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  • Enter the title of your presentation and your name to this title slide.
    When saving your presentation, please add your name and session title to the existing file name (i.e. “15th_Conf_Slides_Beal_Managing_Multiple_Diseases.ppt”)
    Please call Michael Ikeya at (813) 974-9005 if you have any questions.
  • Module 1 (Slide <number>)
    Use this slide if you have no significant financial relationships with any commercial entities.
    If you use this slide, please delete slide 3.
  •  1 minute
     To briefly introduce the recommendations put forth by the Centers for Disease Control and Prevention (CDC), the Health Resources and Services Administration (HRSA), the National Institutes of Health (NIH) and the HIV Medical Association (HIVMA) of the Infectious Diseases Society of America (IDSA).
     Convey Slide Content
    Handout: CDC/HRSA/NIH/IDSA Recommendations
  •  1 minute
     To quickly review the recommendations put forth by CDC, HRSA, NIH and HIVMA.
     Convey Slide Content
    MMWR, July 18, 2003
  •  1 minute
     To explain the urgent need for the creation of the recommendations given the current trends in HIV-infected persons.
     Current trends indicate a reversion to risky sexual behaviors.
     STD rates are increasing.
     The potential for transmission of drug-resistant HIV is of increasing concern.
     Co-infection with other STDs increase HIV transmission risk.
    Transition: “While all of these trends are important issues in HIV care, we will now focus on recent increases in bacterial STDs.”
  •  1 minute
     To demonstrate concerning trends among HIV-infected persons, in this instance men who have sex with men (MSM)
     This graph illustrates that infection rates for gonorrhea and chlamydia at all anatomical sites shown are higher among HIV-positive MSM attending sexually transmitted disease (STD) clinics in the U.S.
  • Module 1 (Slide <number>)
     1 minute
     To illustrate the stable proportion of MSM with primary and secondary syphilis in California who are HIV-infected
     For example, this slide demonstrates an increase in primary and secondary syphilis among MSM in California between 2001 and 2003.
     Consistently, more than half of these men are HIV-positive.
  •  1 minute
     To demonstrate increases in primary and secondary syphilis cases in major U.S. cities since 1997
     Increases in primary and secondary syphilis cases have been observed among men in large U.S. cities.
    Transition: “A significant proportion of this increase is attributable to increases among MSM, as shown in the following slide.”
  •  1 minute
     To review possible explanations for the emerging trends previously discussed
     First bullet:
    The perception that “AIDS is curable”
    An increase in sexual activity as quality of life improves
    The assumptions about being less infectious on HAART, especially if serum viral load is undetectable
    The reduced visibility of end-stage AIDS
     Second Bullet:
    Prevention fatigue – Prevention messages, programs, outreach and counseling have become less compelling to some. Individuals may have grown weary of messages urging ‘safe’ behavior.
    Condom fatigue – Fear of HIV infection has waned over time. Normalization of HIV has led to more risk taking in those seeking pleasure in unprotected sex.
     Third bullet:
    Use of drugs for erectile dysfunction (e.g., Viagra, Cialis, Levitra), as well as other psycho-active drugs, have been associated with increases in risky sexual behavior.
    Use of methamphetamine, in particular, has been associated with increases in syphilis and HIV transmission in some communities.
     Fourth bullet:
    Some venues for meeting partners are well known (e.g., bathhouses, parks), while others are new (e.g., the Internet)
     Fifth bullet:
    Anonymity of partners limits awareness of risk
  •  3 minutes
     To illustrate providers’ performance in asking about sexual risk
    Interactive: This slide is animated.
    Initial: X-axis is UNLABELED
    Introduce the slide: This slide lumps together…(first two key points)
    Ask participants:
    - “What provider group does this bar represent?”
    - Offer suggestions – primary care providers, a mix, HIV care providers, ID specialist, etc.
    Each Click: Bars become labeled
    Emphasize the “HIV Care Providers” and the “ID-trained Provider” bars (4th and 5th bars)
     In 1991, the United State Public Health Service (Healthy People 2000) established a goal that 75% of primary care clinicians provide HIV/STD prevention counseling and risk assessments to their patients. This goal was re-emphasized in HP 2010.
     This slide assembles a wide variety of studies evaluating provider assessment of their patients’ STD-related risk factors.
     Although the methodology and the settings vary widely across these studies, routine STD-related risk assessment—wherever and however one measures it—does not occur with desired regularity.
     Factors associated with increased counseling (Metsch 2004):
    Having sufficient time with patients
    Familiarity with treatment guidelines
     Factors associated with decreased counseling (Metsch 2004):
    Patients perceived as having mental health and/or substance abuse problems
    Having a disproportionate amount of male patients
    Medical care delivered by infectious disease specialists
  •  1 minute
     This is a quote from “The Hidden Epidemic” suggesting the difficult of engaging in discussions about sexual behavior. Effective dialogue requires a high degree of comfort and experience
    Transition: “Yet even when providers do ask about sexual behavior, often they do not document risk factors that patients report.”
  • Module 1 (Slide <number>)
     1 minute
     To visually illustrate that providers are not documenting risks in patients at high risk for transmitting HIV
     The fact that providers do not document risk factors results in funds being inappropriately distributed.
     As a result, prevention and care dollars do not reach the people who need them most.
    “Now we will discuss a case illustrating some of the main points just covered.”
  •  30 seconds
     To demonstrate a common missed screening and diagnostic opportunity
     Convey slide content
  •  30 seconds
     To demonstrate a common missed screening and diagnostic opportunity
     Convey slide content
  •  30 seconds
     To demonstrate a common missed diagnostic opportunity
     Convey slide content
  •  1 minute
     To demonstrate a common missed diagnostic opportunity
     Convey slide content.
