Transcript Prevention Is… - Kaiser Permanente

HIVI
HIV Initiative of Kaiser Permanente and Care Management Institute
Teaching Physicians to Talk about Sex, Drugs, and Maybe
Rock
Or…’n Roll.
Can We Do for Prevention What We
Have Done for Treatment?
Enid K Eck, RN, MPH
Michael Allerton, MS
Background and History
Lets Review
Treatment Quality Measures
Time to Care: > 90% within 90 days
Maximal Viral Control: > 91%
Consistency of Care: 84%-91% HIV RNA “viral load”
& CD4 on time
Co-Morbidity Testing: 94% tested for HCV
Prenatal HIV Screening: 81%->95%
Early Detection: 25.8% CD4 <200 upon Diagnosis
Mortality Rate: <1.0-1.6%/year (3.4% outside KP)
These are KP program-wide statistics.
Treatment Quality Measures
BUT MOST IMPORTANT:
These Result Do Not Differ By Race,
Gender, or Ethnicity
Within Kaiser Permanente
Across All Regions
What If…
We could do the same for Prevention?
BUT…
What do we really know about prevention?
Prevention Is…
HARD!!!!
Invisible when successful
Catastrophic when fails
Not an absolute
Variable over time.
Prevention Is…
A CONTINUUM
Success
Failure
Prevention Is…
A CONTINUUM
Success
Vaccination
Smallpox, polio…
Failure
Prevention Is…
A CONTINUUM
Success
Failure
Cure
Vaccination
Smallpox, polio…
TB, Syphilis
Prevention Is…
A CONTINUUM
Success
Failure
Cure
Vaccination
TB, Syphilis
Smallpox, polio…
PrEP
Malaria…
PEP
Bacterial Meningitis
Prevention Is…
A CONTINUUM
Success
Failure
Cure
Vaccination
TB, Syphilis
Environmental
Smallpox, polio…
PrEP
Water Treatment, Closed
Sewers, Mosquito abatement…
Malaria…
PEP
Bacterial Meningitis
Prevention Is…
A CONTINUUM
Success
Failure
Behavioral
Cure
Vaccination
Hand Washing, Abstinence, Condoms
TB, Syphilis
Environmental
Smallpox, polio…
PrEP
Water Treatment, Closed
Sewers, Mosquito abatement…
Malaria…
PEP
Bacterial Meningitis
Prevention Is…
A CONTINUUM
Success
Failure
AND A CORRELATION
Passive
Active
Prevention Is…
A CONTINUUM
Success
Failure
AND A CORRELATION
Passive
Active
AND FINALLY
Harm Elimination
Harm Reduction
What’s New?
TLC+
National Prevention Guidelines
Three Steps to Success
Requirement One: Start Talking
Requirement Two: Talk Some More
Requirement Three: Start Talking to Your Colleagues
Start Talking
The Need:
New infections each year
40,000-56,000
People living with HIV/AIDS 1,039,000 – 1,185,000
People with HIV/AIDS not
in care
42 – 59%
People with HIV who don’t
know they’re infected
(estimate)
24 – 27%
These are US national statistics.
Start Talking
But do you know WHO to talk to?
Women as a Share of New AIDS Diagnoses
27%
27%
2000
2004
20%
13%
8%
1985
Note: Data are estimates.
Sources: CDC, Data Request, 2006.
1990
1995
Reported HIV Cases Among Teen Girls
and Younger Women, 2003
Females
Males
50%
50%
13-19
63%
37%
20-24
71%
29%
25 and older
Notes: Data based on person’s age at diagnosis, from 41 areas with confidential
name-based HIV surveillance for adults and adolescents in 2003.
Source: CDC, HIV/AIDS Surveillance in Adolescents, L265 Slide Series Through 2003.
HIV Spread Primarily Through Sex,
Increasingly Heterosexual
3% Heterosexual
13%
Other
31%
Heterosexual
19%
IDU
65%
MSM
42%
MSM
6%
Other
1985
Notes: Data are estimates. May not total 100% due to rounding.
Sources: CDC, Presentation by Dr. Harold Jaffe, “HIV/AIDS in America Today”,
National HIV Prevention Conference, 2003; CDC, HIV/AIDS Surveillance Report,
Vol. 16, 2005.
