1、Black Women and HIV: What you should know,David J. Malebranche Assistant Professor Emory University Division of General Medicine,Agenda,HIV 101 HIV Transmission Behavioral Risk for HIV Current HIV Treatment Guidelines Black Women and HIV “Down Low” Men and HIV Conclusion/Questions,HIV 101,Immune Sys
2、tem Review Bone Marrow: creates immune cells Thymus: produces mature T cells Spleen: blood filter for foreign material and stimulator of immune response Lymph nodes: filter for lymphatic fluid, which carries foreign material,HIV 101 (contd),Immune System Cells T cells CD4 coordinates immune response
3、 * CD8 kills viruses, tumors and parasites and suppresses immune response NK cells kills foreign invaders and infection B cells produces antibodies (proteins) to fight infection Polymorphonuclear leukocytes (PMNs) trap and digest foreign material and infections Antigen presenting cells (APC) Macroph
4、ages Dendritic cells,HIV and the Immune System,HIV decreases CD4 T-cell count Peripheral destruction Decreased production/maturation in thymus Two in HIV progression: CD4 count (normal count 600-1500) Viral load (amount of virus in bloodstream) Train analogy,HIV Transmission,Vaginal/Anal sex IV Drug
5、 Abuse Vertical Transmission (during birth) Breast feeding Oral Sex? Kissing? Biting? Saliva, Tears, Sweat?,Co-factors in Behavioral Risk,Mental Health Depression, Anxiety, etc. Sexually Transmitted Infections Herpes, Syphilis, Gonorrhea, Chlamydia Circumcision increased risk for men Media blaming t
6、he victim Poor risk assessment Denial risk behaviors, drug use, sexuality,Protecting Yourself from HIV,Mental Health youre not “crazy” Education - Know your risk! Abstinence Have your sexual partners tested Condoms Microbicides - 2007 Post-exposure prophylaxis (PEP) Sperm Washing before becoming pre
7、gnant,Condoms,Latex best protection Polyurethane for those with latex allergy Lambskin porous; not the best barrier Breakage rate 2% 90 - 98% effectiveness preventing: Pregnancy Gonorrhea/Chlamydia HIV Not as effective against Syphilis, HPV (warts) and HSV (herpes),Acute Retroviral Syndrome,Flu-like
8、 illness fever, muscle aches, sore throat, swollen lymph nodes 2-8 weeks after HIV exposure Rash distinguishes it from the flu HIV Antibody test often negative HIV viral load & glycoprotein testing 30 70% of those infected will have this syndrome,HIV Testing Methods,Elisa Test sensitive test (low fa
9、lse negative rate) blood test Western Blot specific test (low false positive rate) blood test Orasure Q-tip swab in mouth Rapid results Routine lab results,When to Start Antiretroviral Therapy?,HIV Medications,NUCLEOSIDE REVERSE TRANSCRIPTASE INHIBITORS (NRTIs) These drugs work by blocking Step 4, w
10、here the HIV genetic material is converted from RNA into DNA. Approved drugs in this class include: AZT (Zidovudine, Retrovir) ddI (Didanosine, Videx) * ddC (Zalcitabine, Hivid) d4T (Stavudine, Zerit) 3TC (Lamivudine, Epivir) * Abacavir (Ziagen) Tenofovir (Viread) * FTC (Emtriva, Emtricitabine) * Co
11、mbivir (AZT/3TC combination) Trizivir (AZT/3TC/Abacavir combination),Side Effects - NRTIs,Common Headaches Nausea Diarrhea Serious Pancreatitis inflammation of pancreas (All) Lactic Acidosis body burns fat(All) Hypersensitivity allergic reaction (Ziagen) Peripheral Neuropathy nerve burning (Zerit, V
12、idex) Anemia, Neutropenia low blood counts (AZT),HIV Meds (contd),NON-NUCLEOSIDE REVERSE TRANSCRIPTASE INHIBITORS, (NNRTIs)These drugs blocks the same step of the life cycle (step 4), but in a different way. Three NNRTIs have been approved: Nevirapine (NVP, Viramune) Delavirdine (DLV, Rescriptor) Ef
13、avirenz (EFV, Sustiva),Side Effects - NNRTIs,Common Elevated Liver Enzymes Rash Headache Nausea/Vomiting Serious Dreams, Hallucinations, Mood Swings (Sustiva) Severe rash with blistering (Viramune, Rescriptor),HIV Meds (contd),PROTEASE INHIBITORS (PIs)These drugs block Step 7, where the raw material
