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Lecture 12

Psychology 2075 Lecture 12: Lecture 13 Special Focus on HIV
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Department
Psychology
Course
Psychology 2075
Professor
William Fisher
Semester
Fall

Description
Lecture 13 Special Focus on HIV/AIDS HIV/AIDS: The Ultimate STI • Transmitted by most pleasurable human activity • Transmitted by behaviour required for species survival • Keeps host healthy and infectious for 5-10 years HIV/AIDS 101 • GRIDS “discovered” by CDC clerk in Atlanta in 1981 o Noticed tht there is some awareness of a gay plague that shuts down gay men’s immune system • HIV, the virus that causes AIDS, discovered in 1984, and an HIV antibody test becomes available (these tests are still used today) o Tests only certain 3 months after infection – body needs to produce enough antibodies ▪ Now it is closer to 3 weeks • HIV infection results in immune system destruction, opportunistic infection with an “AIDS defining condition,” and death occurs nearly always within 5-10 years o HIV invades the cells of the immune system which then turn into factories to produce more HIV o The first opportunistic infections notices were Kaposi sarcoma and pneumocystic pneumonia • Crossover from primate’s simian immunodeficiency virus and thereafter silent spread, 1910- 1950- 1980s o People began to butcher monkey meat, accidentally cut themselves, and were infected o Decolonization in Africa resulted in the exodus of many French-speaking residents ending up in French-speaking Haiti • “New Homosexual Disorder Worries Health Officials” o A serious disorder of the immune system that has been known to doctors for less than a year—a disorder that appears to affect primarily male homosexuals—has now afflicted 335 people, of whom it has killed 136, officials at the Centers for Disease Control in Atlanta said yesterday. Federal health officials are concerned that tens of thousands more homosexual men may be silently affected and therefore vulnerable to potentially grave ailments. The cause of the disorder is unknown. So far, epidemiologists have found no evidence that the disease is spread from person to person.” o HIV Infected patients were always half alive, half dead until drugs came along • HIV is transmitted via the exchange of bodily fluids–semen, vaginal secretions, blood, tissue—from an infected individual to an uninfected individual o Anal is a good place for absorption • HIV transmission occurs in sexual behavior, sharing drug injection paraphernalia, unscreened blood transfusion and tissue transplantation, and occupational exposure (rare in Canada) o Drugs that used to be pulverized and injected have been replaced with hard to pulverize drugs so you can’t inject them o But people will try and inject them (addicts) – doing so, the health units have provided injection drug users with filters o After using these filters for a while and you have HIV, the filters get HIV, and the filters now contain a lot of drug so can be sold o Post-exposure prophylaxis • HIV transmission is a function of the infected individual’s viral load and access to the uninfected individual’s bloodstream o Blue is the immune system (CD4 cells) o At the point of primary infection, immune system is intact and your viral load is very low (red) o Over the course of the next 5-10 years, your immune system will deteriorate o Initial spike declines to a latency level but you are still infectious o Now have drugs that stop the replication of HIV so it rarely can progress to AIDS o Your chance of getting the disease depends on viral load and the sexual behaviors you are engaging in, and the intactness of bodily mechanisms (wounds, etc.) o Ex. If you give a handjob, likely not even if viral load is high o If you have oral, chance is higher o If you don’t have a detectable viral load, you are not infectious HIV/AIDS 101 • No Risk: Kissing, Hand-Genital sex o Activities that don’t involve the transmission of bodily fluids are no risk • Low Risk but Not No Risk: Oral Sex • High Risk: Unprotected penile-vaginal or penile-anal intercourse o Highest risk is anal • Studies in inner city, low resource high schools and identified key opinions in every social groups (jocks, nerds, etc.) – made a contract with all that they would have HIV protection conversation with 10 people • 80% of males and females have had oral sex • 3-5% use condoms during oral • 75% have had intercourse – 55-60% use a condom 1981-1996: Fear, Therapeutic Impotence, and Death • Clerk filled out requisitions for strange drugs • Then got requests for things that are usually for immunocompromised elderly • By 1984 AIDS and HIV named • For the first 15 years – terrified of getting it and terrified if we had it, and nothing medicine could do to save you – fatal • Ryan White – expelled from school Fear, Therapeutic Impotence, and Death: US AIDS Diagnoses and Deaths • mid-1990s, saw drugs that stop viral replication 1996: Vancouver AIDS Conference – Era of Highly Active Antiretroviral Therapy • Have still not found a way to eradicate HIV – just suppress it 1996-2017: Era of Antiretroviral Therapy • Struggle to make ARV drugs available to AIDS epidemic epicenters • Focus on adherence to medication and avoidance of multidrug-resistance o Adherence means are you taking all of your meds o HIV patients must take them the rest of their lives Highly Active Antiretroviral Therapy: An Individual Health Victory and a Public Health Challenge • HIV undergoes very rapid, error-prone replication • Critical importance of early, multidrug