Right. Hello, my name is Carol Preston. I'm a nurse and the executive director of the association of nurses in AIDS Care. Welcome to this learning activity entitled HIV fundamentals. This activity consists of five modules or chapters that make up a full activity of one hour and 45 minutes. You can stop and restart as needed or click on each module for viewing or reviewing them separately. This learning activity is intended for all levels of HIV and nursing knowledge from novice to experienced over the past 20 years. So many remarkable changes have occurred in approaches to HIV. Now, people who are living with HIV and are effectively treated and remain on HIV treatment have a life expectancy that is similar to people without HIV treatment is simplified without significant side effects and highly effective. HIV is now a manageable chronic disease. However misinformation, outdated information, stigma and shame remain. It is our duty as health care providers to be informed and to spread the word about these advances in this learning activity. You'll hear from Alana Bergman, a nurse practitioner with a large HIV practice. She'll provide a great overview of HIV that includes up to the minute data and dispels old and outdated information. Her second module is on person centered language and how terms that we may use unknowingly contribute to the experience of stigma and shame that damage our patients and diminish their quality of life. Secondly, dr Alicia Dickens and experienced HIV. Nurse practitioner will cover the basics of HIV treatment including U equals U. N. Prep. These are the two most important breakthroughs in HIV prevention and care in our lifetime. She also covers the importance of helping patients identify and address adherence challenges so that we can help them achieve and benefit from these incredible advances. And finally we have a powerful conversation between Jeff Kwong from Anak and mary Penner from prevention access campaign. You'll hear Mary describe some of his experiences and perspectives as someone living and aging with HIV for more than 30 years and the impact of U equals U on his journey. So thank you for taking the time to view this learning activity. For additional information and resources. Please refer to the links provided on the main web page of this learning activity. Hello, I'm Alana Bergman, I'm a nurse practitioner and I'm affiliated with johns Hopkins University. Welcome to this module entitled HIV overview, this is one of several modules which are part of HIV and aging educational series. Upon completion of this activity, participants will be able to understand the timeline of HIV progression, identify viral and immune measurements and functions utilize common terminology in HIV management, identify key populations who are at risk for HIV acquisition and articulate progress made in HIV over the course of the epidemic. So what is HIV HIV stands for human immunodeficiency virus if you've ever taken microbiology and we dredge up the information from our recessed memory. You may recall that viruses are incomplete organisms. They require a host cell in order to replicate In humans. The HIV molecule needs to use the CD four cell in order to reproduce and make more copies of the virus. The function of the CD four cell in our body is to act as a coordinator of immune responses within the body. The CD four cell acts as a sentinel to activate many other components of our immune system. So if CD four cells are systematically impaired or reduced, our body loses the ability to meaningfully respond to attacks from other bacteria or viral pathogen. Aids however, stands for acquired immunodeficiency syndrome and it's clinically distinct from HIV. Most people with HIV do not have and never progress to AIDS. AIDS is defined by having a CD four count less than 200 or by the diagnosis of an opportunistic infection. This is also called an AIDS defining illness. Some examples of opportunistic infections are tuberculosis, PCP pneumonia, Kaposi's sarcoma and her disaster. I make that distinction because number one, it has clinical significance if you inform the clinician that someone has AIDS versus HIV that may significantly impact their plan of care. The second factor is that AIDS is a really loaded term. It invokes fear stigma and associations with death even more than HIV and it can be really offensive to someone living with HIV to be labeled with AIDS. So I encourage you to be clinical and thoughtful about your use of these terms. These are some of the terms that you will hear throughout today's presentation and in the duration of the activities in this series. It's helpful to understand these terms and why they are relevant to HIV care and prevention. The first term I'd like to define is A. R. T. This stands for anti retroviral therapy and includes any medications or combinations of medications used to treat the HIV virus in your treatment facilities. You may also hear the term A. R. V. That also stands for antiretroviral therapy. Another term you may hear is H. A. R. T. This is a fairly outdated term and stands for highly active antiretroviral therapy. Today. All of the treatments that are approved by the FDA are highly effective and so this term has largely fallen out of favor but you may continue to see it in notes, some of the other terms that you'll hear our cd four that refers to the cd four T cells in a person's body undetectable means someone who has achieved HIV viral suppression Were less than 50 copies per milliliter in blood upon microscopic examination. Another term you may hear is U equals U undetectable equals un transmittable. We'll go into detail about what undetectable equals un transmissible means in a later talk, T A. S. P. Or T. S. P. Stands for treatment as prevention. Prep also stands for pre exposure prophylaxis and I want to stress that prep is not synonymous with Truvada. If you're familiar with prep at all. Your you've probably heard of the medication Truvada but it can really refer to any medication that is used to prevent HIV infection and there are more than one medication approved at this time. Pep p E P stands for post exposure prophylaxis and finally vertical transmission refers to mother to child transmission of the HIV virus. HIV is a chronic illness. The timeline of progression for HIV can be divided into four phases. The first phase is the period of HIV susceptibility when someone has not been exposed to or infected with the virus and we're really focused on prevention rather than treatment. The second phase that follows susceptibility is a subclinical phase and acute infection. So this is the time where a person has become infected with the HIV virus but likely is not aware that they have contracted HIV. The third phase is the clinical stage of infection when most people are diagnosed. So this is a time when when people may or may not have symptoms or when they may be presenting to their primary care provider and have routine screening that leads to their diagnosis of HIV lastly is the period of chronic illness. This is the longest phase of HIV infection where we're really focused on viral suppression, recovery and maintenance of quality of life if an individual is not offered and started on treatment at some point during the chronic period. They will progress towards AIDS when evaluating the HIV virus itself. We have primarily two avenues antibody and anti gin testing. If we think back to our path of physiology, we know that the virus appears prior to antibodies and it takes a little while for the body to develop antibodies. So antibody tests are generally used for HIV screening only once someone is diagnosed with HIV they will always be antibody positive. So there really isn't any additional value of repeating antibody testing again because the antigen is present before the antibodies. Several years ago, the screening guidelines changed for HIV to include antigen and antibody testing at the same time, the benefit of using a test that has both antigen antibody testing is that you're able to detect the virus early and there is a lower risk of giving a patient or a person a false negative test result. The most accurate test is to perform an HIV RNA test. This is also called a viral load in general. We use a viral load to determine if treatment is working after starting someone on antiviral therapy, we anticipate that patients will quickly become undetectable Generally within 1 to 6 months. So if we perform viral loads And a person continues to have a high viral load higher than 200, then we know that the medication isn't working either due to missed doses or to viral resistance. There is one other scenario where we use viral loads and that is if we're concerned that someone is acutely infected with HIV meaning that they have anti gin present in their system and they may or may not have antibodies and that antigen tests are likely to be negative. Generally working in opposition to the viral load is the CD four count CD four Count and CD 4% are the two measures of immune function that we use in HIV management. The CD four Is the percent of your lymphocytes, a type of white blood cell that our CD four cells. When we multiply the CD 4% and the total white blood cell count, We get an absolute CD four. The number of CD four cells per millimeter cubed of blood. A normal CD four cell range is from 500 to 1500 cells per cube millimeter. In terms of general principles as your viral load is undetectable. Low your CD four cells are allowed to accumulate and increase. Conversely if your viral load is high, it means that the virus is using the CD four cell to replicate, causing their depletion and resulting in a low CD four count what makes HIV similar to other chronic illnesses in general, HIV is very manageable. Like other chronic illnesses such as hypertension and diabetes, you need to take medication and have regular follow ups with your primary care provider or specialist in order to make sure that you're healthy and well. While living with HIV. However, HIV is quite different from other chronic illnesses because it carries quite a bit of stigma that's associated with it when we talk about HIV, there's a lot of silence, fear and shame that's often associated with an HIV infection that is not associated with other illnesses. Additionally, in some states, there are still laws that criminalize different types of behaviors related to HIV. We all need to remember that how someone is infected isn't important. Regardless of how they were infected. All people living with HIV deserve access to health care treatment