22%
IDU
2004
Proportion of AIDS Cases,
by Race/Ethnicity, 1985-2004
Percent of AIDS Diagnoses
70
60
African American
50
40
White, non-Hispanic
30
20
Latino
10
Asian/Pacific Islander
American Indian/Alaska Native
0
1985
1987
1989
Note: Data are estimates.
Source: CDC, Data Request, 2006.
1991
1993
1995
1997
1999
2001
2003
2004
Start Talking
But to WHO?
Start Talking
But to WHO?
Start Talking
It is strongly recommended that clinicians routinely
obtain a thorough sexual and substance use history
from all patients > 12 years of age to assess risk
behaviors and stratify for appropriate testing.
Start Talking
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Anyone who acknowledges having had unprotected sexual activity
Patients with multiple sexual partners
(serial monogamy counts…)
Patients with current or previous STI
Patients with sexual partners with current or previous STI
Patients with history of recreational or intravenous drug use (IDU),
particularly methamphetamines
Patients with chronic alcohol abuse
Patients with hepatitis B or hepatitis C
Men who have exchanged money or drugs for sex, who have been
incarcerated, or who have had sex with other men.
Women who have exchanged money or drugs for sex.
Start Talking
But What Do I SAY?
Start Talking
ASK…
(It’s not so much what you are saying
as much as what you are listening too…)
Start Talking
For All Patients:
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“I’d like to ask you some questions related to your sexual health that I ask all
my patients.”
Are you sexually active? If no, have you ever had sex?
How many lifetime sexual partners have you had? Timeframe?
Are/were your sexual partners men, women, or both?
Did/do you have vaginal, anal, and/or oral sex?
Have you ever been diagnosed with an STD or thought you might have one?
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Have you ever been tested for HIV or advised to be tested?
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Has your partner?
Has your partner?
How do you protect yourself from STIs and HIV?
Start Talking
For Married Members and Couples
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“I’d like to ask you a few questions related to your sexual health.
These are questions that I ask all my patients regardless of the type
of relationship they are in.”
Do you or your partner have sex with other people outside of your marriage?
How do you protect yourself from STDs and HIV?
Have you or your partner ever been diagnosed with an STD?
Have you or your partner ever been tested for HIV?
How long have you been married/together?
Before you were a couple did you have sex with other people?
If yes, with men, women, or both?
Before you were married, did your partner have sex with other people?
If yes, with men, women, or both?
Talk Some More
Screen:
It is strongly recommended that patients be
appropriately screened for HIV infection and STI
based on their individual risk assessment.
Talk Some More
Screen:
Screen and promptly treat all identified individuals > 12 years
of age at risk sexually active adults and adolescents for the
following STIs –
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Human immunodeficiency virus (HIV)
Neisseria gonorrhea
Chlamydia trachomatis\
Syphilis
Hepatitis B
Hepatitis C
Trichomoniasis (for women)
NOTE: Evidence suggests the presence of other STIs, including herpes simplex,
increases the risk of HIV transmission and acquisition.[1]
[1] From USPSTF-- ‘Based on a paucity of supporting evidence, herpes simplex
virus (HSV) serology testing is not routinely recommended.’
Talk Some More
Intervene:
Patients engaging in high risk activities but recently tested negative
for HIV are the most important population to target for evidence
based prevention strategies and will yield the greatest impact on
HIV transmission rates. Care must be taken to keep the negative
test from reinforcing the risk behaviors, or being cited as “proof” by
the patient that they are not at risk.(36) Untreated depression has
been associated with high risk behavior in gay men(37, 38), and
persistent substance use contributes to transmission both as a
dis-inhibitor to safer practices and as a direct transmission route
in inject drug use.
Talk Some More
Intervene:
Talk Some More
Intervene:
Ways to assist the patient in creating a personalized plan for HIV risk
reduction:
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Avoid language that may be insensitive to patient’s background and which may
impair further disclosure
Motivate patients for behavioral change
Offer latex condoms and information on appropriate handling and lubricants to all
sexually active persons
Counsel regarding drug use, including alcohol, methamphetamine, and injection
drug use
Remind that Oral contraceptives do not prevent HIV or an STI.
Advise to seek prompt treatment for any suspected STI or known exposure to an
STI even in the absence of symptoms.
Reassess sexual practices at future visits and plan for repeat testing as appropriate
Avoid false reassurance
Start Talking to Your Colleagues
Roll Out The National Guideline:
Your Role