intervention • Critical importance of adherence to therapy, viral load, viral escape • But public health challenge because more people are now living with HIV • If all of these people living with HIV were taking all their meds and virus was undetectable, there is just the issue of adherence Current State of the Epidemic: Adults and Children Living with HIV • 36.9 million people living with HIV • 2.0 million newly infected with HIV (incident infections) • 1.2 million adult and child deaths due to HIV • As of 2017 o 80,469 Canadians living with HIV o 36,424 Canadians have died of AIDS o 25% of Canadians living with HIV are unaware o See steady rate of new infection o ~2,000 Canadians acquire HIV each year (slowly declining) o 24% of incident HIV infections are in women o PLWH from endemic countries and Aboriginal PLWH are over-represented among Canadians living with HIV infection Current State of the Epidemic: Canada HIV Prevalence 1975-2017 • The number of people living with HIV are increasing Current State of the Epidemic: Canada New HIV Infections by Exposure Category • Top line (blue) shows the decline in men-sex-with-men • Increasing (green) is heterosexual/non-endemic people Current State of the Epidemic: Treatment as Prevention • “Biomedical tsunami:” Focus on treatment as prevention (TasP) • Relative de-emphasis of safer sex, safer needle use, and maintenance of behaviour change Lesson from the Sex Wars #1 Biomedical Interventions Are Fundamentally Behavioral Interventions • Test and Treat o Test, and wait, and treat • Pre-exposure Prophylaxis – don’t have HIV yet, but take antivirals (adherence) • Antiretroviral Therapy (adherence) • Microbicides (adherence) • Treatment as Prevention (adherence) • Circumcision (volunteer) o In Africa, it was observed that those who got circumcised had lower rate of transmission ▪ Stopped trial because it was unethical to not provide circumcision to the other group Lesson from the Sex Wars #2 The Limits of Treatment as Prevention • Ongoing Viral Detectability, Ongoing Risky Sex, HIV Unaware: Treatment as Prevention is Only One, Valuable, Part of the Picture Izindlela Zokuphila – Options for Health: A Snapshot of Treatment as Prevention • 1,388 South Africans – all treated with HAART • 25% detectable viral load • >50% of participants reported vaginal or anal sex acts with an HIV-/HIV? partner during the past four weeks • 74% of vaginal or anal sex acts with HIV-/HIV? persons were unprotected during the past four weeks • 581 HIV+ participants reported a total of 2,222 unprotected vaginal or anal sex acts with a total of 681 HIV-/HIV? partners, during the past four weeks • Treatment as prevention is important but doesn’t always work Lessons from the Sex Wars #3 Let’s Not Forget Where This Came From • Though you’re taking antiretrovirals, it doesn’t protect against things like syphilis – so we are seeing more antibiotic resistant syphilis due to soul reliance on treatment as prevention (rather than just practicing safer sex) Lesson from the Sex Wars #4 We’ve Been Wrong Before • The road to hell was paved with sole reliance on single prevention approaches Lesson from the Sex Wars #5 On Staying Ahead of the Next Sexually Driven Epidemic • “Discovered” by CDC clerk in 1981 (“GRIDS,” “AIDS”) • HIV, the virus that causes AIDS, identified in 1984 • Retrospectively charted “silent spread” 1910-1950 • What’s next? • Continue to practice safer sex! A Call for Highly Active Retroviral Prevention (HARP) • Only fools today advocate a single method of prevention A Call for Sustained, Comprehensive, Integrated Biobehavioral Interventions • There are limits to real world effectiveness of treatment as prevention • All biomedical prevention strategies are fundamentally behavioural interventions; HIV is an STI: o TasP should not promote nonuse of condoms o Let’s stay ahead of the next sexually transmitted killer • Reliance on a single prevention strategy has been problematic HIV/AIDS PREVENTION RESEARCH Solving The Problem: Changing Information, Motivation, Behavioral Skills and Promoting HIV Prevention Behavior Change IMB Model-Based Prevention Research HIV Prevention Education in a US University Student Population • Residence-based intervention in TV rooms- 3 x 2 hr/wk • HIV prevention information slide show • HIV prevention motivation video • HIV prevention behavioral skills videos People Like Us: Motivational Intervention, History of AIDS 1981-1996 • It is the motivational aspect that was the basis • this is history – this motivation intervention was created and deployed in early 1990s when HIV always killed you • Used Social Comparison Theory Sex, Condoms, and Videotapes • Behavioral Skills Intervention • Script exiting a situation • Script outercourse (handjob) • Script bringing up and negotiating effectively • Script the monogamous relationship University Student Residence HIV/AIDS Prevention Intervention • Significant increase in condom acquisition, condom discussion, and condom use in intervention (versus control) conditions at two month follow-up • Existing couples were more or less impervious to the prevention intervention o the One group they couldn’t reach were existing couples o Some evidence that when they transition out of their relationships and entered new ones, they used condoms HIV Prevention Education in Inner City US High Schools • Used existing teachers • 4 or 5 classes o IMB lesson plans o IMB videos • $2 per student – cheap and easy – a good thing Stakes are High: Modeling HIV Prevention Behavior
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