Are we PREPPED for PrEP?

PrEP is short for Pre-Exposure Prophylaxis of HIV to prevent transmission of disease. Recent studies have demonstrated that a combination medication tenofovir disoproxil fumarate plus emtricitabine (TDF/FTC) and the FDA has approved it's use.  Our own, Infectious Disease clinician, Erika Aarons, RN, CRNP, MSN was on the FDA Advisory panel that evaluated and voted upon approval of this new medication. Read the article here. The FDA resport is here.

This news is exciting in that this the first medication combination identified in 30 years that if taken regularly, can result in a 90% reduction in risk of an HIV negative partner acquiring the disease from their HIV positive partner. So, in serodiscordant partners (one with HIV/AIDs, one not) this is an incredible breakthrough.

Here's a few important issues:
*Medicine only was effective at that rate if taken every single day - those who did not have sufficient medication in their blood did not have the same result
*HIV transmission in serodiscordant couples occurs outside of a couple in 25-30% of cases (Donnell 2010; Cohen 2011)
*Estimated cost of daily therapy is likely to be in excess of $10,000/year.
*Lifetime costs (2010 numbers) for HIV treatment is $379,668 (excluding reproductive health related issues)

So PrEP is amazing scientifically, yet does it remain a wish versus a reality? This is a great example of the challenges faced when we address paying for prevention. I wonder how expensive or inexpensive an intervention would need to be to get support to prevent Diabetes?

HIV at the onset was (fairly) quick and (mostly) deadly disease - with the onset of HAART, HIV can become a chronic disease. At the beginning when there was only one or limited agents, medical science had not demonstrated how sneaky the HIV virus can be. It is now known that to combat disease, people often need three types of anti virals to keep the disease from changing and becoming resistant. I think of it as making a corral for a horse with three fences - keeping it within the triangle. If we use one or two or infrequently use the medicines, HIV learns quickly (becomes resistant) and makes the medicine ineffective.  Regular medicine use is challenged for any medical illness - HIV is no different. But there are some difference with HIV - CDC estimates that 1 in 5 people have disease and are unaware. So in place where there is a lot of HIV, people ages 11 and up and all people sexually active should have HIV screening as part of their routine evaluation. In the Philadelphia Ujima project, we talk about "Know Your Numbers, Own Your Health."

Perhaps next steps need to be more medical advances resulting in more medicines that decrease the cost of transmission preventing medicines?

Kaiser Family Foundation. www.statehealthfacts.org. Data Source: Centers for Disease Control and Prevention, Division of HIV/AIDS Prevention-Surveillance and Epidemiology, Special Data Request; 2010

Donnell D, Baeten JM, Kiarie J, et al. Heterosexual HIV-1 transmission after initiation of antiretroviral therapy: a prospective cohort analysis. Lancet 2010;375:2092-2098

Cohen MS, Chen YQ, McCauley M, et al. Prevention of HIV-1 infection with early antiretroviral therapy. N Engl J Med 2011;365:493-505

Kaiser Foundation 2012 Fact Sheet on Women with HIV here

Hot Off the Press  Aaron, E., Cohen D. Pre-exposure Prophylaxis for the Prevention of HIV

Transmission to Women in the United States AIDS 2012, 26:
000–000

Planning and Intention - A bit more about health and reproduction.

 

So concluding our journal club today where we had an interesting discussion about the ACES study (adverse childhood experiences study) and unwanted pregnancy (Dietz, P, Spitz, A. et al. Unintended Pregnancy Among Adult Women Exposed to Abuse or Household Dysfunction During Their Childhood. JAMA.1999: 282:1359-1364.),  I wanted to add a bit more on the unintended pregnancy issue.

One of the things we discussed was the nuances of unexpected and unwanted in terms of pregnancy. So here's some data from the National Health Statistics Reports July 24, 2012, Intended and Unintended Births in the United States:P 1982-2010. This study looked at data regarding the attitudes of women who had live births.

*Percentage unintended at time of conception 37% in the group evaluated.
*Group that demonstrated significant decline since 1982 = married, non-Hispanic white women.
*Disparity seen between them and unmarried women, black women or women who have educational or economic disadvantage.
*Intended births and teen mothers - only 23% were intended (2006-2010), therefore 4/5 unintended.
Of interest, the authors talk about unintended births as being measured as intended (meant to get pregnant); mis-timed (wanted to, but not now) and unwanted (not wanted to get pregnant or not wanted the infant in the birth order it came into.) They also talk about an 'alternative' definition breaking down the term unintended birth into two elements - action (pregnant/not) and affect or emotional interpretation (wanted or not) They felt that the data was concordant with either evaluation.
It does make you wonder though if the composite effect blurs out subgroup differences here.