and high quality of life whether they have the virus or not. So let's talk about HIV epidemiology. In the United States, More than one million people in the us are currently living with HIV. New infections occur more frequently in the 20-34 age Cohort. However, approximately 17% of new diagnoses in 2019 were people in the age 55 and up cohort. So despite the fact that most diagnoses happen at a younger age, because HIV is really a chronic illness and is quite treatable with adequate management and medication. There are more and more people that are aging with HIV into their 50s, 60s and well into their 70s. As a result, the critical mass of people living with HIV are older adults. As people age with HIV. We need to consider some of the complications that may occur as we age. We're more likely to be diagnosed with other con commitment in illnesses such as hypertension, diabetes and high cholesterol. As healthcare providers, we need to be attuned to potential drug drug interactions and side effects that occur. And we need to really make sure that we adequately manage polyp pharmacy and have excellent communication between the specialties within health care. We also need to recall that older people with HIV lived through the early epidemic and probably recall the fear and discrimination associated with living with HIV and AIDS. Older people may come to treatment with concerns about disclosure and anticipated stigma that they may experience from friends, family, their communities or even potentially from other health care providers. So let's talk about aging with HIV in order to do that, we need to discuss the difference between incidents and prevalence incidents is the probability of an event in our case an HIV diagnosis given your age. So we need to acknowledge that older adults are diagnosed with HIV One in six people with a new HIV diagnosis are age 50 or older. But admittedly most new diagnoses are among younger people, prevalence is the proportion of a population affected by an event. So what proportion of the population falls into a certain group here is where it gets a little bit confusing. Remember that HIV is a chronic illness, it goes far beyond the acute phase. So people are living long rich lives with HIV, even if they're diagnosed at age 30 they will go on to live into their seventies or maybe even eighties. This is a testament to the efficacy of the drugs that we have at our disposal. The drugs work well at achieving viral suppression and are well tolerated allowing people to live with HIV for a long time. And just as an F. Y. I as we get better at preventing HIV infections, this trend is only going to increase over time because we will prevent more infections in the younger age cohorts. So how is HIV transmitted? Let's start with how it's not transmitted. It cannot be transmitted through saliva. So HIV cannot be transmitted through kissing, sneezing, coughing or sharing dishes. It's also not transmitted through skin to skin contact. So hugging and handshaking can absolutely not pass the virus. HIV can also not be transmitted through sweat, tears, urine or feces. So what does that leave 1st? HIV can be transmitted via sex. That can be sex with a man, sex with a woman. Sex with people in general. This includes vaginal or anal, penetrative inserted or receptive sex. It can also be transmitted through needle sharing. This includes people who inject drugs, occupational exposures or sharing medical equipment. So thinking about people who are potentially sharing prescribed medications and treatments like diabetic insulin supplies. Then finally, it can be transmitted from mother to child during pregnancy, childbirth or breastfeeding and through contaminated blood products. I share these things to put you at ease during almost all regular contact with patients. There is no risk of transmission. It doesn't matter how someone became exposed or infected with HIV. There aren't good people or bad people Regardless, No one deserves HIV regardless of their behavior and everyone deserves high quality judgment, free care. We've all had sex and therefore we have all been at risk for HIV at one time or another and we need to remember that as we interact with and provide care for people living with HIV. This is a pictograms of the social determinants of health. The definition of the social determinants of health from healthy people 2020 is that the social determinants are conditions in the environment where people are born, live, learn work, play, worship and age that affect a wide variety of health functioning and quality of life outcomes and risks under each subcategory. There are a variety of contributors, for example, under economic stability, income, employment expenses, debt and financial support, among other things in neighborhood and the built environment. We would discuss neighborhood safety, walk ability, environmental exposure, pollution, playgrounds and access to transportation. All of those things contribute to the way that people interact with one another and put them at higher or lower risks of different types of health in the context of HIV, I think of the social determinants this way No one wants to be diagnosed with HIV. We have the tools available to prevent HIV infection. We have medications to support people living with HIV and prevent them from dying of AIDS despite this technology, people continue to be diagnosed with HIV to present late for treatment and die due to AIDS related complications. Since we've already established that no one wants this. Why does it continue health care, access testing, education stigma, adequate health care coverage and family support. All of these things contribute to a person's ability and willingness to engage in HIV prevention and treatment. So I'd like to talk about the progress that we've made in HIV treatment over the past 20 years. I have this chart here, not because I need you to read all of the details on it. It's very small, but I just want to give an example of the variety and the number of medications that we have available to be able to treat HIV at this point Of all of the progress that we've made over the past 20 or 30 years. One of the most significant changes has been through regimen simplification. People who are living with HIV now have many, many more options in terms of treatment options than they previously did. Many of our medications have been combined into a one pill once a day treatment option. When I began practicing HIV medicine just about eight years ago, we only had one or two combination tablets that could be given to a person living with HIV. Most of the treatments that I used involved multiple pills that were taken multiple times a day. Since that time, I've lost count of the number of one pill? Once a day options that we have at our disposal. There are more than 10 that are available now and they all have benefits and costs. But having so many choices almost ensures that we're able to find the correct fit for each person so that most people living with HIV Have been able to reduce their pill burden to only one pill per day. We've also had the recent approval of injectable medications. So rather than taking a pill every single day for treatment, some people are able to come into the office and receive injections monthly, which can be a very nice option for certain people. We've also had a big improvement in the cost of medications. They are much more widely available. They're covered generally very well by insurance and we've also had a size reduction where previously most of our medications were very large tablets and for some people there could be a burden where they weren't able to swallow the medications, particularly as we age. Now, many of the medications that we have available are quite small and are, you know, the size of a Tylenol or even smaller. We also have many fewer adverse effects to medications. So in the early days of the epidemic, many of the medications were quite toxic and caustic to the system and would create a variety of unpleasant adverse effects and toxicities. Those toxicities are very limited. Now, most treatments that we have are safe and tolerable for the vast majority of people living with HIV all of these improvements, the regimen simplification, reduced pill burden, the newly approved injectables, better cost and smaller size has resulted in improved quality of life for people living with HIV. So in the past 20 years of the epidemic we've made wonderful headway in reducing morbidity and mortality for people living with HIV, we've increased the visibility of HIV. You may have seen billboards, advertisements or even seen people living with HIV in the media. So previously where HIV was in the dark, we're now seeing many aspects of HIV treatment and people living with HIV come to life. We've also seen improvements in funding for HIV research and for HIV treatment, but we still have a long way to go. We know that HIV stigma remains a barrier to to linking people to care to meaningful care engagement and to maintaining viral suppression. We also know that access to prep is limited. Prep or pre exposure prophylaxis, as we discussed earlier, is medication that prevents HIV infection and we know that it is not reaching the key populations who need it most Finally, HIV criminalization laws persist in many states, there are lots of places in this country where just being a person living with HIV can be seen as a criminal act. We need to do more to make sure that these laws go away and that we reduce stigma enabling people to access care and to maintain high quality of life while living with HIV. These are my references and additional resources. Please feel free to utilize them. Knowledge. Check why are older people most affected by HIV? Despite higher new infection rates among younger age cohorts, a older people are becoming infected with HIV at higher rates than young people be older people do not respond to treatment as effectively as younger people see treatment advances have made HIV a chronic illness increasing prevalence despite improvements in incidents or d younger people adhere to treatment better than older adults. The correct answer is, c treatment advances have made HIV a chronic illness increasing prevalence despite improvements in incidents. The rationale for this answer is that advances in treatment such as increased efficacy, reduced adverse effects and regimen simplification are helping people with HIV to live longer, more, more full lives with this chronic illness as a result, despite the high incidence of new infections among