    Interactive: Ask: “Why was the diagnosis missed?”
    Elicit 3 – 5 responses from participants
    Case Answer: Assumptions were made about the sexual history. Provider completed a clinical risk assessment, but did not do a behavioral risk screening.
    Briefly discuss the type of assumption (heterosexual assumption) made by the physician and how this assumption affected the outcome.
  •  1 minute
     To review barriers just identified (answers to interactive discussion)
     Convey slide content (read only those barriers not elicited from participants)
  •  1 minute
     To share ways providers may overcome identified barriers
     There are many potential ways to overcome these barriers, including developing policy and procedures in clinics, such as recommending specific questions to be asked of patients regarding risk behaviors.
     Some interventions target the individual level (e.g., recommending specific questions to be asked of all patients, training providers to enhance competence, identifying ways to overcome patient stigma about HIV).
     Other interventions are aimed at the structural level (e.g., developing clinic policy for risk screening and integration into overall care, developing a plan to respond to information that might surface).
    Handout: Handout 1: Patient Administered Questionnaire
  •  1 minute
     To review the benefits of knowing risk behavior (answers to interactive discussion)
     There are benefits to the clinician and patient.
     Convey slide content (read only those benefits not elicited from participants)
  •  1 minute
     To identify and describe the differences between screening and assessment in the context of asking about behavioral risk factors
     Risk Screening:
    “A brief assessment of behavioral and clinical factors associated with transmission of HIV and other STDs.”
    Identifies patients at highest risk of transmitting HIV: those having unprotected sex, using drugs or at risk for pregnancy
    Encompasses the following:
    Who: Number of sex partners; HIV status of partners
    What: Type of sex: oral, anal, vaginal; condom use; barriers; risk of pregnancy; intravenous drug use
    Where: Meeting venues, shooting galleries
    Can be multi-modal: verbal, written, and computer or video assisted
    Benefits:
    Takes very little time
    Screens out those not at risk (the majority of patients)
    Client-centered
     If screening is positive, an in-depth assessment should follow.
     Assessment:
    An in-depth evaluation of risk that requires a more detailed and often open-ended approach.
    Identifies reasons why the patient is at risk for transmitting HIV
    Encompasses the following:
    Why: The patient’s circumstances, knowledge and attitudes regarding risk behaviors
    How: Patient’s readiness to change the behavior
    Usually involves a face-to-face discussion
     Assessment is likely to lead to further behavioral interventions and/or referrals.
  •  1 minute
     To review the essential framework of a successful risk screening (which, if positive, will continue into assessment)
     Convey slide content
     This is an intimate and emotional topic for most patients, so respect and tact is very important.
     Start with less threatening questions.
     At the initial visit, ask all patients all components of the sexual history to avoid letting your assumptions cause you to miss an important piece of information.
    Common assumptions: Older patients are not sexually active; heterosexual patients only engage in vaginal sex; married patients do not have outside partners
    Normalize: May use an introductory statement such as, “I ask all of my patients this questions.”
     At subsequent visits, screen all patients. Behavioral practices are dynamic. This allows you to easily identify patients at risk for transmitting HIV in a brief manner.
     Patients who respond positively to the risk screening will require a more in-depth assessment.
    Interactive: BRING TONY BACK TO EMPHASIZE POINT – Check your assumptions: Ask group “How many assumptions did you make?”
  •  1 minute
     Adopt an open manner with lots of active listening cues from time to time
    Head nodding and eye contact, “uh-huh” or “keep going”
     Some medical jargon that may seem basic can be confusing to some patients:
    e.g., “STD,” “intercourse,” “fellatio” or “receptive anal sex”
    May need to be explicit
    There are ways of redirecting slang to more descriptive terms, such as “penis in mouth”, that is understandable to virtually all patients
     In restating and expanding: “Oh my partner hates condoms” might be re-directed as “Am I understanding you to say that condoms aren’t the best choice for you and your partner?”
  •  1 minute
     A non-judgmental approach involves recognizing patient anxiety and recognizing our own biases
    Does not mean we condone all behaviors
    Means we are willing to listen and discuss the patient’s true concerns
     There are different expressions of anxiety to watch for: changes in posture, speech, anger, and avoidance of questions.
     Provider anxiety can be masked by avoiding to show surprise or dismay at what the patient tells you.
     So how do we recognize a bias? Anything that “pushes your buttons” is recognizable as a bias. For instance:
    An HIV-positive gay man with many partners who is not disclosing his HIV status
    A married patient going to a commercial sex worker
  •  30 seconds
     To introduce the concept of open-ended vs. closed-ended questions and to re-emphasize permission-giving, non-judgmental statements
     For the sexual history, open-ended questions are indispensable for getting the patient to talk, which is what we want: “who, what, when, where.”
     Providers are accustomed to using open-ended question to elicit the patient’s chief complaint:
    e.g., “What brings you in today? What can I do for you?” But then providers tend to take back over very quickly to direct the interview.
    A recent study showed the average time clinicians allow their patients to talk at the beginning of the interview was 7 seconds.
     Almost any “Yes/No” question can be easily turned into an open-ended one by beginning it with “Tell me about…” For instance:
    “Do you have discharge?” becomes “Tell me about any symptoms you have.”
    “Have you ever had an STD?” becomes “Tell me about any STDs you’ve had in the past.”
    Or else, follow a “Yes/No” question with “Tell me about that” or “How did that go?”
     Permissive statements let patients know they are able to have these discussions with their provider. An opening statement can begin with:
    “Tell me more…”
    “I’d like to hear about…”
  •  1 minute
     To discuss specific examples of questions
     These are different examples of open-ended questions.
