Denise Jaworsky

Use of newer antiretroviral agents, darunavir and etravirine with or without raltegravir, in pregnancy: a report of two cases.

BACKGROUND Although antiretroviral therapy during pregnancy is associated with significant reductions in the risk of vertical transmission of HIV, attainment of this outcome in highly treatment-experienced pregnant women might be complicated by the lack of active drugs available to assemble a potent regimen. The recent licensing and availability of darunavir, etravirine and raltegravir has broadened management options available for highly treatment-experienced patients. However, data on their safety and efficacy in preventing vertical transmission are limited. METHODS A retrospective chart review of two cases describing obstetrical, infant and treatment outcomes associated with the use of regimens that include darunavir and etravirine with or without raltegravir during pregnancy was conducted. RESULTS We document two cases of pregnant HIV-positive women treated with antiretroviral therapy including darunavir, etravirine and raltegravir. Vertical transmission was averted and no congenital anomalies were observed. CONCLUSIONS In the absence of human development toxicity data for these agents, these cases provide preliminary anecdotal data on their safety during pregnancy. Although the outcomes of these cases are reassuring, additional studies and registries are required to establish the safety and efficacy of these agents during pregnancy.

Peer Sexual Health Education: Interventions for Effective Programme Evaluation.

Peer education is used as a health promotion strategy in a number of areas, including sexual health. Although peer education programmes have been around for some time, published systematic evaluations of youth sexual health peer education programmes are rare. This article discusses the advantages and disadvantages of youth sexual health peer education programmes, the importance of programme evaluation, and strategies for developing effective programme evaluation tools. The value of conducting both process (programme delivery) and outcome (programme impact) evaluation is examined as well as methods for conducting these forms of assessment. Considering the wide range of peer education programmes and the diversity of communities served, the article concludes that the creation of a single evaluation method may be an impossible task. To address this challenge, principles for effective programme evaluation are proposed with tools that can be tailored to the unique goals of specific sexual health organizations.

Case Series of Fertility Treatment in HIV-Discordant Couples (Male Positive, Female Negative): The Ontario Experience

The success of combination antiretroviral therapies for the treatment of human immunodeficiency virus (HIV) has resulted in prolonged life expectancy (over 40 years from diagnosis) and an improved quality of life for people living with HIV. The risk of vertical HIV transmission during pregnancy has been reduced to less than 1%. As a result of these breakthroughs and as many of these individuals are of reproductive age, fertility issues are becoming increasingly important for this population. One population in which conception planning and reduction of horizontal HIV transmission warrants further research is HIV-discordant couples where the male partner is HIV-positive and the female partner is HIV-negative. Sperm washing is a technique carried out in a fertility clinic that separates HIV from the seminal fluid. Although sperm washing followed by intrauterine insemination significantly reduces the risk of horizontal HIV transmission, there has been limited access to the procedure in North America. Furthermore, little is known about the conception decision-making experiences of HIV-discordant couples who might benefit from sperm washing. Chart reviews and semi-structured interviews were completed with 12 HIV-discordant couples in Ontario, Canada. Couples were recruited through HIV clinics and one fertility clinic that offered sperm washing. Participants identified a number of factors that affected their decision-making around pregnancy planning. Access to sperm washing and other fertility services was an issue (cost, travel and few clinics). Participants identified a lack of information on the procedure (availability, safety). Sources of support (social networks, healthcare providers) were unevenly distributed, especially among those who did not disclose their HIV status to friends and family. Finally, the stigmatisation of HIV continues to have a negative affect on HIV-discordant couples and their intentions to conceive. Access to sperm washing and fertility service is significantly limited for this population and is accompanied with a number of challenges.

Development, implementation, and evaluation of a student-initiated undergraduate medical education elective in HIV care

Background: The literature indicates that medical students require more comprehensive HIV training. Aim: Medical students at the University of Toronto developed and implemented the preclerkship HIV elective (PHE) with the aim to increase trainee HIV knowledge, address important issues in HIV care, and prepare students to serve affected populations. Methods: Developed in partnership with the Ontario HIV Treatment Network and in consultation with local AIDS service organizations and the University of Toronto Faculty of Medicine, the PHE was inaugurated in November 2008 as an elective supplement to medical curriculum content. Eighteen second-year medical students participated in the PHE, consisting of lectures, small group sessions, clinical observerships, community placements, reading assignments, and an HIV counseling and testing workshop. Participants completed a self-assessment of HIV knowledge prior to starting and after PHE completion. Results: Self-assessment scores of HIV knowledge among PHE participants significantly increased from 78.1% (pre-PHE) to 90.2% (post-PHE) (p = 0.0016). Common themes from feedback on participant satisfaction included enthusiasm for small group sessions, clinical observerships, community agency placements, and the diversity of topics covered. Conclusions: Student-run initiatives can supplement medical curriculum content and program feedback may be used to advocate for curriculum changes. Factors influencing success include student leadership and interest, community partnerships, and faculty mentorship.

The Continuum of HIV Care in Rural Communities in the United States and Canada: What Is Known and Future Research Directions

Abstract: The nature of the HIV epidemic in the United States and Canada has changed with a shift toward rural areas. Socioeconomic factors, geography, cultural context, and evolving epidemics of injection drug use are coalescing to move the epidemic into locations where populations are dispersed and health care resources are limited. Rural–urban differences along the care continuum demonstrate the implications of this sociogeographic shift. Greater attention is needed to build a more comprehensive understanding of the rural HIV epidemic in the United States and Canada, including research efforts, innovative approaches to care delivery, and greater community engagement in prevention and care.