younger people, the prevalence of HIV is highest among older adults in the United States. Thank you for viewing this learning module. Please be sure to view our other modules as part of an Ax HIV and aging educational series. Hello, I'm Alana Bergman, a nurse practitioner affiliated with johns Hopkins University, welcome to this module. Person centered language. This is one of several learning modules which are part of an Ax HIV and aging educational series. The learning objectives for this module are to define person centered language. To understand how person centered language helps to destigmatize HIV and to use humanizing and respectful language to discuss HIV. So what is person centered language? That's pretty easy. It's language that puts the person first before their HIV status before their sexual or gender identity before their occupation or their mental health. Because the one thing that we all have in common is that we are people, it's much easier to be empathetic for others when we remember how similar we are as people, rather than emphasizing our differences. The quote in red is from scholars at the Center for Practice transformation at the University of Minnesota. It says using person centered language is about respecting the dignity worth, unique qualities and strengths of every individual. I love this quote because it gets to the heart of person centered language, It's about respecting that each person is made up of 1000 qualities and strengths. So no one quality can define a person, we can't define someone by a single identity or attributes. Why is person centered language important? Language is important. It conveys layers of meaning. Each time we say something, we convey the intended message, but we also run the risk of conveying bias, positive or negative or we run the risk of conveying stereotypes as healthcare providers. We need to choose language carefully in order to build therapeutic relationships with our patients to gain trust and to communicate accurately and communicate unbiased information to the community, nurses are the most trusted profession from nursing assistants up through nurse practitioners and nurse researchers. People look to us for answers and we need to make sure that the information that we present communicates the precise message that we intended without realizing it. Our language choices might be fueling negative or untrue stereotypes that impact our patients mental wellness and perpetuate stigma in the community. We know that HIV stigma is alive and well. Today I've seen it 1000 times in my practice. People are ashamed by their status. Health care providers speak in hushed tones about HIV and why in part, we often choose language that communicates that HIV is something to be ashamed of choosing Language carefully allows us to build therapeutic relationships to gain trust and to communicate accurate information with our patients. So, some practical guidelines for talking about HIV. I have three rules for talking about HIV. This is in terms of talking to people living with HIV or for talking to the general community because I want to make sure that I'm not inadvertently communicating negative bias that others will take and pass on. So I want the community to hear and repeat language that de stigmatizes HIV. So my first rule is that HIV does not define a person when we put HIV before the person as in if we say someone is HIV infected or HIV positive, we imply that the HIV is the most important thing about them when really it's probably the least interesting and the least important feature about that individual. Everyone would rather be known for their positive qualities rather than for a clinical diagnosis with historically negative connotations. So my first rule is that we use the term people person living with HIV take the important part the person, the individual and symbolically and linguistically put it before the virus. When we talk about HIV, it's important to remember that HIV is a chronic illness no different than diabetes or high blood pressure. We wouldn't describe a person first by their blood pressure. And similarly, we don't define people living with HIV by their virus. When we talk about HIV remember this is something that people live with every day for years at a time when HIV is well controlled. It doesn't limit the lifespan. We don't want to talk about it as a death sentence or something causing imminent and irreversible harm. Imagine you were just diagnosed with HIV and the people around you talked about how irreversible and devastating it was. You probably wouldn't feel empowered to take your medication and continue with your life. So I want to remove that finality from our vocabulary about HIV by remembering that HIV is a chronic illness from now on. We'll all talk about HIV is something to overcome and work beyond people living with HIV are survivors and that's how we should talk to and about them. Finally, my third rule of thumb is that AIDS is not a virus. There is no AIDS virus only human immunodeficiency virus. Aids us a clinical designation intended for clinicians to describe someone's immune function. You can't contract AIDS, you can't give someone AIDS and most people living with HIV do not have AIDS. If someone has shared their HIV zero status with you, you still don't know anything about their immune function. So unless you're treating the virus and have a good understanding of that person's immune system and their clinical needs just leave AIDS out of it. There's no reason to bring up such a charged term in our everyday vocabulary. So I'd like everyone to remember that words matter here. We'll go over some practical tips for comparing person first language to hurtful or stigmatizing language so that we can try and remove the hurtful or stigmatizing language from our vocabulary. So first is person with HIV person with HIV centers. That first and foremost we're talking about a person who is more than their virus. When we say HIV positive, woman or man, we're making the virus more important than the person living with. HIV brings up thoughts of survivorship and resilience. HIV infected indicates that the person is a victim. I prefer to use person or client rather than referring to people as patients. People living with HIV are always people, they're occasionally patients when they come to see us in a clinic or in a hospital but most of the time they're not patient is a temporary term and is again centered on victimology rather than survivorship. We've already reviewed. For the most part, we're removing AIDS from our vocabulary in 98% of situations. HIV is the most clinically appropriate term and it has fewer negative connotations for most people. Then we have some person centered language that's not specific to HIV, but it's still related and useful to think about. For example, people who use drugs or a person with a substance use disorder centers, the person over their behavior or their struggle with addiction addict is a negatively commentated word that indicates a failure to control behavior rather than acknowledging what we know to be a mental illness and not a moral deficiency. Similarly, prostitution is peppered again and again with negative connotations and forgets that at the end of the day, sex work is work. It's not an easy life or profession. So let's acknowledge that people don't take sex work on for pleasure, they take it on as work. Then finally, there are so many incredibly hurtful and harmful terms for our LGBTQ friends. I'm not going to list them here because I think there are many words that we can't even get educational value from, but we know what they are using transgender person or person of a transgender experience is a more dignified and human way to talk about a person who is transitioning genders here too. It's so important to acknowledge and accept a person's desired pronouns, It doesn't hurt at all to call someone by their desired pronouns, whether it's he, she or they, it might seem awkward at first, but you'll get used to it and remember the english language is in a constant state of transition and flood. It was weird when we transitioned from Old Shakespearean English, but now it seems totally normal and I really believe that 20 years from now using non binary pronouns will be similarly normal and easy. Here are my resources and references. Please feel free to look some of these up and enjoy them knowledge. Check an example of person centered language is a HIV infected woman be drug addicts. See person with HIV the prostitute. The answer is C person with HIV the rationale is an example of person centered language is person with HIV terms such as HIV infected drug addict and prostitute can be interpreted as heartful or stigmatizing and should be avoided. Thank you for viewing this learning module. Please be sure to view our other modules as part of an ax HIV and aging educational series. Hello, my name is Alicia Dickens and I am a nurse practitioner at Can Community Health in Norfolk. Welcome to this module on the basics of HIV treatment. This is one of several learning modules which are a part of an ax HIV and aging educational series. These are the learning objectives for this module on completion of this activity, participants will be able to identify at least two primary goals of HIV treatment describe the significance of U equals U. And T. S. P, which is treatment as prevention And finally named two factors to consider when selecting an HIV Regimen. So in terms of the goals of HIV treatment, we want to prevent any HIV associated morbidity and mortality by achieving suppression of our replication to undetectable levels. We want to preserve immune function, we want to improve clinical outcomes and we want to eliminate the risk of HIV transmission. In the early days of HIV treatment, we used to always tell our patients hey, if if we can get your HIV stable, everything else will be stable. So in terms of chronic illnesses and inflammation, um preserving immune function and improving clinical outcomes is definitely a a real goal. In terms of HIV treatment, There was a 2019 CBC analysis that actually revealed that about 80% of new HIV infections in the us in 2016 came from the nearly 40% of people who either did not know they had HIV or who had received a diagnosis but they were not receiving HIV care and treatment and that is a real, a huge red flag in terms of, you know, getting people tested, getting them diagnosed and linking them to care. So when we want to talk about ending the HIV epidemic in the United States, we basically break it down