14、 for new HIV virus is cut into specific pieces. Six protease inhibitors have been approved: Saquinavir (SQV, Invirase and Fortovase) Indinavir (IDV, Crixivan) Ritonavir (RTV, Norvir) “boosted” regimens Nelfinavir (NFV, Viracept) Amprenavir (APV, Agenerase) Kaletra (ritonivir/lopinavir) Atazanavir (R
15、eyataz),Side Effects - PIs,Common Diarrhea Nausea Headaches Fatigue Rash Liver irritation,Serious Kidney Stones (Crixivan) Fat deposits/wasting Diabetes (high blood sugar) High Cholesterol Bone damage,HIV Meds (contd),FUSION INHIBITORS These drugs block Step 2, blocking HIVs ability to infect health
16、y CD4 cells by adhering to its outer membrane. One fusion inhibitor has been approved: Fuzeon (Enfuvirtide) administered as a twice daily subcutaneous injection,Side Effects Fusion Inhibitors,Injection site reactions Allergic reactions Pneumonia Leg and foot nerve pain Insomnia Depression Constipati
17、on Pancreas problems,Initiation of Antiretroviral Therapy,2 NRTIs and 1 NNRTI D4T/3TC and Sustiva Combivir and Kaletra 2 NRTIs and 1 PI or “boosted” PI Combivir and Viracept or Crixivan Combivir and KaletraWhats the best regimen to start with?,Vertical Transmission,HIV transmission from mother to ch
18、ild 25 30% HIV transmission risk to infant without treatment Treatment AZT reduces transmission from 27% to 10% compared to placebo Viramune reduces transmission from 21% to 12% compared with AZT,HIV and Black Women,Statistical disclaimer be critical thinkers Greatest risk factors 38% through hetero
19、sexual sex 25% through IVDU “Significant” number of black women contract HIV through sex with IVDU 64% of HIV infections among all U.S. women in 2001 Why are infections occurring?,The “Down Low”,What does Down Low mean?Who is more at risk for HIV “Down Low” men or “Gay” identified men?,The meaning o
20、f “Down Low”,Secretive Undercover Discreet An R. Kelly Song A homosexual black man who doesnt identify as “gay” A homo “thug” A married or coupled heterosexual man who has sex with men on the side,Deconstruction,Black Masculinity,Two main roles during slavery: Physical labor Breeding,Theatrical Movi
21、e Stereotypes,Athletes,Hip Hop Artists,Criminals,Black Masculinities Combined,“GAY”,The social construction of “gay”,Rainbow flags Pink triangles Pride Marches “Will and Grace” “Queer as Folk” “Queer Eye for the Straight Guy” Homophobia vs. “Gay-o-phobia” Religion Culture,Gender Role Conflict,“Occur
22、s when rigid, sexist, or restrictive gender roles result in personal restriction, devaluation, or violation of others or self.” Gender-Role Conflict Scale (GRCS) 37 item scale Success, Power and Competition Restrictive Emotionality Restrictive Affectionate Behavior between men Conflicts between Work
23、 and Family Relations(ONeil et al., 1986),So What is “Down Low” in the context of HIV prevention?,Battle of the brainwashing and discriminationBlack Masculine Stereotypes Vs. “Gay” Stereotypes,“Down Low” relation to HIV,Myths: More promiscuous than heterosexual or “gay” men alone More likely to have
24、 unprotected sex More likely to have HIV Reality: Potential mode of HIV transmission to black women (and other black men) Thirty-three percent of black men with HIV contract it from IV drug use,Qualitative Research,8 Focus Groups 81 self-identified BMSM Atlanta, NYC and Upstate NY NYC Dept. of Healt
25、h, Columbia University and New York State Black Gay Network $25 participant compensation Support from AIDS Education Training Center (AETC),Racial Stress,“Being a black man is a hard struggle. Not just being gay, being straight being a general black man is an everyday struggle. I dont care how you p
26、ut it, white America either wants me in a cell or a grave.” (Rochester, 21)“Because were black, we all have the same face. So when you approach somebody, they think that youre going to automatically cross them in a very aggressive, intimidating way. Youre black first.” (Atlanta, 33)“For me, whether
27、its sexuality or just gender, its always gonna be an issue of race. Im gonna be seen as a black man.” (Albany, 42),Gender Role Expectations,“You know, thats the way I was brought up. Grow up, go to high school, go to college, marry a woman Then you have children. And you had a house, the dog, and I