Comparison of late HIV diagnosis as a marker of care for Aboriginal versus non-Aboriginal people living with HIV in Ontario

BACKGROUND Studies have found that Aboriginal people living with HIV/AIDS (APHAs) are more likely than non-APHAs to receive suboptimal HIV care, yet achieve similar clinical outcomes with proper care. OBJECTIVE To compare the proportions of individuals diagnosed late with HIV between APHAs and non-APHAs within the Ontario HIV Treatment Network Cohort Study (OCS). METHODS The analysis included OCS participants who completed the baseline visit by November 2009. Two definitions of the outcome of late HIV diagnosis were used: the proportion of participants with an AIDS-defining illness (ADI) before or within three months of HIV diagnosis; and the proportion of participants with a CD4(+) count <200 cells/mL at diagnosis. Logistic regression analysis was used to assess the association between Aboriginal ethnicity and late HIV diagnosis. RESULTS APHAs were more likely to be female and have lower income, education and employment. No statistically significant differences were noted in the proportions receiving a late HIV diagnosis defined by ADI (Aboriginal 5.2% versus non-Aboriginal 6.3%; P=0.40). Multivariate logistic regression analysis revealed a significant association between Aboriginal ethnicity and late HIV diagnosis defined by CD4(+) count after adjusting for age and HIV risk factor (OR 1.55; P=0.04). DISCUSSION APHAs were more likely to have a CD4(+) count <200 cells/mL at diagnosis but had similar clinical outcomes from late diagnosis when defined by ADI. However, differences may be underestimated due to recruitment limitations and selection bias. CONCLUSION Additional work is needed to address the socioeconomic and health care needs of APHAs.

Learning from Interviews with HIV-Discordant Couples (Male Positive, Female Negative): The Challenges and Successes

This article examines the challenges and successes of recruiting participants and maintaining momentum in a small qualitative study on the experiences of HIV-discordant couples (where the male is HIV-positive and the female is HIV-negative) undergoing fertility assessment and/or treatment in Ontario, Canada, to reduce the risk of HIV transmission to the woman and fetus. The purpose of this article is to identify barriers and successes encountered in our study, consider how these are addressed in the literature, and highlight specific factors that need to be considered when studying a unique population similar to ours.

The role of people living with HIV as patient instructors – reducing stigma and improving interest around HIV care among medical students*

ABSTRACT People living with HIV/AIDS (PHAs) are increasingly recognized as experts in HIV and their own health. We developed a simulated clinical encounter (SCE) in which medical students provided HIV pre- and post-test counselling and point-of-care HIV testing for PHAs as patient instructors (PHA-PIs) under clinical preceptor supervision. The study assessed the acceptability of this teaching tool with a focus on assessing impact on HIV-related stigma among medical students. University of Toronto pre-clerkship medical students participated in a series of SCEs facilitated by 16 PHA-PIs and 22 clinical preceptors. Pre- and post-SCE students completed the validated Health Care Provider HIV/AIDS Stigma Scale (HPASS). HPASS measures overall stigma, as well as three domains within HIV stigma: stereotyping, discrimination, and prejudice. Higher scores represented higher levels of stigma. An additional questionnaire measured comfort in providing HIV-related care. Mean scores and results of paired t-tests are presented. Post-SCE, students (n  = 62) demonstrated decreased overall stigma (68.74 vs. 61.81, p  < .001) as well as decreased stigma within each domain. Post-SCE, students (n  = 67) reported increased comfort in providing HIV-related care (10.24 vs. 18.06, p  < .001). Involving PHA-PIs reduced HIV-related stigma among medical students and increased comfort in providing HIV-related care.

Important considerations regarding antiretroviral therapy in HIV-positive women

As the incidence and prevalence of HIV infection in women continue to rise, it is important to consider gender-specific issues when reviewing antiretroviral therapy options for women. Several studies report higher plasma concentrations as well as higher rates of adverse events in women for certain antiretroviral agents as compared with men. Ancestral history as it relates to pharmacogenomics has also been shown to impact drug metabolism and hypersensitivity reactions. Contraindicated drugs in pregnancy and changes in antiretroviral concentrations intrapartum, as well as interactions with oral contraceptive pills are also important issues to consider. The potential effects of gynecological and hormonal issues need to be considered in the treatment plan. Finally, social issues including mental health issues, caring for children, illicit drug use and history of abuse are also important factors as they can affect antiretroviral drug adherence in women.

High rates of posttraumatic stress symptoms in women living with HIV in Canada

Purpose Women living with HIV experience high levels of trauma exposure before and after diagnosis. One of the most challenging outcomes following trauma exposure is posttraumatic stress disorder. Despite high exposure to traumatic events, the presence and contributors to posttraumatic stress disorder symptoms have not been examined in women living with HIV in Canada. Methods The current study examines the presence of, contributors to, and geographical regions associated with self-reported posttraumatic stress symptoms (PTSS) among 1405 women enrolled in the Canadian HIV Women’s Sexual & Reproductive Health Cohort Study (CHIWOS). Results Separate linear regression models were run for the three provinces in the cohort: British Columbia, Ontario and Québec. Scores consistent with posttraumatic stress disorder were reported by 55.9%, 39.1% and 54.1% of the participants in each province, respectively (F(2, 1402) = 13.53, p < .001). Conclusions The results demonstrate that women living with HIV have high rates of PTSS, and that rates and variables associated with these symptoms vary by province. These results suggest the need for trauma-informed practices and care for women living with HIV in Canada, which may need to be tailored for the community and identities of the women.