into diagnosing treating, preventing and responding. We want to diagnose all individuals with HIV as early as possible. We want to treat people rapidly treat them immediately as soon as we find out that they're HIV diagnosed. We want to initiate HIV therapy. We want to prevent new HIV infections by using proven interventions such as which is pre exposure prophylaxis, pep which is post exposure prophylaxis and serene service program. We also want to respond quickly to potential HIV outbreaks and that means promptly treating STD um and testing people for HIV and getting them on therapy. One of our main core concepts as it relates to HIV treatment is U equals U. And that basically means undetectable is un transmittable. The Centers for Disease Control and Prevention supports the science behind undetectable which is un transmittable and basically what that means is U. Equals U. Refers to the fact that people living with HIV who take their antiviral medication regularly and who maintain an undetectable viral load and remember viral load is the amount of HIV in the blood. Um Those people cannot sexually transmit HIV. So for the person the patient you know I think this is empowering, I think people um who take HIV medicine and who maintain their undetectable status, I think U equals you can basically motivate them into maintaining good health. Um HIV tends to stigmatize our patients a lot. And so I think this again can really empower our patients into maintaining good health. So you know a lot of times people will always ask well you know, is that U. Equals U stuff real. You know, where's the science? Where's the support? So there are several studies that support U. Equals U. Um H. P. T. N. HIV prevention trials network was a huge study that showed zero, I'm gonna say it again. zero transmissions of HIV Between more than 1700 mixed status couples. That is when one person is HIV positive but that that person was on antiretroviral therapy and was undetectable. Um they did not transmit the virus. So again that study showed zero transmission And over 1700 mixed or discordant couples in the power study, There were zero transmissions of HIV out of 58,000 condom less sex acts again between people with HIV on antiretroviral therapy who have undetectable viral loads and their HIV negative partners. The partner to study Which was an extension of the partner one study. And it studied M. S. M. So men who have sex with men, There were zero transmissions out of 77,000 condom. This sex act again between people living with HIV who are on antiretroviral therapy with undetectable viral loads. The Swiss statement is a statement that came out in 2008 January of 2008 and it basically says that people who are HIV positive who are on effective antiretroviral therapy and who are without any sexually transmitted infections are essentially sexually non infectious. So again these are the studies. Um and and these are thousands among thousands of condom less sex acts. Um that proved U. Equals U. Is real. And you know I tell patients it works so a little twist on U equals U. Is basically treatment as prevention. And so when we talk about treatment as prevention, our basic core concept is based on U. Equals U. But it hinges on getting people tested and getting people diagnosed. And so I think that's the main state of this particular core concept is we gotta get people tested and if they test positive we got to get them um diagnosed and and linked to care. Um we get hung up on getting people diagnosed, they may not be experiencing any symptoms um and they just don't know that there's something wrong a lot of times when people come into to get tested a lot of times, maybe they're having some symptoms of S. T. V. Um They may have been notified actually about the health department. Maybe they were named as a contact from an individual who tested positive for an STD or HIV um or maybe their partner actually reached out to them and said hey I'm having some problems. I'm having some symptoms. I would like you to get tested. But again I think the core concept of treatment as prevention, it basically you know, is based in getting people diagnosed um and then linking them to care. So this this slide right here actually shows the classes of HIV antiretroviral therapy, non nucleoside reverse transcriptase inhibitors, we call them nukes, um protease inhibitors entry inhibitors, Integrase strand transfer inhibitors, non nucleoside reverse transcriptase inhibitors. We call that group non nukes and then attachment inhibitors. And basically what happens when we start someone on antiretroviral therapy, we basically will pick Um two or 3 medicines and we try to pick at least two different classes. Oh, um, antiretroviral therapy, each class of medication actually has an effect on a different point in the HIV viral replication cycle. So again, each class of medication has an effect at a different point in that HIV viral replication cycle. And basically that's how the medication works. So this list um show some characteristics to consider um and all people who are living with HIV so some things that we have to think about, especially when we're thinking about initiating therapy co morbid conditions. So that can mean hypertension, diabetes, you know, kidney disease, liver disease, it can also mean mental health. So, you know, is that person or some psychiatric medications because sometimes we do have to think about drug drug interactions um is that person co infected with Hepatitis B, Hepatitis C or tuberculosis. There is some overlap with some of the Hepatitis B medications because some of the heavy medications can also treat HIV um sometimes if someone has tuberculosis, there could be some drug drug interactions with some HIV medication. So again, we just have to consider that and know that and be aware of that and make any adjustments along the way we get Jenna, typical drug resistance testing on all of our patients. H. L. A. b. status and H L. A B 57 01 is basically a genetic variant and that particular genetic variants can cause hypersensitivity to one of the HIV medicines. And that particular HIV medicine is called the back of the ear or Zion region. And basically that is a blood test and we just check the status and it is negative. Then we are able to utilize that medication if we desire. We want to consider individual preferences and you know, especially right now individual preferences is a big deal. You know, we have single tablet regimens, we have injectables and so you know, it's it's good to um get your patient to participate in the decision making in terms of you know, which antiretroviral medication they would like to be on if they want to consider an injectable or maybe they don't like needles and they don't want to consider an injectable um side effects and side effects. I'm gonna actually say actual and perceived side effects because sometimes just the thought, you know, people had to get caught up in, you know side effects or you know what they heard about something or what they read about something and so side effects. Again it can be a big deal especially um if someone is just kind of caught up in side effects or if they had maybe a bad reaction to something else. So actual or perceived side effects. Um sometimes you have to spend a lot of time with your patients kind of diving through all of that information um anticipated adherence to therapy, um cost and convenience pre treatment HIV RNA which is viral load, Pre Treatment CD four Count. And those two are important because there are some antiretrovirals that there is a limit, there may be a viral load limit or tv for limit um that you have to take into consideration um prior to initiating that particular agent. So this list right here is a list of our single tablet regimens and they're broken down into the classes of antiretroviral. So under under integrates inhibitor um F. T R which is single tablet regimen. You see big Tar VG Envoy astride Bill Triaminic, the Vado Gianluca and so those are all of the trade names and if you look to the left of those names, you'll see the generic either the name or the abbreviation and for a lot of our single tablet regimens the medication to know, fear be it, to know for Alice cinema or to know for their dice apostle for mari. Um that medication is in most of our single tablet regimen and this, this slide is important because sometimes mistakes or errors can happen. People can get a little confused especially when they use the generic name in terms of putting people on medication or switching their medication or continuing their medication. So for example, I can tell you um when I worked at the V. A. A lot of times there may be a veteran who would come through the emergency room and they might say, hey, you know, I'm HIV positive and I'm out of my medication. And so you know, the example that I'm thinking of this particular patient was on complex era. Well when the emergency room provider looked at the medicine, they looked quickly and they actually saw that Tenofovir DF F. T. C. And they actually initiated a triple A for the patient. And so by the time that patient got around to the infectious disease clinic and had an appointment Like two or 3 weeks later they had been on actually the wrong medication. Um So instead of them being on their comp lera, they were actually on their triplets. So again, you know, care has to be taken and attention to detail has to be made when looking at these meds. They are so similar, especially with some of the agents that they contain and so again, the non nukes or the non nucleoside reverse transcriptase inhibitors, a triplet which is actually not being manufactured anymore. Um sympathy complain era of Dempsey Del Street Go and some Tusa in terms of the protease inhibitor single tablet regimen. This is a slide about our long acting antiretroviral. So it is called complex era. It is new, it has not been FDA approved that long. Um basically it's an injectable of capital photography and real pill marine. So those two medicines was initially FDA approved for patients to get those injections every four weeks. Um it's just, I mean, I think really within the last couple of weeks, the FDA approved that the patients can get those injections actually every eight weeks now implantable options and long acting oral options. Just know that those are in research and development at this time. So those are, you know, we're looking forward to those coming. So adherence adherence, you know, when we talk about HIV appearance or antiretroviral adherence, it is a big deal. It is adherence