     Closed-ended questions are great for gathering more specific details about the patient’s responses to open-ended questions. Most providers are well accustomed to using this type of question. For this reason, we will focus on open-ended questions.
     The type of question you will use depends on the information you wish to elicit. This can clarify the who, what, and where about sexual practices.
     More examples of open-ended and closed-ended questions can be found in the Pocket Risk Screening Guide (Handout #2).
    Handout: Handout 2: Pocket Risk Screening Guide (additional examples of questions can be found in this handout)
  •  1 minute
     To discuss specific examples of questions
     Convey slide content
    Handout: Handout 2: Pocket Risk Screening Guide
  •  1 minute
     To discuss specific examples of questions
     Convey slide content
    Handout: Handout 2: Pocket Risk Screening Guide
  •  1 minute
     To discuss specific examples of questions
     Convey slide content
     Using a combination of open-ended questions and closed-ended questions can enhance the type of information gathered from your patients. For example, when asking your patients about their partners, you may begin with an open-ended question such as “Tell me about your sex life.”
    A possible patient response is, “Oh, I just met this guy in a chat room about three weeks ago. We met in person soon after that and it’s been great. We just started having sex about a week ago.”
    You have found out the gender of the partner, where your patient met the partner, how well your patient knows the partner, and that they are sexually active. Now is the time to ask more specific questions such as “Do you have other partners?” or “Where do you usually meet your partners?”
    Handout: Handout 2: Pocket Risk Screening Guide
  • ****Module 1 Skills Practice****
     15 minute
     To practice the essential elements of an effective behavioral risk screening
     Use open-ended questions to initiate a conversation with a patient/client.
     Use closed-ended questions to gather more specific information.
    ***Module 1 Skills Practice***
  •  1 minute
     To distinguish between diagnostic testing and screening
     Diagnostic testing is performed to establish the etiology of a complaint, a symptom, or a sign. The patient essentially drives this encounter.
     By contrast, asymptomatic persons (and symptomatic persons who do not spontaneously report symptoms) at risk for an infection or disease are selected for screening to identify the infection.
     Screening is most effective when the disease in question a) occurs relatively frequently in the target population, and b) does not usually cause symptoms.
    Transition: “We have heard that a number of STDs are occurring at increasing rates in our HIV-infected patients. The next slide illustrates the frequency of asymptomatic infections."
  •  1 minute
     To show why it is necessary to screen for STDs
     Explain slide carefully…
    A large percentage of men and women present asymptomatically for rectal and pharyngeal gonorrhea.
    In women, asymptomatic cervical chlamydia infection is common.
    In men, asymptomatic rectal chlamydia infection is common.
    The majority of cases of herpes present asymptomatically in both men and women.
     Asymptomatic patients with these infections may not realize they are putting their partner(s) at risk for infection.
     The presence of an STD, even one that is asymptomatic, increases the amount of HIV present at the site of infection.
    e.g., men with asymptomatic chlamydial urethritis have significantly higher levels of HIV in their semen than men who do not have chlamydia, which increases the risk of transmitting HIV to uninfected partners
  •  1 minute
    To identify potential questions of providers about screening
    Address each bullet briefly. Indicate that some of this information will be provided in the form of handouts and in the following slides.
     Do I need to treat if asymptomatic? Absolutely! Most STDs do not cause symptoms or even visible signs on exam.
    e.g. 90% of women with cervical chlamydial infection have a cervix that appears normal
    How often? The CDC/HRSA/NIH/IDSA provide specific recommendations for periodic screening in HIV-infected persons.
    What tests? This depends on the STD. We provide specific information on this in the course supplementary materials.
     What anatomic sites? This also depends on the STD, but it also depends on the sites exposed.
    e.g. People who report receptive anal sex should be screened for relevant STDs by collection of rectal samples
    Do I need to treat patient’s sex partners? Absolutely. This is the only way to break the chain of transmission.
     How much time? This depends on the STD and on the tests available.
    e.g. If urine-based testing is available for chlamydia and gonorrhea, providers can simply ask the patient to provide a urine sample
    Who pays? This is a valid concern of many health providers. Unfortunately, we cannot provide an answer, partly because there is so much variation across sites and payer types. Rather, we suggest you contact your local clinic or program authorities.
    Additional guidance needed? Any provider with limited experience in assessment for or management of STDs should be encouraged to contact knowledgeable resources, including STD clinic providers or infectious disease specialists for assistance, as indicated. Suspected lymphogranuloma venereum (LGV) is a good example.
  •  1 minute
     An overview of STD screening recommendations for patients at the initial clinic visit
     Convey slide content
     These recommendations are only for screening specifically to identify clinical factors associated with increasing risk for transmission.
     STD symptoms are urethral or vaginal discharge; dysuria; intermenstrual bleeding; genital or anal ulcers or other lesions; anal pain, pruritus, burning, discharge, or bleeding; and for women, lower abdominal pain with or without fever.
     Screening for gonorrhea and chlamydia should be based on patient’s behaviors, prevalence, availability of tests, and cost.
    Handout: Introductory Slide Set Handout 1: CDC/HRSA/NIH/IDSA Recommendations
    Handout 2: Pocket Risk Assessment Guide
  • 1 minute
     An overview of screening recommendations for patients at the initial clinic visit (continued)
     Convey slide content
     Women who suspect pregnancy or who have missed their period should be tested for pregnancy.
     Refer women to appropriate counseling, reproductive health care, or prenatal care, as indicated by responses to questions about pregnancy.