Particularly interesting was the authors mention that
*Women in poverty (below 150% ) make up 56% on unintended births and only 35% intended
           (supporting the previous blog mention of poverty as a marker for unplanned births)
*More than one in five intended pregnancies and births (22.8%) are in teenage (ag 15-19) mothers. (birth rate 40.2 births/1000 in 2008. ) If we could disrupt factors such as poverty and influence the situation where unintended births to teens was postponed until age 20, we could have teen birth rates drop for 11% of all births to 4%!

Here's an interesting video about the benefits of contraception from the Guttmacher Institute

Working with WOAR to Educate Teens on Safety in Sexual Health

WHEP ELECTIVE: Women’s Health in the Community

For my Women’s Health in the Community elective, I reached out to the organization Women Organized Against Rape (WOAR). WOAR provides counseling services, advocacy for victims of sexual violence, and educational programs to stop sexual and domestic violence and bullying. As a future gynecologist, I am aware of the dangers of intimate partner violence and sexual assault, and I wanted to better educate myself on the topic.

Once I got in touch with Teresa White-Walston, Director of Educational Services, we discussed WOAR’s educational programs and how I could contribute. Teresa works closely with local schools, teaching teens about bullying, self-esteem and character building. She saw the need for sexual health education for her students, as many of them become involved in sexual activity before they are ready and, often, are misinformed by their peers on the topic.

I developed a lecture geared toward middle school girls where I covered basic female reproductive anatomy, facts about teen sexual activity, sexually transmitted illnesses (STI) risks and the realities of teen pregnancy. Researching, alone, for this presentation was an eye-opening experience! Here are some interesting facts that stood out to me (AND my students):


-43% of teenage girls and 42% of teenage boy have had sexual intercourse, but only 33% are currently sexually active (CDC Youth Risk Behavior Survey)


-15-24 year olds account for only 25% of the sexually active population in US, but are nearly 50% of all new STI’s diagnosed annually (CDC)


-In 2009, more than 400,000 girls aged 15-19 years old gave birth (CDC)


-50% of teen moms have a high school diploma by age 22, compared to 90% of teenage girls who don’t give birth (CDC)


As I gave my lecture to classrooms of curious 6th, 7th, and 8th graders, I could see that many of the things I taught were completely new to them. First of all, most of the girls had no idea what body parts they had or what their proper names are. Secondly, my students were surprised to see that only 33% of teens are sexually active. Based on the media and schoolyard gossip, they thought the number was closer to 80 or 90-percent! I’m glad I could show them otherwise. The information I gave the students about STI’s seemed to hit the kids from left field. Sure, they’ve heard of HIV and how bad it is. But they didn’t know about all of the other STI’s or how many people have them. I shocked many when I informed them that some sexually-transmitted infections are life-long and could have serious consequences like cancer and infertility. As for the pregnancy part of the lecture, it seemed like each of the students knew someone who got pregnant and gave birth before she was ready. I ended each lecture with a discussion on the magnitude of engaging in sexual activity, the importance of waiting until one is ready, and what a responsible teenager should do when she is.

I hope the information I gave these girls empowered them to stand up against peer pressure and wait until they are truly ready and fully educated to be sexually active, as there are many consequences to consider and protect against. I hope I prepared them with a good foundation on reproductive health and safety. In the end, it is each girl’s responsibility to protect herself, and I hope these girls rise to the challenge to take care of her health and future.


Teresa was terrific. In addition to teaching, she took the time to give me some training for crisis counseling. We discussed the issues surrounding sexual and domestic violence and how to empower victims. She even took me to the Philadelphia Sexual Assault Response Center, so that I could see where a rape victim is treated and what she must go through.


Unfortunately, my time with WOAR has come to an end. However, Teresa and the schools I visited would love to have more Drexel students come through and do similar work to what I had been doing. As medical students, we offer more medical information than Teresa and her volunteers can give to their students, and there is a great need for strong role models at these schools. Please consider working with WOAR either through a Women’s Health elective or as a volunteer. You will be able to reach out to many young girls who need your expertise, and you will probably learn a few things along the way as well. If you are interested, email WHEP at mnickens@drexelmed.edu. To learn more about WOAR, check out their website: www.woar.org.

Submitted by Jennifer Lee, Class of 2012

Distress and Sexual Health

Female Sexual Dysfunction includes disorders of desire; arousal; orgasm and sexual pain. Desire disorders include hypoactive sexual desire disorder and sexual aversion disorder. To make the diagnosis of Hypoactive Sexual Desire Disorder two key elements must be in place (hypoactive sexual desire and marked distress - personally or interpersonally as a result of the condition) Additionally, we exclude depressed desire that is due to medications, substances or general medical conditions or those due to another Axis I disorder.
How prevalent a problem is this? Research tells us that there is a range 9-26% and a mean of about 10% of women with HSDD.(Leiblum)- this include premenopausal and postmenopausal women.
Is this an isolated sexual health concern? No - data shows that women with HSDD are generally less healthy than their non-HSDD counterparts. They have less vitality, more bodily pain, poorer physical, social, emotional functioning. It is likely that women will come into the office with diffuse feelings of body aches and feeling unwell as part of their presentation. Sexual health affects both the physiology and psychology of women.

