brand.
Irritation = abrasion = HIV window of opportunity
If not put on correctly: condoms may break/slip.
If clients are involved in sex work the NOPD has been known to search purses and use the presence of CONDOMS to justify an arrest.
Sexually active individuals should always be encouraged to know and understand what vaginal and anal health is.
When the health of the vagina and/or anus is compromised the risk for HIV increases exponentially.
Having an in-depth understanding of vaginal and anal well being is 1/2 the battle in HIV prevention.
For example: If a man a notices blood on the toilet paper after a bowel movement should he bottom during anal sex that night? Does he know what the blood indicates or how to self treat?
Silicon/Water based lubes are the only lubes that should be used with condoms. Oil based lubes erode latex.
Silicon Lube is superior: lasts longer & is best for Anal Sex.

Lube REDUCES friction.
Friction can cause condoms to break as well as the sex to be "dry".
Dry sex causes abrasion. Abrasion is an opportunity for STD/STIs and HIV to enter what was one intact skin.
Even if clients do not report sharing needle equipment. A lot of the time they will re-use the same needle repeatedly. While not sharing is harm reduction from infections such as HIV/HEP C as evidenced by the photo below the needle begins to dull after the FIRST use.

Reusing needles blunts them, which damages the veins- so they are far more likely to collapse, experience thrombosis and become unusable. The risk of an abscess increases as well.
Sharing Needles is a significant risk factor for contracting HIV. The needle provides sufficient airtight dead space for the HIV+ blood of the infected user to be passed on to the second user. It is important to engage clients/community members about the dangers of sharing equipment & their harm reduction options.
spermicide increases the risk of HIV infection.
Common Barriers for Consistent Use:



507 Frenchmen
Fridays Only 2:30-4:30


discrete by bike delivery
(504) 535-4766


Last Friday of Every Month
Art Egg Warehouse Room 200 (2nd Floor)
Approximately
45,000 people
who inject drugs live in Louisiana, and
more than a quarter of them reside in New Orleans.

State health authorities estimate that
6 percent of people who inject drugs are living with HIV

In Louisiana, nearly half of injection drug users newly diagnosed with
HIV developed AIDS within six months,
indicating that they were tested at a late stage in the disease.


In New Orleans,
48 percent of injection drug users living with HIV are not receiving HIV-related medical care.
"
"
Source: Human Rights Watch: In Harm's Way State Response to Sex Workers, Drug Users and HIV in New Orleans
source(s): Louisiana HIV/AIDS Surveillance Quarterly Report, LA DHH/OPH, 12/31/10, CDC, 2012. http://www.cdc.gov/hepatitis/HCV/HCVfaq.htm#section1
In Louisiana:

12% of all newly diagnosed HIV infections occur as a result of injecting drugs while using unsanitary or ‘dirty’ needles

16% of total HIV/AIDS infections occur as a result of injecting use

Over 40% of Injection Drug Users in Louisiana are infected with Hepatitis C
Syringe Exchanges in NOLA
Syringe Access Program
TryStero Syringe Distro
Women w. A Vision
MEN WHO HAVE SEX WITH MEN
HETEROSEXUAL MEN
HETEROSEXUAL WOMEN
TRANSGENDER (M/F) INDIVIDUALS
Injection Drug Users
who have unprotected sex with:
multiple partners (increased risk if partners are concurrent)
with someone living with HIV+
casual/anonymous/internet partners
men who have sex with men
who they themselves:
inject drugs and share equipment
exchange sex for drugs/money
who are HIV+ themselves (and their viral load is not suppressed)
who have unprotected sex with:
multiple partners (increased risk if partners are concurrent)
with someone living with HI
casual/anonymous/internet partners
men who have sex with men
who they themselves:
inject drugs and share equipment
exchange sex for drugs/money
who are HIV+ themselves (and their viral load is not suppressed)

who have unprotected sex with:
multiple partners (increased risk if partners are concurrent)
with someone living with HIV+
casual/anonymous/internet partners
who they themselves:
inject drugs and share equipment
exchange sex for drugs/money
who are HIV+ themselves (and their viral load is not suppressed)
AKA EVERYONE
(basically.)
Yes, utilizing any and all prevention tools.

BUT also,
limiting the # of partners (especially the duration between them. Multiple concurrent partners increases risk for contracting HIV.)

Knowing what is risky sex so as a sexual active person you can make an informed decision about your sex life.

Understanding that routinely putting one's self at risk/having risk sex might be a symptom of depression/anxiety and/or other issues of well being that should be addressed with a wellness counselor.
Getting tested with your partners.

Making an action plan for using as many harm reduction strategies as possible while still having your IDEAL sex life (that also happens to be safe).