    Handout: Introductory Slide Set Handout 1: CDC/HRSA/NIH/IDSA Recommendations
    Handout 2: Pocket Risk Assessment Guide
  •  1 minute
     An overview of screening recommendations for patients at subsequent or follow-up clinic visit
     Convey slide content
    Handout: Introductory Slide Set Handout 1: CDC/HRSA/NIH/IDSA Recommendations
    Handout 2: Pocket Risk Assessment Guide
  •  1 minute
     To revisit the key points of screening
     Convey slide content
     Evidence supports condom efficacy for bacterial STDs, but participants should be reminded that condoms are not 100% effective, especially when not used correctly or consistently.
  •  1 minute
     To briefly review available tests
     The use of actual tests varies from setting to setting. Therefore, the most common types of tests for the STDs listed will be reviewed.
     Emphasize that more information about specific tests is available in the handout.
    Handout: Intro Slide Set Handout 1: CDC/HRSA/NIH/IDSA Recommendations
  •  1 minute
     To briefly review available tests
     The use of actual tests varies from setting to setting. Therefore, the most common types of tests for the STDs listed will be reviewed.
     Emphasize that more information about specific tests is available in the handout.
    Handout: Intro Slide Set Handout 1: CDC/HRSA/NIH/IDSA Recommendations
  •  1 minute
     To emphasize resources available to aid in the diagnosis of symptomatic STDs
     Convey slide content
    Handout: Handout 3: Signs and Symptoms of Frequently Encountered STDs
    Handout 4: Recommended Treatments for STDs in HIV-Infected Adults
  •  1 minute
     To highlight availability and usefulness of the CDC’s “STD Treatment Guidelines”
     Convey slide content
    Handout: Handout 4: Recommended Treatments for STDs in HIV-Infected Adults
  • Module 1 (Slide <number>)
    *Prophylaxes Toxo. and some common respiratory pathogens
    The single strength TMP-SMZ is effective and may be better tolerated.
    If TMP-SMZ stopped for adverse reaction, strongly consider reinstitution after AE resolves (AII)
    Fever and rash secondary to TMP-SMZ may tolerate reintroduction using a gradual dose increase (desensitization can occur in up to 70% of patients) (BII)
    One should note that the DS tablet regimens above cover toxo, wheras, the SS “May” cover Toxo.
  • Module 1 (Slide <number>)
    *For pts. who cannot tolerate TMP-SMZ, these regimens cover Toxo. prophylaxis.
    Note that of the above, the Atovaquone is the most expensive.
  • Module 1 (Slide <number>)
    Efficacy data is lacking for these regimens but clinicians may chose to use them in unusual situations in which the recommended agents cannot be used.
  • Module 1 (Slide <number>)
    Purpose of this recommendation is to:
    Reduce pill burden
    Decrease drug toxicity
    Decrease drug interactions
    Decrease selection of drug-resistant pathogens
  • Module 1 (Slide <number>)
    Lifelong unless immune reconstitution occurs.
  • Module 1 (Slide <number>)
    *For pts. who cannot tolerate TMP-SMZ, these regimens cover Toxo. prophylaxis
  • Module 1 (Slide <number>)
    Pts. should remain on secondary prophylaxis for life unless immune reconstitution occurs as above.
    Based on studies and most were on a PI, had CD4 > 300, undetectable VL and longest follow-up was 13 mos.
  • Module 1 (Slide <number>)
    Many patients are tested at initiation of care when CD4 Cell counts are high. For those who have been found to be Toxoplasmosis IgG Antibody NEGATIVE, and are not on a Toxo preventive PCP prophylactic regimen, their risk needs to be reassessed when their CD4 + cell count is nearing <100 cells/µL.
  • Module 1 (Slide <number>)
    Prophylactic monotherapy with dapsone, pyrimethamine, azithromycin, or clarithromycin cannot be recommended. (DIII)
  • Module 1 (Slide <number>)
    Discontinuation is recommended as prophylaxis of primary Toxoplasmosis Encephalitis adds very little to disease prevention once the CD4 is greater than 200 cells/. Also, because discontinuation reduces pill burden, the potential for drug toxicity, drug interaction, and selection of drug resistant pathogens.
    The greatest risk of developing TE occurs when the CD4 is < 100.
    The risk of TE occurring when the CD4 has increased to 100-200 has not been studied as rigorously as a rise to > 200 cells. Thus, the recommendation of not stopping Primary TE prophylaxis until CD4 > 200.
  • Module 1 (Slide <number>)
    After successful treatment of primary infection, suppressive therapy (secondary prophylaxis or chronic maintenance therapy) should continue lifelong unless immune reconstitution occurs.
  • Module 1 (Slide <number>)
    The numbers of patients who have been evaluated have been small, and occasional recurrences have been seen. It is still considered reasonable to discontinue chronic maintenance therapy of the above criteria are met.
    Some would obtain a magnetic resonance image (MRI) of the brain as part of the evaluation before determining if maintenance therapy should be discontinued.
  • Module 1 (Slide <number>)
    There is no difference in TE prophylactic recommendations for pregnant women.
  • Module 1 (Slide <number>)
    The combination of Azithromycin with rifabutin is more effective than azithromycin alone; however, the additional cost, increased occurrence of adverse effects, potential for drug interactions and absence of a difference in survival when compared with azithromycin alone do not warrant a routine recommendation for this regimen.
    Clarithromycin and Azithromycin both confer protection against respiratory bacterial infections (BII)
    Before prophylaxis is initiated, disseminated MAC disease should be ruled out by clinical assessment, which might include obtaining a blood culture for MAC if warranted. Routine screening of respiratory or gastrointestinal specimens for MAC cannot be recommended. (DIII).