to your medical appointments, you know, getting your labs coming to your visits. But most importantly it is adherence to your antiretroviral therapy and we know that there can be lots of barriers to antiretroviral adherent. It may arise from a patient's personal or cultural beliefs, cognitive abilities or health status, including co morbidity, brief conversations can identify teachable moments. Studies show that through open discussion providers and patients can uncover barriers, identify strategies and set goals to improve its appearance and again, it's it's a big deal because with HIV medicine you have to take it pretty perfect in order to stay healthy and to keep that vowel replication suppressed and you know, we talked a lot about social determinants of health. So a patient educational level, a patient's employment status, food insecurity, um, transportation. I mean, those are things that can have a potential negative impact on adherence. You know, I can remember a time where a patient told me I take my medicine really, really good up until that last week of the month and when my food run out or when my food gets low, I really don't take my medicine like I'm supposed to because I don't have enough food. And so that's one instance that I can think of. Another instance. You know, basically I work in Norfolk, it's a college town. I see a lot of college students and you know, we have patients and because of their insurance, they have to use a mail order pharmacy and the patients are saying, well, no, I don't want my medication mailed to my house. You know, my parents don't know that I'm positive. I don't want it mailed to my house. Um, so those can be potential barriers, um, to adherence or they can certainly have a negative impact on appearance things that we can do to help. You know, we tell patients set alarms, you know, to remind you to take your medicine, we give people peel boxes, they have these cute little key rings that you can put extra pills in. So people can maybe keep a stash of medicine, maybe in their glove compartment or maybe if they're in school in their locker or in their backpack and some people actually get, they get their partners involved um to assist them with taking their medicines. I've had patients tell me, hey, me and my partner, you know, every evening after dinner we take our medication together so we keep each other accountable and so that works too. Other things that can affect adherence that are a little bit out of the patient's control is prior authorizations. Um a lot of times with the insurance companies, they require a prior authorization. HIV medicine can be very, very expensive. So a lot of times we have to get the officer staff to kind of walk through that process so that we can get that paperwork done so that patients can get their refills and their medication and knows timely. Mhm. So addressing antiretroviral adherence barriers again, explaining the importance of adherence. Um even if the viral load is undetectable, we want to keep it undetectable in the way you keep it undetectable if you're taking your medicine every day. Again, I had mentioned pillboxes and alarms um using teach back method to assess understanding of medication dozing and this is important. Um I have a lot of low health literacy patients and so a lot of times when I'm talking to them, I want them to talk back to me. I want them to repeat. What did you give me say? I need you to repeat it back because I need to ensure that you understand what I said. Um so that's very, very, very important. Sometimes people try to be silent or they just try to say mm hmm. Or they just try to nod their head. But you really need to assess understanding. And the only way to do that is to get your people talking back to you. So you talk to them and then you get them to repeat back to you what you just said, assess for any side effects that may impact adherence. So you know, if the patients say, well I get diarrhea and you know, I'm a truck driver, I can't be on the road having diarrhea. Um you know that is a side effect that can potentially impact adherence. Um, address any access issues, transportation insurance concerns. So like I said the prior authorizations a lot of times copays, copays usually are not a problem. But if someone has Medicaid or Medicare or if they have like in insurance that that is associated with the federal government, you can't use copay cards for them. So copays can potentially be a problem. Um, and then you also want to ensure continuity of medications um during care transition. I can tell you with covid, you know, people were, I got to go out of town, I gotta take care of family member. So we were trying to make sure that they were able to get their medication and their refills while they were out of town. Um, in this area. This is a huge military town here. I have a couple of patients who work on the merchant seamen, their merchant seamen, they work on those boats that are out there refueling the ships, and a lot of times they're out on the water for four months at a time. So again, it's trying to do an override to make sure they have enough medication with them. So again, it's just talk to your patients and get to know your patients and get to know their story and then assess any type of barriers and being strategized and problem solved to try to get those those issues addressed to taken care of. So key points we're gonna summarize HIV treatment is highly effective. Antiretroviral therapy A. R. T. Can reduce complications associated with HIV and also prevent transmission of HIV treatment options have improved in terms of safety and tolerable. Itty nurses and other providers play a key role in helping patients adhere. So, you know, art, which is antiretroviral therapy. These are some additional references and additional information um that our resources for you, we encourage you to view of the learning modules in our series and when we all work together, we can help improve the lives of persons living with HIV. This is our knowledge check goals of HIV treatment include which of the following a decreased risk of HIV transmission, B stop replication of HIV See, curing HIV Dean A and B. Only E. All of the above and our answer is D. A. And B only the rationale is goals of antiretroviral therapy include improving survival, reducing mortality for people living with HIV suppressing the replication of HIV and decreasing the risk of HIV transmission. At this point, there is no cure for HIV. Hello, my name is Alicia Dickens and I am a nurse practitioner at Can Community Health in Norfolk. Welcome to this module on HIV prevention and older adults, pre exposure, prophylaxis, prep and post exposure prophylaxis. How these are the learning objectives for this module on completion of this activity, participants will be able to describe the importance of prevention and older adults identify candidates for pre exposure prophylaxis which is prepped and post exposure prophylaxis. Discuss the indications and monitoring for pre exposure prophylaxis and post exposure prophylaxis. So, we're gonna begin with a very interesting grasping This graphic looks at new HIV diagnosis among people aged 50 and older in the United States And unfortunately it tells us that among people aged 50 and older, most new HIV diagnosis were among men. So when we look at the category of men, the M. S. M. Category is the highest at 66% and then it goes down to heterosexual contact and injection drug use for the category of women, interestingly enough. Um It's heterosexual contact. So that is still sexual contact with men. Um that, You know, produces that new HIV diagnosis at 86 followed by injection drug use. This next slide is very telling S. T. I. S. Which is sexually transmitted infections, an older adult. So sexually transmitted infections more than double, more than doubled In the past 10 years among persons 65 years of age and older in the United States. And basically we're talking primary syphilis and gonorrhea. And my general take on this situation is a couple of different things. Number one, a lot of times older we consider our older adults in a lower risk category. And and they are technically by definition but a lot of our older adults um you know they may be participating in sexual activity with someone who is significantly younger than they are. And so that younger age group um there they have higher risk factors. And so there are a higher risk category. And so you know these days certainly in the last 10 years there's a lot of overlap between sexual and social networks. And so we get this you know high risk category of younger patients kind of intermingling with the older patients. And I think you know here we are we're talking about S. T. I. S. And older adults. I think the other factor which is related to S. T. I. S. Or STD sexually transmitted disease. I think one of the things that's very telling is that a lot of places do not test three sites for sexually transmitted diseases. And what I mean by that is you know, you can go in somewhere. You can give a urine sample and that urine sample can do it. You can do a nuclear acid test on that sample and test it for chlamydia or gonorrhea. And if you go somewhere and ask for STD tests and that's all they do and it's negative. You think hey I'm good. I'm fine. However we do three site testing. So we would swab your throat or your fair nix and swab your rectal area because a lot of times those stds cannot be picked up um just in your urine. So if you have rectal gonorrhea it's not gonna be picked up in your urine and you're you're a genital area. Um if you have fair and geo gonorrhea again it's not going to be picked up in that euro genital area. And so I think that's a big problem because I think, you know, people get that one test, that urine test is negative and they think okay I'm good and then you're out and you're potentially spreading the disease and you're not getting treated. Um and I think that just kind of you know, it adds fuel to the fire. So I think that is a big deal a lack of three site testing for S. T. I. S. And then I think the intermingling of the overlap of the social networks with the younger versus the older um people who maybe you know having sexual activity barriers to HIV prevention and older adults. And so, you know, this schematic shows us that number one, a lot of providers do not discuss sex and I would also say a lot of providers and a lot of patients don't see themselves at risk, they don't perceive that they are at risk for HIV infection, physical challenges. So older adults have