28、grew up like that, and I did that. I did the marriage thing, and the children, and the wife. You know, but thats because thats what was instilled in me. And I remember on my wedding day my big brother said to me, he said, You know you dont have to do this. He saw something in me I didnt wanna see in
29、 myself. So, you know and I said, Youre crazy, I gotta do this. Everybodys watching. You know, and it was always about everybody. You know, pleasing everybody instead of dealing with inner self.” (Harlem, 38),Black Masculinity,“As being a young black male, if I would come and say somethings wrong wi
30、th me. They medical providers would say, Oh, look at this, you know they probably just hip-hoppin and screwin down and you know, smokin the blunts, and then he gonna come here, talkin about he sick. So its like Im stereotyped already. And now if you say youre gay, everybody can get the picture of th
31、e feminine, gay brother. So I guess it can come to the sexuality because they feel, Oh, you must have been loose in the booty already.” (Harlem, 19),Religion/Spirituality,“This one woman came up to me, she said “You aint been to church in 3 months, and Ive seen you with some man, and I know he sleep
32、s with men. Whats up with you?” And I said to her “Are any one of your 5 baby daddies saved?” I just wanna know. Everybody act like yall aint never done nuthin wrong. To me, being gay and sleeping with a man, is no more, no different than me sleeping with a woman. Cause Im not married so according t
33、o the bible, its all fornication. And thats for him to judge me. People in church, they just get saved and quote-unquote, “get Jesus,” and they act like they just perfect.” (Rochester, 21),Medical Culture,“I was talking to her the doctor about the symptoms I was having. And shes like, she asked me w
34、hen the last time I had anal sex? And I told her like whenever it was. And shes like, Well, you know, and this really surprised me, Well, you know, the anus really isnt made for that. And I was like, Yeah, I know, but its a little too late. You know?” (Manhattan, 34),Why is all this important?,30% H
35、IV prevalence for 23-29 year old BMSM in large metropolitan areas (YMS, 2001) 14.7% HIV incidence rate (YMS, 2001) 93% of HIV-infected BMSM not aware of their status (YMS, 2001) 16% of lower income LA black men who are heterosexual admit anal sex with other men Black women comprise 75% of the female
36、 AIDS cases in the United States (CDC, 2000) BMSM who are “disclosers” have higher rates of unprotected anal sex (41% vs. 32%) and higher HIV prevalence than “nondisclosers” (24% vs. 14%) (YMS, 2003),HIV, Statistics and Media Hype,No scientific studies on HIV and “down low” black men NONE! Few scien
37、tific studies on the social context of sexuality among black men (or women) NY Times, Village Voice, Washington Post “Down Low” experts “Down Low” has become a catch phrase for self-marketing and promotion The Culture of Fear “Bowling for Columbine”,Real Topics on the “Down Low”,Child sexual abuse (
38、male and female) “Situational sex” Gender and power dynamics in sex Lack of condoms in prisons Sexual prejudice in the Church The mental health of black people in the United States,Conclusions,No Justification for “Down Low” Sexuality is not as static as we think Know your partners status Treat ever
39、yone like theyre HIV positive until you know for sure Assess your own risk based on your behavior, not who you are,Reconstructing HIV Prevention,HIV prevention for the entire black community Start addressing our mental health Scrap the overemphasis on “Down Low” Focus on HIV risk behavior More qualitative research to compliment the statistics Realistic assessment of role of churches Emphasize womens resiliency factors Redefining gender roles,Contact Information,David Malebranche, MD, MPH dmalebremory.edu (404) 616-0347 wk 69 Jesse Hill Jr. Drive Atlanta, GA 30324,