  • Module 1 (Slide <number>)
    Treatment of MAC disease with Clarithromycin dosed at 1000 mg BID was associated with a higher mortality than 500 mg BID. Higher doses should not be used. (EI)
    Clofazamine has been associated with adverse clinical outcomes and should not be used. (DII)
  • Module 1 (Slide <number>)
    Some experts would obtain a blood culture for MAC prior to discontinuation of therapy to substantiate that disease is no longer active.
  •  1 minute
     To review the highlights of Module 1
     Convey slide content
  •  1 minute
     To interact with the group about lessons learned from this Module
    Interactive: Briefly survey group: Ask “What is one thing you will change in your practice?”
    Possible responses:
    I will ask my patients about their sexual partners: the who, how, what, and where
    I will ask about IV drug use
  •  1 minute
     To remind participants this is a multi-module course and to illustrate topics to be covered in subsequent modules
     Mention topics to be covered in upcoming modules:
    Module 1: Behavioral Risk Screening and STD Screening
    Module 2: Prevention Messages and Addressing Misconceptions
    Brief clinician-delivered intervention methods are feasible and effective
    Prevention messages can help guide patients toward safer behavioral goals
    Misconceptions of patients can be identified and addressed
    Module 3: Brief Behavioral Interventions and Referrals
    Tailored interventions are needed and are effective
    Assessment of behaviors, circumstances, attitudes and readiness help identify goals
    Behavioral goals are reached through incremental steps
    Referral options may be needed for some patients
    Module 4: Partner Management
    Describe local laws and regulations relevant to partner notification and disclosure
    Multiple disclosure options exist
    Bring up partner disclosure with all patients
  • Transcript

    • 1. Incorporating HIV Prevention into the Medical Care of Persons Living with HIV John F. Toney, MD Professor of Medicine Division of Infectious Diseases and Tropical Medicine University of South Florida College of Medicine Medical Director Southeast STD/HIV Prevention Training Center CDC National Network of STD/HIV Prevention Training Centers
    • 2. 2 Disclosure of Financial Relationships Dr. Toney has no significant financial relationships with commercial entities to disclose. This slide set has been peer-reviewed to ensure that there are no conflicts of interest represented in the presentation.
    • 3. The Recommendations • Developed by CDC, HRSA, NIH, HIVMA, with evidence-based approach • Apply to medical care of all HIV-infected adolescents and adults • Intended for those providing medical care to HIV-positive persons
    • 4. What are the Recommendations? Medical providers can substantially affect HIV transmission when they – screen for risk behaviors – identify and treat other STDs – communicate prevention messages – discuss sexual and drug-use behavior – positively reinforce changes to safer behavior – refer patients for services (substance abuse treatment) – facilitate partner notification, counseling, and testing
    • 5. Why is it Important NOW? Emerging trends among the HIV- infected: –Increases in unsafe sex –Increases in syphilis, gonorrhea –Transmission of drug-resistant virus STDs increase amount of HIV shed at genital mucosa (cervix, urethra, rectum) –Directly increases risk of transmitting HIV (Rietmeijer, Chen, Collis, Novak, Tang, Weinstock, Blackard, Jost, Erbelding)
    • 6. MSM Prevalence Monitoring Project — Test positivity for gonorrhea and chlamydia among men who have sex with men, by HIV status, STD clinics, 2003 Medianpositivity HIV-positive HIV-negativeorunknown 0 5 10 15 20 25 Urethral gonorrhea Rectal gonorrhea Pharyngeal gonorrhea Urethral chlamydia (CDC, 2003)
    • 7. HIV Status Among Men Who Have Sex With Men Primary & Secondary Syphilis Cases – California, 2001–2003 (8/2004 Provisional Data - CA DHS STD Control Branch) 0 100 200 300 400 500 600 700 2001 2002 2003 Year Numberofcases HIV Positive HIV Negative Unknown
    • 8. Primary and Secondary Syphilis Cases, by Sex, 1997-2002: Some Large US Cities New York City 0 200 400 Los Angeles 0 200 400 San Francisco 0 200 400 Chicago 0 200 400 1997 1998 1999 2000 2001 2002 Males Females 1997 1998 1999 2000 2001 2002 1997 1998 1999 2000 2001 2002 1997 1998 1999 2000 2001 2002 (CDC, 2003)
    • 9. 9
    • 10. 10
    • 11. 11
    • 12. 12
    • 13. Median Concentration of HIV-1 RNA in Semen Among 135 HIV-Infected Men With (n=86) and Without (n=49) Urethritis in Malawi 1.5 4.1 12.4 8.9 0 2 4 6 8 10 12 14 without urethritis with urethritis 1 week 2 weeks X104 copies/ml Cohen MS, Hoffman IS, et al. Lancet. 1997 Jun 28;349(9069):1868-73
    • 14. 14
    • 15. 15
    • 16. Why is this occurring? • Improved HIV therapy, well-being, and survival • Prevention message “fatigue” • Increased use of erectile dysfunction drugs, methamphetamine, poppers • Old & new ways to meet partners – Baths, parks – Internet • Anonymous partners (Ciesielski 2003, Katz 2002)
    • 17. 0 10 20 30 40 50 60 70 80 90 100 INFECTIOUS DISEASE TRAINED PHYSICIANS HIV CARE PROVIDERS NON-INFECTIOUS DISEASE TRAINED PHYSICIANS PRIVATE PHYSICIANS PRIMARY CARE PROVIDERS Do Providers Ask About Risk? %ofProvidersWho AssessedSTDRisk Private Physicians Tao 2003 Primary Care Providers Bull 1999 Non-ID trained Physicians Duffus 2003 ID trained Physicians Duffus 2003 HIV Care Providers Metsch 2004 Ongoing care N= 417 providers N=208 providers N= 12.7 million visits N= 317 physicians N= 317 physicians
    • 18. Discomfort as a Barrier “Ironically, it may require greater intimacy to discuss sex than to engage in it.” The Hidden Epidemic Institute of Medicine, 1997
    • 19. 0 10 20 30 40 501985 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 Year of Diagnosis Percent AIDS cases HIV cases Reported Cases with no Identified Risks: National HIV/AIDS Reporting System 1985 to 2003 (CDC, 2003)
    • 20. A Missed Screening Opportunity… • Tony is a 40 year-old HIV-positive man • CD4 = 350, viral load <50, on HAART • Presents for routine visit, feeling well • Physical exam, including external genitalia: normal • Continue current regimen • Routine follow-up scheduled for 3 months Concerns?
