HIV risk

Helping Women Understand Their True HIV Risk

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To know a woman’s real risk for HIV, you have to know more than her sexual behavior and history of sexually transmitted infections. You also have to know about her partner and the background HIV prevalence where she lives, an expert said here at the 16th European AIDS Conference.

This information can identify the invisible vulnerable: women who are at risk of acquiring HIV not because of their own behavior, but because of the circumstances of their lives, said Nneka Nwokolo, MD, from Chelsea and Westminster Hospital in London.

“Women need to accurately perceive their risks,” she told the packed audience, and “healthcare workers are in a unique position to help them do that.”

In much of the world, PrEP guidelines are aimed at obvious risks: behavior by the patients themselves that can make them vulnerable to HIV. Often this includes men who have sex with men, sex workers, people with many sexual partners, and people who do not use condoms. This might be why some PrEP guidelines, such as those in Switzerland, don’t include women at all.

In European guidelines, “there’s very little guidance on when to recommend PrEP for women,” Dr Nwokolo said.

In the United States, heterosexual women at high risk for HIV are addressed in the PrEP implementation guidelines. They recommend that physicians determine risk by asking a woman if she has a partner living with HIV, has multiple sex partners, has a history of inconsistent or nonexistent condom use, has engaged in sex work, or has had a recent bacterial sexually transmitted infection.

But the guidelines do not mention risks to a woman’s partners.

Partner Imperil

“There’s this idea, and I think it’s very prevalent even among healthcare providers, that certain kinds of women can’t catch HIV,” Dr Nwokolo told Medscape Medical News. “Why are we ignoring the fact that there are all these women who don’t fit into the traditional risk categories — they are not from a black African background, not intravenous drug users, not having sex with a lot of people — and they have HIV?”

 To illustrate the hidden risks women face, Dr Nwokolo presented several composite case studies during the Women Against Viruses in Europe (WAVE) workshop.

In one, she described Precious, a 35-year-old married woman with two children who lives in London but is originally from Nigeria. She only has sex with her husband and they do not use condoms. She tested negative for HIV 7 years ago when she had her last child. Her sexually transmitted infection status is unknown.

She also described Maria, a 25-year-old, white, heterosexual woman who lives in London. She has had six casual partners in the previous 6 months and rarely uses condoms. She’s had chlamydia in the past and has genital herpes.

“So who would be a good candidate for PrEP?” Dr Nwokolo asked the audience. Attendees picked up a small electronic device and voted. No one thought only Precious ought to receive PrEP, about one-quarter of the audience thought Maria should receive PrEP, and about one-third thought both could be candidates.

Because of the context in which they are having sex, Precious might be at greater risk for HIV than Maria, Dr Nwokolo explained.

“It’s important to recognize that many partners — male partners — of black African women, who make up the majority of women who have HIV in the United Kingdom, have other partners,” she said. “So the major risk for HIV acquisition for black African women, certainly in the United Kingdom, is their male partners.”

These women are doubly compromised by circumstance, she added. Not only might their partners be having sex outside the relationship, the women themselves might feel they can’t demand condom use or decline sex.

These women “may not think about their risk of HIV because they don’t perceive that they have any control over that risk. So they put it to the back of their minds and just hope for the best,” she pointed out.

Where Sex Occurs

Maria, who has all the individual risk markers for HIV, might not be at risk, at least not in London.

HIV acquisition is “actually quite low” among heterosexuals in the United Kingdom, Dr Nwokolo reported.

However, if Maria lived in the Ukraine, where HIV rates are 20% among heterosexuals who inject drugs, she might be a good candidate for PrEP. And if she lived in a region with a great deal of undiagnosed and untreated HIV, her behavior could put her at high risk.

In the United States, guidelines take such risks into account, and state that “clinicians should consider the epidemiologic context of the sexual practices reported by the patient,” Dr Nwokolo explained.

This is important because some areas, particularly the Southern states, have very high rates of HIV and of late diagnosis, meaning that people can be dating and having sex without realizing they are infected with the virus.