a lot of physical challenges. And again, I just think that adds to the stereotype that older people are not having sex misconceptions, lack of knowledge and that lack of knowledge runs deep. So on the provider side, lack of knowledge, you know, not knowing anything about prep, not knowing anything about these overlapping social and sexual networks not knowing about the three site STD testing. Um and the same goes for the patient, the patient, you know, probably would not know that information. Additionally, a lot of people in general just don't know how prevalent HIV is in our community and then last but certainly not least stigma. Um you know, it's funny because I see a good number of Older patients, 65, I've gentleman in his seventies and they take prep and they say I come here because I don't want my regular doctor to know that I'm taking prep. Like I don't want my my family doctor to know that, you know that I'm bisexual and so that stigma is real and it's rampant. One of the things that we can do is that we can normalize or we can try to normalize as much as we can sexual history questions. So we want to incorporate sexual health questions into health histories. We want to be non judgmental and use non judgmental language and I think it's important to find an approach that works to you. I think you have to come off being genuinely concerned about your patient and you don't want to seem like that that interest is not genuine. So again I think it's just important to be transparent and find an approach that works for you. one of the things when we talk about sexual history questions or sexual history taking the step to to that is then HIV testing. So I think just like we normalized sexual history questions or incorporating those questions in our health histories. And again we want those health history to be taken from adolescents to hospice. The same goes for HIV testing. And I think you know the sexual history taking is part one and I think the HIV testing is right up under that Part two. And again, HIV testing, anybody, anybody who's sexually active from 1365 is you know what the c. d. c. recommends. So these are listed are some of our prevention options. So various methods include condoms and dental dams pre exposure prophylaxis. Prep is medication that people take every day who are HIV negative to stay HIV negative and the in post exposure prophylaxis Um if someone has an exposure, if they're within 72 hours of that exposure, they can come and get a three drug regimen that they could take for 30 days to prevent HIV acquisition. Some other things in terms of prevention options, limiting your sexual partners um and also not sharing needles or syringes. So what is pre exposure prophylaxis? So we throw this word around prep prep prep all the time and when we throw the word around, you know, it's implied that we're talking about the medication. But what is it is actually an HIV prevention program for people without HIV. So it's for people who are HIV negative and they want to stay HIV negative and what we do, we use medication to reduce the risk of acquiring HIV for that patient. And it is a harm reduction program. It is a whole program. We counsel patients, we see them every three months, we get lab work um do STD tests and um it is a full harm reduction program. So we throw the word around like it's a medication and the medication is definitely at the core of that. But it does include you know, medical office visits and laboratory testing the evidence for prep sexual transmission. It is highly effective, highly, highly effective. Um But the effectiveness that you see here 99 is based on high levels of adherence. So I tell patients You have got to take your medication every day in order for it to work in order for you to get that 99% effectiveness, you gotta take it every day. I can tell you I have had patients on front who had missed doses here and there. They were not adherent to their prep and they popped HIV positive. So prep works as long as the patients take the medication, like they're supposed to candidates for prep any sexually active adults without HIV again without HIV who report having anal or vaginal sex in the past six months and any of the following. Their partner has HIV especially if their partner has a detectable viral load, bacterial sexually transmitted infections in the past six months history of inconsistent or no condom use of sexual partners and I would add multiple partners. So if they have more than one sexual partner, they're definitely at risk. Persons without HIV who inject drugs who also have an injection partner with HIV or who share equipment. Again, they're at risk for HIV acquisition and we would want to get them on prep. Also clinical eligibility for prep documented HIV test within one week before initially prescribing prep, no signs or symptoms of acute HIV infection which is kind of a flu like syndrome or like mono, you know, fever, sore throat, maybe a rash, feeling really tired and fatigued. Um no contraindicated medications and an estimated creatinine clearance of greater than 30 ml per minute same day prep prescriptions are encouraged and what I tell people is we do same day prep just like we want to get people on HIV treatment immediately. We want to start people on prep immediately. So again that negative test and I know I use actually within two weeks and no HIV exposure since that test, all laboratory testing is obtained on that day. The patient has no symptoms of acute HIV infection. And if if for whatever reason if they come into the clinic and it's been more than two weeks, what we do, we'll do a rapid HIV test as long as that's negative, then we'll go ahead and start prep on that day, we'll go ahead and draw the blood while we wait, you know for the HIV results, but we'll go ahead and get them started on that same day. So prep medications. So Truvada which is tenofovir dice approx. So for Marie 300 mg and interested in being 200 mg. It is now generic and that is one tablet once a day. And then the other medication is dez cov to know for their elephant of mad 25 mg and m transcended being 200 mg, one tablet once a day. And this particular medicine is not for persons who are at risk of HIV acquisition from vaginal sex. So if your assist gender. Female, we have to give you Truvada cab photography and this is new and exciting. This is our injectable prep literally it was just FDA approved you know a couple of weeks ago um it is administered as an I am injection every eight weeks so I am so happy to talk about that. So in terms of patient monitoring again and this is for oral prep at least every three months. So we do STD and HIV screening, patients have access to clean needles and syringes. Um And drug treatment for persons who inject drugs every six months assess renal function especially for patients 50 years and older and screened for S. T. I. And truthfully I do that every three months I do that every three months. So patient monitoring for injectable prep. We want to check uh HIV um antigen antibody test and a viral load one month after initiation and being every two months after that you know when we renew your prescription. So this is a very interesting quote. While a number of factors could impact prep prescribing including patients low familiarity with the drug or practitioners lack of opportunity and offering prep In order for the drug to be effective at eliminating HIV in the United States in the next 10 years the proportion of prescribing needs to increase again. The proportion of prescribing needs to increase with more effort placed on identifying risk across populations and clinical specialties. And I'm telling you I have had patients you know come to me and this is even you know while working at the v. A hospital you know hey I asked my primary care provider, you know, I told them I was interested in prep and I wanted to get on prep and they said, well no, just use condoms or they said they weren't familiar with it and they didn't know anything about it. And then the thing that really kind of gets at you is that person or that provider didn't take the extra extra step of finding out, okay, I'm not comfortable prescribing this to you. Let me find out who can we want to get the word out about prep. We want people to be educated about prep. We would love for them to be comfortable with prescribing it, but if they're not that we want them to know where the resources are so that they can refer patients. Um two clinics who provide prep services. So what is post exposure prophylaxis or pep? That is an intervention for people without HIV. And basically what they do, they're using medication to reduce the risk of acquiring HIV following a potential exposure to HIV. It has to be taken within 72 hours of the exposure And you take the medication for 28 days. Post exposure medication. So basically the Tenofovir or the Truvada. Tenofovir dice a proxy for Marie and m tracks of the bean and you can either use rotogravure 400 mg twice a day or photography, which is typically a I tend to use, okay um I will use real to grow fear if I have a woman of childbearing age. But again these medications work um You know we say within 72 hours but it's as soon as possible so as soon as someone can get to a clinic, We don't necessarily want people sitting around waiting till the 70th hour. Um As soon as you can get this medication on board the better. So patient monitoring for post exposure prophylaxis, baseline HIV antibody testing, I always do a viral load testing as well. Hepatitis B and C. Serology, S. T. I. Testing. You want to check for liver and kidney function and then four weeks later we check everything again and then my preference is to then transition that person on to prep. Um But you know, again, it's up to the patient but you know, that's my goal. Let's get you on post exposure prophylaxis and then let's transition you over to pre exposure prophylaxis. So key points. So in summary, in summary, older adults remain at risk for HIV infection. Clinicians should assess and normalize sexual history taking as part of routine care. Prep and Pep offer an additional method to prevent HIV nurses and other health professionals play a key role in helping identify patients, council patients regarding risk reduction and supporting patients using prep or, yep. Thank you for viewing this learning module on HIV prevention in older adults. Pre exposure prophylaxis prep and post exposure prophylaxis. Pep. We have provided some additional resources for you. We encourage you to view the other learning modules in our