    • 21. A Missed Screening Opportunity… • During this routine visit • Provider does not inquire about Tony’s recent sexual activity or symptoms of STDs • Tony does not volunteer that his girlfriend, also HIV+, recently had yeast infection; around the same time, he noticed irritation on his penis, resolved after using miconazole cream • No laboratory screening for STDs is performed
    • 22. A Missed Diagnostic Opportunity… • Returns 3 weeks later with generalized rash • Rx topical steroids, dermatology follow-up • No STD test performed
    • 23. • Dermatology orders RPR: positive at titer of 1:128 • Returns, and reports receptive/insertive anal and oral sex with 5 male partners in prior 3 months • Uses Internet to meet partners, mostly anonymous • ‘Almost always’ uses condoms with them, while reports no condom use with girlfriend What went wrong? A Missed Opportunity…
    • 24. • Inexperience or discomfort asking questions • Discomfort responding to issues that arise • Incorrect assumptions about sexual behavior and risk • Patient perception of stigma from a medical care provider • Limited time is available Provider Barriers to Screening for Behavioral Risk Factors
    • 25. Overcoming Barriers • Identify specific questions to ask all patients • Train providers to enhance competence • Develop clinic policy for risk screening and integration into overall care – Questionnaire • Develop plan to respond to information that might surface • Determine ways to overcome stigma
    • 26. Identifying Risk: Benefits • Clinician Perspective – Assists in clinical intervention/exam – Provides focus for an in-depth risk assessment and direction for risk reduction or referral • Patient Perspective – Opportunity to ask questions – May affect self-motivation for behavior change – Patients want to have these discussions yet often will not initiate on their own
    • 27. Asking about Behavioral Risk… • Screening • Brief inventory of risk • Identifies patients at highest risk of transmitting HIV • Encompasses: • Who • What • Where • Can be multi-modal: • Verbal, written or computer-assisted • If positive, leads to an in- depth assessment • Assessment • In-depth evaluation of risk • Identifies reasons why patient is at risk for transmitting HIV • Encompasses: • Why • How • Usually involves a face- to-face discussion • Likely to lead to further behavioral interventions and/or referrals
    • 28. Framework for Asking about Behavioral Risk • Reinforce confidentiality • Establish rapport • Check your assumptions… • Ask all patients about: • Sexual activity, STD symptoms, substance abuse • WHO: Gender and number of partners • WHAT: Specific sexual practices, drug- related behaviors • WHERE: Partner meeting venues, venues that promote drug use
    • 29. Risk Screening Techniques – Be tactful and respectful o Eye contact, affirmative gestures – Be clear o Avoid medical jargon • “have you had any genital ulcer diseases?” o Restate and expand patient statements o Clarify stories when necessary
    • 30. • Be non-judgmental • Recognize patient anxiety • Recognize our own biases • Emotional responses to behavior • Belief in impossibility for behavior change • Avoid value-laden language • “You should…” • “Why didn’t you…” • “I think you…” Risk Screening Techniques
    • 31. Open-ended Questions: • Enrich type of information gathered • Helps build rapport and confidence Closed-ended Questions: • Gather specific, discrete information (NOT limited to YES/NO questions) Permission Giving Statements: • Use an opening phrase that works for you • Avoid biased comments that judge a given behavior – have an open mind. Use ALL Three Methods Risk Screening Techniques
    • 32. Risk Screening: What Should We Ask? GENERAL QUESTIONS • Determine whether the patient has been having sex… • OPEN-ENDED: “To provide the best care, I ask all my patients about their sexual activity – so, tell me about your sex life.” • Statements about sex practices and drug-related behaviors may need clarification… • OPEN-ENDED: “I don’t know what you mean, could you explain..?”
    • 33. • Determine number and gender of partners, current and past… • OPEN-ENDED: “So, tell me about your partners” • Ask about HIV status of sex and/or injection partners… • OPEN-ENDED: “Talk to me about the HIV status of your partners” Risk Screening: What Should We Ask? WHO
    • 34. • Ask about various types of sexual activity… • OPEN-ENDED: “Tell me about the types of sex you have” • Determine where patient meets sex and/or injection partners (e.g., venues)… • OPEN-ENDED: “Where do you meet your partners?” • Don’t forget: Internet, bars, bathhouses, circuit Risk Screening: What Should We Ask? WHAT, WHERE
    • 35. • Ask about condoms/barrier contraception… • OPEN-ENDED: “What do you do to protect yourself during sex?” OPEN-ENDED: “What’s your experience been with condom use?” • Ask about drug-injection equipment… • OPEN-ENDED: “What do you do to protect yourself when injecting drugs?” • OPEN-ENDED: “How do you know your equipment is clean?” Risk Screening: What Should We Ask? PREVENTION METHODS
    • 36. Goal – Practice the essential elements of an effective behavioral risk screening • Use open-ended questions to initiate a conversation with a patient/client • Use closed-ended questions to gather more specific information Skills Practice GATHERING THE INFORMATION
    • 37. Diagnostic Testing vs. Screening Diagnostic Testing • Goal: assess signs, symptoms, and patient complaints Screening • Goal: test apparently healthy people to find those at increased risk of disease • Patient is asymptomatic!