Talking About Risk

The presentation was thought-provoking and really shows us the limitations of our own perception of patient risk, said Karoline Aebi-Popp, MD, from the University of Bern in Switzerland. “Doctors need to take a thorough sex history, including not only the number of sexual partners, but also their sex practices and where they are from.”

But the suggestion that women from African backgrounds are more likely to acquire HIV from a single sex partner who has other partners went a bit too far for Annette Haberl, MD, from Frankfurt University in Germany, who said she sees a lot of couples of African origin.

It could be that on an individual basis, Precious might be in a situation where she needs PrEP, “but I don’t know if it’s so different from couples from other origins,” Dr Haberl told Medscape Medical News.

The goal, said Dr Nwokolo, is not to convince a woman like Precious that she needs PrEP. It is to start the conversation in a nonstigmatizing way and to introduce the idea that PrEP is for women, too.

If a woman sees her partner going out with his other girlfriend, it might prompt her to think about PrEP, she explained.

“It’s up to us as healthcare providers to encourage women to know their risks and support them in accessing PrEP,” she added.

Oral Sex and HIV Risk

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Fast Facts

  • There is little to no risk of getting or transmitting HIV from oral sex.
  • Other STDs and hepatitis can be transmitted during oral sex.
  • Latex barriers and medicines to prevent and treat HIV can further reduce the very low risk of getting HIV from oral sex.

Oral sex involves using the mouth to stimulate the penis (fellatio), vagina (cunnilingus), or anus (anilingus).

Risk of HIV

The chance an HIV-negative person will get HIV from oral sex with an HIV-positive partner is extremely low. However, it is hard to know the exact risk because a lot of people who have oral sex also have anal or vaginal sex. The type of oral sex that may be the riskiest is mouth-to-penis oral sex. But the risk is still very low, and much lower than with anal or vaginal sex.

Though the risk of HIV transmission through oral sex is low, several factors may increase that risk, including sores in the mouth or vagina or on the penis, bleeding gums, oral contact with menstrual blood, and the presence of other sexually transmitted diseases (STDs).

Risk of Other Infections

Other STDs, such as syphilis, herpes, gonorrhea and chlamydia, can be transmitted during oral sex. Anilingus can also transmit hepatitis A and B, intestinal parasites like Giardia, and bacteria like E. coli.

Reducing the Risk

Individuals can further reduce the already low risk of HIV transmission from oral sex by keeping their male partners from ejaculating in their mouth. This could be done by removing the mouth from the penis before ejaculation, or by using a condom.

Using a barrier like a condom or dental dam during oral sex can further reduce the risk of transmitting HIV, other STDs, and hepatitis. A dental dam is a thin, square piece of latex or silicone that is placed over the vagina or anus during oral sex. A latex condom can also be cut length-wise and used like a dental dam.

The risk of HIV transmission through oral sex is even lower if the HIV-negative partner is taking medicine to prevent HIV (pre-exposure prophylaxis or PrEP) or the HIV-positive partner is taking medicine to treat HIV (antiretroviral therapy or ART) and is virally suppressed.

Depo-Provera May Hike HIV Risk in Women

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Meta-analysis shows increased risk versus nonhormonal or no contraception.

Increased rates of HIV infection were seen among women using depot medroxyprogesterone acetate (Depo-Provera or DMPA), whereas other methods of contraception including oral contraceptive pills or norethisterone enanthate (Net-En, an injectable progestin steroid) did not, according to a new meta-analysis.

Pooled data from 10 studies conducted in sub-Saharan Africa showed DMPA use was associated with a 40% higher HIV risk (hazard ratio 1.40, 95% CI 1.10-1.57) versus nonhormonal or no contraception, whereas 10 studies examining oral contraceptive pills (pooled HR 1.00, 95% CI 0.86-1.16) and five studies examining norethisterone enanthate (pooled HR 1.10, 95% CI 0.88-1.37) were not associated with increased HIV risk, according to Lauren Ralph, MPH, division of epidemiology of the School of Public Health at the University of California at Berkeley, and colleagues.