Understanding that YES sex should be FUN and part of it being fun is not taking an STI/STD or HIV with you when the sex/relationship is over.
Pr
EP

see slide 67
HIV RAPID
TESTS
Insti HIV-1
ORA-QUICK

UNI-GOLD
Results: 60 seconds
>99% accurate
Sample: finger prick/blood
Results in 20 mins
Samples: Oral Fluid or Blood
>99% accurate

Results in 10 mins
Sample: Fingerprick (Blood)
>99% Accurate

RAPID-RAPID
Under the directive of the Office of Public Health OHL HIV Screening uses the rapid rapid protocol.
What that looks like:
if the 1st insti test is
preliminary-pos
or
we run the unigold test
if
POSITIVE
an appointment is made with an infectious disease doctor because ONLY they can run labs and give a diagnosis
if
NEGATIVE.
The client is informed that they need to test again in a month to insure that the discordant result is/isn't the result of an acute HIV infection
*
*All test for HIV ANTIBODIES and NOT the virus itself
HIV/AIDS is preventable and treatable but still not curable. .
HIV-1/HIV-2
HIV-1/HIV-2
There are 2 main genotypes: HIV 1 and HIV 2.
With subtypes in each genotypes.
HIV-1 is the most prevalent worldwide.
HIV-2 is found primarily in Africa.
"The Berlin Patient,” Timothy Brown is thought to be the only individual functionally cured of HIV.
Diagnosed with HIV in 1995 then diagnosed with leukemia 2006 doctors attempts chemotherapy to treat his cancer. When the cancer failed to respond they attempted a stem cell transplant. The transplant was successful and his donor had the CCR5 mutation (a mutation of a white blood cell protein that enables the person to be resistant to certain strains of HIV).
4 years later he remains both HIV and cancer free.
Where's the cure at?
101
AIDS
by irritating the cells that line the vagina and the rectum, making them more vulnerable to attack
PRE
-Exposure Prophylaxis
PrEP is a once daily pill intended for high risk NEGATIVES to REDUCE their risk of being negative.
SEX WITH
An important note:
Bottoming (receptive) puts one at greater risk for contractor HIV than Topping (insertive).
Circumcised men are at great risk for contracting HIV in unprotected sex.
UNPROTECTED
HAVING
who have unprotected sex with:
multiple partners (increased risk if partners are concurrent)
with someone living with HIV.
casual/anonymous/internet partners
men who have sex with men
who they themselves:
inject drugs and share equipment
exchange sex for drugs/money
who are HIV+ themselves (and their viral load is not suppressed)
who have unprotected sex with:
multiple partners (increased risk if partners are concurrent)
with someone living with HIV+
casual/anonymous/internet partners
men who have sex with men
who they themselves:
inject drugs and share equipment
exchange sex for drugs/money
who are HIV+ themselves (and their viral load is not suppressed)
It is important to advocate that EVERYONE can ACTIVELY REDUCE Their Risk by:
A universal cure has yet to be found but with each trial we are understanding more about the complexity of HIV. Every bit of knowledge gained from this trails is adding to the overall equation that one day, hopefully in our lifetime, will result in a cure.
California HIV/AIDS STATISTICS
based on data from 2012
1
IN
287
residents of Alameda County were HIV + by the end of 2012.*
Alameda County ranks
4th,
behind LA, SF & SD in HIV/AIDS cases & is the 7th largest county in California.
At least
20%
of people living
with HIV do not know it. Meaning
= 1,000 people in Alameda may be infected and not know it.
PLWHA
PLWH increased 68% between 2002 & 2012. This increases the burden of care while PLWH are living longer (therefore the # is ) and funding for HIV has decreased dramatically.
to link & retain PLWH on HIV Treatment.
Less $$ = Less resources
44.1%
12.6%
Current trends show new transmission increasing among MSM and decreasing in non-IDU heterosexual.
showing that HIV prevention and linkage to care work is working in the heterosexual cohort, but clearly missing increased risk behaviors, particularly among young MSM of color.
African American and Latino MSM make up
53%
of all MSM living with HIV in Alameda County - including MSM who inject drugs.
Alameda County has the highest % of women living with HIV in the western US.
58% of those newly diagnosed with HIV are African American women.
Meanwhile, African American women only account for 12% of the Alameda female population.
Like men HIV disproportionately affects African American women.

NEW cases of HIV are

most dense
in Oakland & Central Country,
Most
concentrated

Oakland, Hayward, San Leandra & Berkeley.
New HIV Cases by AGE in Alameda County
African American men make up
11
% of the Alameda male pop
. &
40% of Newly Diagnoses
HIV Cases
Latino men = 22% of new diagnoses
White men = 26% of new diagnoses
59.8%
of all MSM HIV cases from 2012-2012 occurred among Latino and African American
Transgender African American women
are also disproportinately affected with
a positivity rate of 4.4%
.

The positivity rate among
Latino Transgender women is 2.9%.
Poverty: limits access to health care, HIV & STI testing. Economic hardship can lead to circumstances of increased HIV risk or just low on the priority list of basic concerns.*
Socioeconomic Factors Affecting HIV Risk:
POVERTY
STIGMA/DISCRIMINATION/HOMOPHOBIA
PREVELENCE OF HIV and other STIS*
*It is mostly a determinate for high risk heterosexuals.
High prevalence across communities & cultures.
All three factors greatly discourage people from seeking prevention, testing & treatment services.
All three contribute to individuals lacking a sense of agency when it comes to protecting themselves from HIV and putting themselves at risk.
Countless studies have proven the link between high HIV prevalence & the concentration of those living below the poverty line.
Poverty directly effects a persons literal & perceived access to health care & preventative services.
Alameda County is:
4th in Syphilis, gonorrhea and has a high incidence of chlamydia.
STIs = increased vunlerablity to HIV transmission if exposed.
More STIs, high HIV transmission.
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