series. We want to work together to continue to help improve the lives of persons living with HIV. This is our knowledge check which of the following individuals are candidates for prep. A 62 year old male who injects drugs and shares injection equipment. B 72 year old male with a recent diagnosis of Syphilis. See 55 year old woman with a partner with HIV who has a detectable viral load D. Only B and C. Or E. All of the above the answer is E all of the above. This is the rationale HIV. Pre exposure prophylaxis or prep is indicated for persons without HIV who may be at risk through sexual or drug use behaviors. Candidates include sexually active individuals without HIV who have partners with HIV, especially if their partner has a detectable viral load, bacterial sexually transmitted infections in the last six months history of inconsistent or no condom use with sexual partners. Persons who inject drugs without HIV who have an injection partner with HIV or who share injection equipment. Hello, my name is Jeffrey Kwong and I'm an adult gerontology nurse practitioner and HIV clinician and welcome to this learning module which is part of an ax HIV and aging educational series. Joining me today is Murray Penner who is the U. S. Executive director at prevention access campaign. He'll be sharing his perspectives and experiences as a person living with HIV. Thank you so much for joining me today Marie, can you tell us a little bit about your experience as a person living and aging with HIV? Well sure thank you so much for this opportunity to to talk about such an important topic. I have been living with HIV since 1986 and um you know I was 25 years old when I was diagnosed and I'm 60 now obviously I've seen a lot of things happen in that you know Now nearly 36 years that I've been living with HIV. I think the most important thing that I would like to share about my experience in living with HIV particularly as I'm aging is that um the complications related to other conditions really becomes something that we are now paying attention to or I have to now pay attention to. Unlike in the early days when I was younger I didn't have all these complications, hypertension, um prediabetic prostate cancer, high cholesterol, lots of other things that are now taking place in my life. And so you know we often hear about the once daily pill and how that has revolutionized HIV treatment, which is great. It certainly is easier than the early days. But I've got a lot of other pills that I'm taking now and a lot of other conditions to worry about as well and those comorbidities if you want to want to call it that are something that you know, I think HIV clinicians providers really need to understand and recognize that it's not just HIV that you're um you know, that you're working with here, it is all the other conditions not to mention um for me anyway, uh and particularly now during covid the, you know, the mental health issues that have arisen and even being isolated and by myself a lot more than I would have been when I was younger and could get out and around a lot easier is also something that needs to be taken into consideration. Um it's it's clearly been um you know, I I clearly have a very privileged life, so I I'm not saying that I've got all of these issues, but it's just changed significantly as I've gotten older in terms of the focus on all the other life conditions that I'm dealing with. Absolutely, and I think as part of our educational series, we've tried to address some of these ceiling issues that you mentioned in terms of other chronic conditions in terms of mental health. Um one thing I want to touch on or bring up, because I know your organization is very renowned and a strong advocate of U equals U. Can you tell us a little bit about the significance of U equals you both from a global perspective and also from a personal perspective what that means. You know, this is, this is my passion. Um I'm very privileged to get to do this work as as a person who is employed in the HIV arena, But um, U equals U undetectable equals un transmittable. Um, Is revolutionary. It was it's been revolutionary in my life. I first heard about U equals U in about 2008 when the Swiss came out with a statement saying, you know, if you're undetectable, you're not going to transmit HIV to your sexual partners. And I was very skeptical at the time as a person living with HIV, I was always concerned that I was going to transmit to my sexual partners. And so I wasn't having sex very much. And and you know, clearly that's another thing I think we need to think about is that older people still have sex. And so that the the the intersection with HIV and being undetectable and being older and the opportunity that that provides you to continue to have a worry free stigma free life in terms of your HIV, I don't have to worry that I'm gonna transmit to my sexual partners because I'm not, I'm taking my medication regularly. I'm not going to transmit for me. U equals U really gives me hope and it gives me a sense of freedom from the shackles if you will of stigma and worry and fear of transmitting to someone else. Um, I can enjoy my life without having to worry about that part of that part of being HIV positive and from your work and an organization that supports and promotes U equals U. Can you tell us a little bit or you know, what has your experience been in terms of um just the health care provider knowledge about U equals U. Do you think? What are, what are some of the challenges in terms of getting the message out to healthcare providers about that is a really good question. And you know, again, I'm fortunate my my doctor has always talked about it. My pharmacist talks about it. I've got a lot of people around me that are talking about it and it's it's even interesting. I went to pick up my medication the other day and the pharmacist said, hey, I'm just making sure do you know about U equals U. And I started laughing and was able to, you know, kind of tell him what I did and everything. But nonetheless, um, I think there are providers, we hear about providers a lot that are very reluctant to share about U equals U with their patients. And you know, some of the reasons cited are, well, you know, if I tell my patients about U equals you, they'll stop taking their medication or they will have risky sex or you know, they just, they just don't understand what it means. Well, you know, the real power of U equals U. Is understanding what it means. And so it's a provider's responsibility in my view to tell their patients about U Equals U. So that they have the information so that they can make decisions about you know the sexual activities that they have and and how they have sex. You know, there are times when you don't need to wear a condom if you're HIV positive and you've got a HIV negative partner, there may be times when you do um you know particularly if adherence is an issue because clearly U. Equals U. Only works if you're adherent to your medication. So if an adherence is an issue it might be wise to use condoms or make sure that you're HIV negative partner is on prep. Um You know or if there are multiple sex partners or if you're worried about S. T. I. S. There are times when you can negotiate that depending on what the situation is, but patients need to have all of the information in order to make those decisions. So it's really critically important that providers talk to their patients about U. Equals you and make sure that they understand. And I don't think it's just a one off where you say it once and never talk about it again because it's just important to reinforce that same message over and over again. Excellent. Excellent points. Thank you so much for sharing. Um I want to go back a little bit to something that you mentioned. Two were alluded to a little bit earlier which is stigma and we talk about that in some of our other foundational modules and clinicians viewing our learning series, we'll hear about it several times. Um can you tell us a little bit about your experience with stigma and what do you think health care providers can do to help combat that issue or make that better for for patients? Yeah, that's so critically important because I think HIV stigma is really the emergency that we're dealing with in public health and and really is what impedes a lot of our progress. Um you know, as as as my experience goes, um I was fortunate that I didn't have terribly many experiences of stigma but in the early days of the epidemic I remember I had to have my gallbladder taken out and I people came in in Hazmat suits and you know, all of this like really like protective gear. It was like you see on the news that that even china is now doing with you know with Covid, it was this very scary and very stigmatizing um experience to go through. That that's clearly changed in the medical system now it's not the same as it was then, but that was certainly something that that I experienced then I've also had providers um you know who are not as familiar with treating people with HIV, not not my HIV doc or some of the regular doctors that I have that have, you know asked some really insensitive and um and and just inappropriate questions about, you know, not understanding about HIV and so, um that stigma is really prevalent now, you know, not taking away from me and going to the larger population. I think that because there's such a a bias against people living with HIV in many cases they're dirty, you know, they spread disease, they're vectors of disease, all those kinds of terrible things that we hear. Um You know, I think it keeps people from accessing medical care and getting into onto treatment. Um I think it even probably prevents um some people from getting tested and and getting on prep when they, you know, when they when they could easily do that. The services are there, that the medications are there, but there's just an access issue. And then, you know, people that are um, you know, in in unstable housing situations, um people that are concerned that their family members are going to find their medications, all those kinds of things. That's all rooted in stigma. And people are just scared to actually um find out if they're HIV positive and if they are many times, you know, get into medical care and and stay on medical care. I didn't get into medical care for the first, probably year of my diagnosis because I was too afraid to even speak the words that I was HIV positive, I was afraid I was gonna lose my insurance. Um, you know, I wasn't able to get life insurance, there's