After over 2 decades of research, possible links between DMPA and increased incidence of HIV has been a hotly debated issue, the authors explained in The Lancet Infectious Diseases. But despite their findings, they stopped short of calling for a ban on this form of contraception.

Ralph and colleagues wrote that controversy over DMPA has already caused some sub-Saharan African countries to consider withdrawing this form of birth control from family planning programs, which would leave women in these countries with fewer contraceptive options.

“The moderate elevation in risk for DMPA is not enough to justify a complete withdrawal of DMPA from women’s contraceptive options in most settings,” said lead study author Ralph in a press release. “This is likely to lead to more unintended pregnancies and their associated maternal and infant morbidity and mortality.”

For the meta-analysis, the authors reviewed 26 studies, searching PubMed for the terms “hormonal contraception,” “HIV/acquisition,” injectables,” “progestin” and “oral contraceptive pills.” The review included articles published in English after Dec. 1, 2011, as well as relevant abstracts from International AIDS Society meetings and the Conference on Retroviruses and Opportunistic Infections from 2011 to 2014.

Of these, 12 studies were designed to examine the link between hormonal contraception and HIV. The remaining studies sampled women from the general population at health centers and family planning clinics. The median age of participants in the studies ranged from 25 to 40 years.

The link between DMPA and HIV risk was also seen in these general population studies (pooled HR 1.31, 95% CI 1.10-1.57). But because the 10 studies from the primary analysis were associated with a greater level of heterogeneity (I2=42.5%, CI 0%-72%) than the general population studies (I2=27.3%, CI 0%-67%), most results of the primary studies were considered not applicable to the general population.

Two of 12 studies in the primary analysis examined high-risk populations, such asserodiscordant partners and commercial sex workers. Those two high-risk groups were associated with the greatest increases in HIV risk (HR 3.93, 1.37-11.2, and HR 1.73, 1.10-1.57, respectively). However, the high heterogeneity (I2=54.0%, CI 0%-88.7%) between these two studies meant their data couldn’t be pooled, the authors wrote.

Ralph told MedPage Today that there were only “a limited number” of studies that met the criteria for analyzing populations of high-risk women. “Thus, there remains uncertainty for this important subgroup of women,” she said.

While some of these findings may not be statistically significant, they may have clinical significance, including in developed countries. Diane Harper, MD, MPH, MS , professor, department chair for family and geriatric medicine at the University of Louisville School of Medicine in Kentucky, who was not involved with the analysis, suggested that it could help primary care and ob/gyn physicians who treat high-risk patients in the U.S., including serodiscordant couples, commercial sex workers, and drug addicts.

“I think there are valid populations in the U.S. for which we do need to pay attention and I think that the study very clearly says to me that there are so many other options of birth control that do not have this increased risk of HIV,” said Harper. “In these populations we should not be using Depo-Provera, that it just really is not a wise clinical choice.”

 One limitation the authors addressed was that the primary analysis was mainly on observational studies as opposed to a randomized, controlled trial.

In an accompanying editorial, Christopher J. Colvin and Abigail Harrison, division of social and behavioral sciences of the School of Public Health and Family Medicine at the University of Cape Town in South Africa, called the environment surrounding any proposed trial about DMPA and HIV “polarizing” and arguments on both sides “rhetorical” and “generic.”

Colvin and Harrison wrote that studies such as this “synthesize and evaluate the existing observational data and identify many ways in which further modeling, epidemiological studies, behavioral and clinical research, and basic biological silence could work synergistically to increase our knowledge.”

Harper saw this limitation as one of the strengths of the study.

“What makes the paper so strong is that it has been able [to get these results] without increasing costs and doing another trial and putting more women at risk for HIV and repeating this in another population,” she said.

Another limitation cited by the authors was potential “confounding effects of misreported condom use,” especially since “many study populations were drawn from HIV prevention trials in which condom use is strongly encouraged and women may feel pressure to report socially acceptable behaviors,” they wrote. But they added that over-reporting of condom use was likely the same in all groups studied, including the reference samples.