    • 38. Why Bother Screening? Percent of Persons with STD Who Are Asymptomatic 0 10 20 30 40 50 60 70 80 90 100 Men Women Urethra Rectum Pharynx Cervix Rectum Urethra Any Gonorrhea Chlamydia Genital herpes
    • 39. Providers’ Questions About Screening • Do I need to treat if asymptomatic? • How often? • What tests? • What anatomic sites? • Do I need to treat patient’s sex partners? • How much time? • Who pays?
    • 40. STD Screening: The First Visit • All patients • Ask about STD symptoms • Syphilis: serology • Hepatitis A/B/C status • Patients who report receptive anal sex • Rectal gonorrhea • Rectal chlamydia • Patients who report receptive oral sex • Pharyngeal gonorrhea * Check with local laboratory/program regarding availability of approved tests for pharynx/rectum *
    • 41. • Women • Chlamydia: routinely test all sexually active women ≤25 years; older women who are at increased risk • new partner, no condom use • Trichomoniasis • Gonorrhea: if at risk • new partner, no condom use • Pregnancy: ask a woman of childbearing age if she suspects pregnancy or has missed her period • Identify possible current pregnancy, interest in future pregnancy, or sexual activity without reliable contraception STD Screening: The First Visit
    • 42. • Periodic retesting for all sexually active patients • Annually for all, more frequent (every 3-6 months) depending on risk: • Multiple or anonymous sex partners • Unprotected vaginal or anal intercourse with partner with negative or unknown HIV status • Sex or needle-sharing partner with above risks • “Life changes” associated with increased risk STD Screening: Subsequent Visits
    • 43. Points to Remember • Screen more frequently rather than less • Screen at all anatomic sites exposed (rectum, pharynx, cervix, urethra) • Report of condom use does not always predict absence of STD • Condoms are not always used consistently or correctly
    • 44. Tests Recommended for STD Screening STD TEST COMMENT Syphilis Serology with nontreponemal tests (RPR or VDRL) Confirm positive result with serum treponemal test (FTA-ABS, TPPA) Trichomoniasis Saline microscopy of vaginal fluid, culture, antigen detection test Genital herpes Type-specific serology (consider) Genital herpes increases genital HIV shedding
    • 45. Tests Recommended for Chlamydia & Gonorrhea Screening GENDER TEST COMMENT Women • NAAT on cervical swab or urine • Culture or other non-NAAT assay of cervical swab • NAAT include PCR, SDA, TMA; most sensitive tests (>90% vs. 70%) • Non-NAAT include culture, unamplified DNA probe, antigen detection tests Men • NAAT of urine or urethral swab • Culture or other non-NAAT assay of urethral swab • NAAT only test performed on urine • Collect first 15-30 cc of urine stream without cleansing urethral meatus Both • Culture of rectal or pharyngeal swab (NAAT if locally validated) • Depends on reported sexual exposure at these sites
    • 46. • Recognize common syndromes and know directed work-up • Use available tools (wall charts, pocket cards, reference manuals/atlases) • Online resources: The Practitioner’s Handbook for the Management of Sexually Transmitted Disease www.STDhandbook.org Management of the Symptomatic Patient
    • 47. • CDC STD Treatment Guidelines highlight specific regimens for HIV- infected persons when appropriate www.cdc.gov/std/treatment Treatment of STD in HIV-infected persons
    • 48. 48 Pneumocystis carinii Pneumonia Prevention of Disease Initiation of Primary Prophylaxis • CD4 < 200 cells/µL (AI) • History of oropharyngeal candidiasis (AII) • CD4 percentage < 14% (BII) • History of AIDS (BII) • If unable to monitor CD4 q 3 mos. begin when CD4 200-250 cells/µL (BII)
    • 49. 49 Pneumocystis carinii Pneumonia Primary Preventive Regimen • *TMP-SMZ 1 DS po qd (AI) • TMP-SMZ 1 SS po qd (AI) • TMP-SMZ 1 DS TIW (BI)
    • 50. 50 Pneumocystis carinii Pneumonia Alternative Preventive Regimens • Dapsone 50 mg bid, or 100 mg qd (BI) • *Dapsone 50 mg qd + pyrimethamine 50 mg po q wk + leucovorin 25 mg po q wk (BI) • Dapsone 200 mg po + pyrimethamine 75 mg po + leucovorin 25 mg po q wk (BI) • Aerosolized pentamidine 300 mg q mo. Via Respirgard II( ™) nebulizer (BI) • *Atovaquone 1500 mg po qd (BI) • TMP-SMZ 1 DS po t.i.w. (BI) * Denotes regimens with efficacy in prophylaxis of Toxoplasmosis if patient intolerant of TMP-SMZ
    • 51. 51 Potential PCP Prophylaxis Regimens • Aerosolized pentamidine by other nebulization devices (CIII) • Intermittently administered parenteral pentamidine (CIII) • Oral pyrimethamine + sulfadoxine (CIII) • Oral clindamycin + primaquine (CIII) • IV trimetrexate (CIII)