all these different things that that really are contributing factors to, well er stigma that's all stigmatizing, right? So especially today when you can live with HIV, just like the person who doesn't have HIV, you can live a normal and full life and so um you know, I think there's just stigma everywhere as it relates to HIV and I think providers really need to be aware of that and recognize that the words that they use matter. I think it I think all of us need to recognize that the words that we use matter um you know, I mean I can even speak to like dating apps when you're, you know, trying to meet someone and they'll ask the words are you clean? I get that quite a bit, it's like really, yeah, I took a shower today, okay, I'm clean. Um you know, they're, they're saying, you know, I hope you don't have HIV cause if you do. So I mean I think that's probably the place that I experience stigma even today is really on dating apps and that's a that's a it's a terrible feeling when you, you know, you get blocked as soon as somebody asked your status and you tell them you're HIV positive and undetectable, so um yeah, there's lots of examples um again I've been fortunate and haven't maybe had as many as some people have, but there are lots and lots of stories about people and the experiences they have um being stigmatized because they're HIV positive. Um thank you for sharing your perspectives on that. I think that's very telling and so important for others to hear, especially those of us who are viewing this, who work in the health care field. One thing that I wanted to also ask you about was, you know, when we think about aging with HIV, So the patients who were aging with HIV or persons who are aging with HIV now are in their fifties, sixties, seventies, eighties and beyond And many of them um or every everyone lived through the early 80s and sort of the early days of the epidemic and we've seen such a transformation of the epidemic throughout the last couple of decades. Um there has been this phenomenon of people who, who may have lost um the folks at the very beginning or who have been through, you know, experiences of stigma etcetera, and this so called survivor syndrome. Um, I think people have turned that that phrase, can you tell us a little bit about what that that means and how that has impacted you. It's so, in my way. Sure, sure. And it has um, you know, survivor syndrome is really about, you know, making it through um a really traumatic experience when you have watched a lot of your friends and loved ones not make it through that experience. Um very, very traumatic. I will say that um around the holidays, I get really depressed and I've done a lot of therapy about it. I've really, you know, spent a lot of time working on what that means and why that happens. And for many, many years, especially early in the epidemic, I was always afraid that this was gonna be my last christmas. And so, um, you know, it always took me back to this place of all of my friends are gone, I'm still here. It's like, it's almost like I feel like I shouldn't be here as well. And so I used to dread the holidays because it brought up all those memories. Um, and, and I still dread the holidays this particular year was really, really tough and, and talk about depression and mental health issues that, that I experienced. It was, it was tough. Um, I, I continue to, you know, I went to funerals every week, um, in the, in the height of the epidemic and that is a traumatic experience to live through and, and to and to carry. And um, I struggled with that a lot Jeff. It's, it's um, it's a tough, it's a tough situation to deal with. And I think that particularly in the last couple of years as we've, you know, seen covid around us and we've seen more people dying. I don't, I, I think it's been just exacerbated that, you know, those kind of feelings continue to come up. Um, I don't know, I feel guilty sometimes for having made it through and it's like what if, you know, my friends would have had access to the same? Um, I was in a clinical trial right before. Um, you know, protease inhibitors were approved and I think that's what got me over the hump if you will into, you know, into the antiretroviral therapy era. And so, um, I don't know, I feel guilty and it's tough. It's it's something that I think providers really need to be aware of and and think about and help understand um where their patients are coming from and I don't think it's a one size fits all either. I think everybody experiences it in different ways. And so that's one of the things I would like to say about um working with people who are aging and are living with HIV and probably people living with HIV in general as well is that it's not a one size fits all approach and you can't just generalize that everybody feels the same way. And so talking to patients and understanding where they're coming from and living with the disease, especially as people get older, I think is really critical. One of the exciting things about HIV care today is really our advancement in treatment and the ability to um for some individuals take a single pill once a day or even some long acting injectable options? Um just in terms of adherence though, we know that that is still such a critical part of, of providing HIV care. Can you tell us what it's like just in terms of from a personal perspective having to take daily medications or what are some of your strategies or thoughts on, you know, helping um keep people adherent to therapy. Yeah, that's um yeah, that's so critically important. And you know, my strategy is pretty simple. First of all, I've got eight other medications that I take in addition to my once a day um one pill for HIV with with two medications in it. But um I have a pill box, you know, and it's sitting on my dresser and so every morning when I'm getting dressed, I make sure that that that day's pills are, are gone out of that out of that pillbox, The long acting injectable option is really great. Um it's a really great option. And now as of I think, last, I don't know, I think this week you can take your treatment long acting injectables every other month versus every month. It was every month for for the first part of the approval and you know, I think about that and I think that would be great not to have to worry about my HIV medication, but I've got all these other pills that I've got to take every day anyway. So it's really, honestly for me right now anyway, it's just as easy to take that one pill once a day with my other medication because I don't want to forget the other medication either. And so it's, it's just really easy. I think the other challenging thing with long acting injectables right now is you've got to go to the doctor to get those shots. They're not, it's not a easy, simple self administered shot that you can take and be done with. It's, you got to go to a to a specialist in to a doctor or a specially trained person in order to actually get those shots. And so for me that means going to the doctor every two months versus right now, I'm going every six months. And so, you know, it adds a couple of extra doctor visits in there. And my routine is pretty, pretty easy right now. I will say that in the early days of the epidemic boy, those um, those regimens were tough. You know, sometimes they were three times a day. Um, sometimes you have to keep things refrigerated. There were a lot of different challenges associated with the medication and they're so much simpler today. And it really is easy. If you can, you know, if you can navigate all the insurance and everything to get those medications, it's easy to take it once a day. I recognize that one of the challenges is adherence in terms of, Um, why we don't have more people virally suppressed in the United States today. I mean there's, it's it's sad that we've got, you know, roughly 400,000 people living with HIV in this country who are not virally suppressed. Um Talk about U equals U again, but just for a moment, you know, if we could get a good proportion of those individuals virally suppressed, we would really reduce reduce new transmissions. Just, you know, it's the foundation of of what it would take to end this epidemic. So clearly prep is important alongside of it. But that's it's critical. And so um you know, I take it very seriously. Uh and U equals U has actually helped motivate me to be more adherent. It's helped me um realize that I don't want to miss a dose of medication any days. Um so yeah, there's lots of strategies. People use different strategies. Mine is pretty simple. Just a pill box on top of my dresser in the morning. Great. Um so you are learning module series is really for health care providers in all different settings, hospitals, long term care facilities, hospice, home care. And we know that, you know, we will need to engage all of these providers as as more of our patients agent to older adulthood. Just in closing what is one or two key things that you would want to make sure that providers in these settings really understood um in order to provide quality care, what Take home message which you provide. Yeah, I think I probably mentioned most of these throughout, but I'll sum it up with a couple of things. one. I think it's important to remember that people living with HIV who are older have been through some very traumatic experiences and and so sort of that trauma, trauma informed care um really being cognizant of the fact that there may be um mental health issues associated with you know, the trauma etcetera. So I think um recognizing that um I also mentioned you know, the recognition that there are so many other conditions that are important to us as we age with HIV in addition to just are HIV. And then I also think that it's important to sort of remember that what I said earlier about, it's not a one size fits all approach. And just because one person over here might have said something about living with HIV being this, it's gonna be a different experience for the next person. And so um the taking a little extra time to understand what the needs of some someone um you know, someone's life is um is probably really important. Great well thank you so much Murray for taking the time today to share your perspectives for additional information. We've provided some additional resources for viewers on the website. We encourage you to view our other learning modules as part of this series and working together, we can help improve the lives of persons aging with HIV. Thank you
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