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

CHECK IT OUT - HOT OFF THE PRESSES APRIL 2012!!








NO MORE PADS,

NO MORE DRIPS -  

TIPS TO ADDRESS AND HELP PREVENT

URINARY INCONTINENCE

Urinary incontinence (UI) in older women is an under addressed problem by patients and clinicians. In general, women's rates of UI are twice that of men and are a problem for 80% of institutionalized elder (e.g. living in nursing homes.) Because women don't bring it up (less than half in some studies) and clinicians don't screen, clinicians miss the more than one out of three women with this condition. A woman's lifetime risk is 30-60% This 'miss' is incredibly expensive. It is expensive in terms of quality of life (women have greater isolation, depression, anxiety, falls/fractures as well as bedsores and admission to long term care facilities) - but it is expensive in care delivery. Excluding cost of long term care facilities, some estimates are up to $20 billion dollars (about 1/3 are for absorbant products alone)

More than one in five young women have IU, for middle aged women the range is about 42-56 percent and in elderly the number is about 75%. With boomers, booming, we will see more and more of IU. Clinicians and patients alike need to be more aware and discuss this.

So, the breakdown of types of IU and urine leakage include functional (mobility or access reasons); stress (pressure overcomes pelvic muscles); urgency (bladder signals urination is needed and releases urine); mixed reasons and overflow (this occurs more in men than women but is often seen in neurological conditions or as a result of medications). Overactive bladders refers to bladder wall hyperreactivity that creates urgency (but leakage does not occur) It is also important to recognize that the urinary incontinence can be associated with rectal or fecal incontinence, so even if not identified by the patient, elements of rectal tone should be included in the evaluation.

Women at higher risk include - ethnicity being Caucasian, being postmenopausal; having multiparity; having a higher BMI, using hormonal therapy; having Diabetes/Sleep Apnea/CHF; having neurologic diseases (Parkinsons, MS) An interesting point I came upon is that women with two or more of the following (DM, HTN, Back Pain, Arthritis, COPD;  hearing/visual deficits; cognitive deficits; parkinsons) are also a higher risk.

The pelvic muscles are an amazing grouping of muscles. It is extremely rare in a human body to have a muscle group simultaneous contract and relax in a coordinated fashion. That's what the pelvic floor does. That is why you can void without deficating and deficate without voiding. It is also why the coordination can get confused - post hysterectomy or birth or trauma.

In older women - more than 50% have mixed UI. So it is important to assess if it is stress or urgency predominant in order to treat.  One item jumps out when reviewing contributing factors of incontinence and that is the functional status and the ability to void.

We have no practice standard to assess functional strength of pelvic muscles (and maybe we should!!) So if pelvic floor muscles are weak, women will have IU. How we hydrate and when we void are another important element.

Many people only urinate when they feel they can't hold any more urine and are very uncomfortable. The 'waiting until your eyes turn yellow' approach is NOT bladder healthy. 

Retraining on intake and urination is important in addressing incontinence and bladder diaries are used to guide this. Some women have to schedule getting up and voiding in their daily calendar to remind them and that is one strategy that can work. Another important piece of information about hydration is that is you are dehydrated, concentrated urine is an irritant and can contribute to the sense of urgency!

A reversible element a clinician must screen for is urinary infection (taking into consideration that asymptomatic bactiuria should not be treated.) Functional status is also important. If gait is unsteady or arthritis is severe and transfers take a long time, incontinence can results. If there are sensory deficits (vision, hearing) o if it takes far longer to get to the toilet than is planned, women can have leakage. Sometimes, soft cognitive deficits (which can be hidden) are the reason why strategies to address incontinence don't work.

Medications also play a role - these include caffeine and alcohol as well as diuretics.
As seen in the chart, multiple medications can have a urinary effect. It is reasonable to consider that if a patient has polypharmacy, she should be screened for incontinence.

CHECK IT OUT - HOT OFF THE PRESSES APRIL 2012!! Info for clinicians and consumers here: 



http://www.effectivehealthcare.ahrq.gov/ehc/products/169/1030/ui_cons_fin_to_post.pdf





Advocating For Patients

Two weeks ago, on April 7th 2011, I attended the Planned Parenthood lobby and rally day in Washington DC. It was my very first real use of the U.S. political system outside of the utilization of my right to vote. I was nervous and (albeit embarrassed to admit) quite under educated about the true politics of “women’s health”. As an undergraduate student who was extremely involved in women’s health and education I used Planned Parenthood many times as a resource for the education and medical health of the women I worked with on campus. Thus, when I saw the flyer for the rally I contacted the coordinator that night to sign up.

In true over-worked, sleep-deprived med student fashion I debated backing out last minute for fear the rally would cut into my precious study time for our upcoming exams. Somehow, however I overcame the “med school mentality” and hopped on a bus the next morning with 30 other PP supporters ready to show Washington how important the Planned Parenthood organization is to this nation.

PP coordinators had packed the day full of lobby’s with Pennsylvanian senators including an all day rally on the national mall lawn. There were people from all walks of life who had come out to support the cause. It was truly inspiring to see the medley of medical providers, little children, senators, Catholics, atheists, mothers, and fathers all out in support of women’s health.


During the lobby sessions I heard both sides of the PP budget cut battle. Senators who supported PP were happy to see us and could not stop thanking us for being there for this important moment in the history of women’s health. Senators who opposed PP, however, showed sentiments at both ends of the spectrum, from understanding and speculation of facts about the organization to total disinterest.

While not every lobby session was able to convert a senator, there were plenty of lives changed by the day’s activities. I met a man at the rally who had come all the way from Tennessee, missing school and work, to share his voice with congress and keep his sister and future daughters safe and reproductively healthy. I can’t tell you how many locals stopped to talk to him as they were riding by on their bicycles and how many women came up to thank him for coming.


This brings to light the point that, while we as health care professionals do work extremely hard every day to protect the health of our patients in our offices and on the wards, there are other important educational and health promoting opportunities out there that can make us even better at what we do, so we should choose to engage in them.

Sometimes it takes being on the front lines of the fight to really realize the true meaning of why were fighting at all.

For more info on Planned Parenthood/how to get involved CLICK HERE
For info regarding the budget cuts involving PP visits CLICK HERE

Blog post by Nicole Perry, MS II