    • 52. 52 Stopping Primary PCP Prophylaxis • HAART response with ↑CD4 to > 200 cells/µL for ≥ 3 mos. (AI) • Note, most observational studies showed • Most were on PI • Median CD4 at time of D/C was > 300 cells/µL • Most had VL below assay limit of detection • Median follow-up 6-16 mos. • Restart if CD4 decreases to < 200 cells/µL (AIII)
    • 53. 53 Prophylaxis to Prevent Recurrence of PCP • First Choice: • TMP-SMZ 1 DS po qd (AI) • TMP-SMZ 1 SS po qd (AI)
    • 54. 54 Prophylaxis to Prevent Recurrence of PCP • Alternatives: – Dapsone 50 mg bid, or 100 mg qd (BI) – *Dapsone 50 mg qd + pyrimethamine 50 mg po q wk + leucovorin 25 mg po q wk (BI) – Dapsone 200 mg po + pyrimethamine 75 mg po + leucovorin 25 mg po q wk (BI) – Aerosolized pentamidine 300 mg q mo. Via Respirgard II( ™) nebulizer (BI) – *Atovaquone 1500 mg po qd (BI) – TMP-SMZ 1 DS po t.i.w. (BI) * Denotes regimens with efficacy in prophylaxis of Toxoplasmosis if patient intolerant of TMP-SMZ
    • 55. 55 Discontinuation of Secondary Prophylaxis • HAART response with CD4 increase from < 200 to > 200 cells/µL x at least 3 mos. (BII) • If PCP occurred when CD4 was > 200 cells/µL, should probably continue PCP prophylaxis for life (CIII) • Restart if CD4 decreases to < 200 cells/µL (AIII) or if PCP recurred at CD4 > 200 cells/µL (CIII)
    • 56. 56 Prevention of Disease Toxoplama gondii • Initiation of Primary Prophylaxis – Toxoplasmosis IgG Antibody Positive – CD4+ < 100 cells/µL (AIII) – Preferred: • TMP-SMZ 1 DS po qd (AII)
    • 57. 57 Prevention of Disease Toxoplama gondii • Alternative Preventive Regimens • TMP-SMZ 1 SS po qd • Dapsone 50 mg po qd + pyrimethamine 50 mg po qw + leucovorin 25 mg po qw (BI) • Dapsone 200 mg po + pyrimethamine 75 mg po + leucovorin 25 mg po qw (BI) • Atovaquone 1500 mg po qd +/- pyrimethamine 25 mg po qd + leucovorin 10 mg po qd (CIII)
    • 58. 58 Primary Toxoplasmic Encephalitis • Discontinuation of Primary Prophylaxis: Once the CD4 is > 200 cells/µL for at least 3 months(AI) • Restarting Primary Prophylaxis: Once the CD4 < 100-200 cells/µL (AIII)
    • 59. 59 TE Prevention of Recurrence • First choice: • Sulfadiazine 500-1000 mg po q.i.d. + pyrimethamine 25-50 mg po qd + • leucovorin 10-25 mg po qd (AI)
    • 60. 60 TE Prevention of Recurrence • Alternative: • Clindamycin 300-450 mg po q 6-8 h + pyrimethamine 25-50 mg po qd + • leucovorin 10-25 mg po qd (BI) • Atovaquone 750 mg po q 6-12 h ± pyrimethamine 25 mg po qd + • leucovorin 10 mg po qd (CIII)
    • 61. 61 Discontinuing TE Chronic Maintenance Therapy (secondary Prophylaxis) • Patients who have completed TE treatment should remain on suppressive therapy lifelong, unless: – Asymptomatic without signs or symptoms of TE AND – Sustained (≥ 6 mo.) increase in CD4 to > 200 cells/µL following HAART (CIII)
    • 62. 62 TE Secondary Prophylaxis Chronic maintenance therapy should be restarted if the CD4 count decreases to <200 cells/µL (AIII)
    • 63. 63 MAC Prevention of Disease • Chemoprophylaxis when CD4 < 50 cells/µL • Prophylaxis first choice: • Azithromycin 1200 mg po qw (AI) • Clarithromycin 500 mg po bid (AI) • Alternative regimens: • Rifabutin 300 mg po qd (BI) • Azithromycin 1200 mg po qw + rifabutin 300 mg po qd (CI)
    • 64. 64 MAC Primary Prophylaxis • Discontinuation • When CD4 > 100 cells/µL X 3 mo. (AI) • Restart • When CD4 decreases to < 50-100 cells/µL (AIII)
    • 65. 65 MAC Secondary Prophylaxis • Should be lifelong after acute treatment unless immune reconstitution occurs. • First Choice • Clarithromycin 500 mg po bid (AI) + ethambutol 15 mg/kg po qd (AII) with or without rifabutin 300 mg po qd (CI) • Alternative • Azithromycin 500 mg po qd (AII) + ethambutol 15 mg/kg po qd (AII) with or without rifabutin 300 mg po qd (CI)
    • 66. 66 MAC Secondary Prophylaxis • Discontinuation • After completion of 12 mo. treatment, and remain asymptomatic, and have > 6 mo. increase in CD4 > 100 cells/µL after HAART • Restart • If the CD4 count decreases to < 100 cells/µL
    • 67. 67 Recommended Preventive Vaccinations • Influenzae Yearly • Tetanus booster (Td) q 10 years • Pneumococcal vaccination (repeat X 1 in 5-6 years after the 1st ) • Hepatitis A (day 0 and repeat day 180) • Hepatitis B (day 0, day 30 and day 180) • PPD yearly or if past positive, cough screening questionnaire
    • 68. Take home messages • Ask about behaviors that can transmit HIV/STDs • Use open-ended questions to enhance communication • Practice to increase comfort level with discussing risk behaviors • Screen appropriately for STDs • Remember: Most STDs are asymptomatic
    • 69. What is one thing you will change in your practice…?
    • 70. Risk screening STD screening Prevention messages Addressing misconceptions Brief behavioral interventions Referrals Partner managementWhat are your Next Steps?
    • 71. Questions?