What's the physiology of sexual function in women? The physiology is that of central neuroendrocrine function matched with peripheral intact anatomic and vascular function. Centrally - Desire is augmented by excitation that is driven by dopamine, norepinephrine, testosterone, estrogen and inhibited by serotonin and prolactin. Arousal adds nitric oxide and acetycholine with the above factors and has the same inhibitory ones. Orgasm has oxytocin as an excitatory hormone. External genitalia needs estrogen, testosterone and progestin to function. Vasocongestion needs working and responsive vasculature- thus nitric oxide, norepinephrine, cholinergic fibers and prostaglandin E are excitatory with serotinin as inhibitory.
How do these factors play a role in diagnosis and interventions? Anything that decreases dopamine (or increases serotinin) will have adverse sexual side effects. Anything that lowers testosterone - like hyperprolactinemia, opiates or menopause - will also lower sexual functioning.
What diseases can decrease desire or arousal? Chronic diseases such as Diabetes, Thyroid disease, Cardiovascular Disease, Depression and Renal Failure. Other illnesses - adrenal disease, head injury, neurologic diseases including hyperprolactinemia, bilateral oophorectomy and incontinence can do so as well. (Basson)

What medication or substances adversely effect sexual health? Perhaps most well known are antidepressants that block reuptake of serotinin (SSRIs; SNRIs) Other psychiatric medicines such as benzodiazepines; antipsychotics; mood stabilizers and anti epileptics can do so. Less well known, perhaps, are H2 blockers, NSAIDs, oral contraceptive, thiazide diuretics, non-selective beta agonists. Additionally narcotics and other hormones (estrogen, progestins, anti androgens, GnRH agonists) are involved (Clayton, Kingsberg.) It is important, up front, when we prescribe these medications to make patients aware of the potential side effect!
How do I screen? If you wait for most women to ask about this, there are numerous reasons why they won't ("It is appropriate to talk to the doctor about this?" "How do I discuss this?""Maybe there isn't anything I can do?") The literature shows that docs have to ask and patients want us to. (Stengel) In the ideal, we should include sexual health screening at least on annual exams. There are  tools and surveys you can use: Brief Sexual Symptoms Checklist for Women (Hatzichristou); Decreased Sexual Desire Screener (Clayton); Female Sexual Distress Scale - Revised (DeRogatis)

What can we do about it? First off, sexual health tracks with physical health. So many of the same lifestyle issues we discuss (regular exercise, healthy nutrition, weight loss, smoking cessation, minimizing intake of alcohol) all help sexual health. There are some medications that are used - though none currently FDA approved (and there others in the pipeline to watch for) but most patients are likely to benefit from counseling (education, personal, couples, cognitive behavioral, mindfulness, etc.), lifestyle changes and medication.

The most commonly used medication is bupropion (which increases dopamine and NE)- which is used for non-depressed women with HSDD (it can also be used with depressed women, as well) Testosterone has been used - and a gel is in the pipeline. A melanocortin receptor agonist (this stimulates dopamine) is also in the pipeline.

It seems odd that few people would perceive erectile dysfunction (and associated distress) as 'not real' or not a significant health concern, yet there are those who feel that female sexual dysfunction is somehow different. Women may be more complex, physiologically and psychologically when it comes to sexual health. Remember, if a woman with diminished desire isn't bothered by it, then neither are we! But for many women, sexual health is part of overall health. Physicians need to learn about this health issue, develop skills in communication about sexual health and ask patients on a regular basis. By doing this, we can uncover health concerns that may appear to be 'playing in the background' - yet are the health burden at the heart of the problem.

RESOURCES
Leiblum SR, et al. Menopause. 2006;13:46-56.
Basson R, Schultz WW. Lancet. 2007;369:409-424.
Clayton A, Hamilton D. Psychiatr Clin N Am. 2010;33:323-338.
Kingsberg S, Janata J. Urol Clin N Am. 2007;34:497-506.
Stengel C. Martinez L. http://twshf.org/survey.html. Accessed August 2010.
Hatzichristou D, et al. J Sex Med. 2010;7:337-348
Clayton A, et al. J Sex Med. 2009;6:730-738
DeRogatis L, et al. J Sex Med. 2008;5:357-364