HIV PREVENTION IN A CLINICAL CARE SETTING
Our expert is Jeanne Marrazzo, MD, MP. She is a Professor in the Division of Allergy and Infectious Diseases in the Department of Medicine, University of Washington. Her research includes biomedical prevention of HIV. As the Medical Director of the Seattle STD/HIV Prevention Training Center, she is also involved in education for providers and students.
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BE ALERT TO THE POSSIBILITY OF ACUTE HIV INFECTION IN YOUR PATIENTS
Although the incidence of new HIV-1 infections has decreased by 1/3 in the years since 2001, there will nevertheless be approximately 2.3 million new cases worldwide this year. Of these, 50,000 will occur in the United States. Roughly 15,000 will be women.
EARLY DETECTION NEEDED TO SLOW THE EPIDEMIC
In the past decade, we have had extraordinary success with approaches to prevention. These include: prevention of mother-to-child HIV transmission; medical male circumcision; pre-exposure prophylaxis; vaginal microbicides; and prevention of transmission to uninfected partners of an HIV-infected person with the help of effective antiretroviral therapy. What’s needed now for slowing the epidemic further still is prevention and also early detection. This means more broadly based testing coupled with high levels of both treatment and adherence.
HIV PREVENTION IS A PART OF PRIMARY CARE FOR WOMEN
Some still think of HIV as a gay man’s disease, and tend to leave women out of the risk assessment and decision-making. This is unfortunate because women are vulnerable to HIV. Further, 16% of HIV positive individuals do not know they have it, and they account for a disproportionate number of new infections. We recommend that everyone have an HIV test at least once in their lifetime, and more often if they are at increased risk of acquiring HIV. Have a conversation about HIV with your patients and recommend that at some point they be tested.
INTEGRATE BEHAVIORAL RISK ASSESSMENT WITH TARGETED RISK REDUCTION
Individuals who are not infected with HIV but are at high risk should be receiving interventions. Is the woman dating a guy whose HIV status is unclear and she’s concerned? Or maybe she knows he is HIV positive but it’s under control with antiretroviral medications? Maybe her partner is HIV positive, she wants to become pregnant and is worried about delivering a healthy child? Has she recently been diagnosed with a sexually transmitted infection? Does she use injected drugs or share needles? In any of these cases, consider pre-exposure or post-exposure prophylaxis.
PROPHYLAXIS AND RISK REDUCTION
Many insurance plans will cover pre-exposure prophylaxis for women at high risk. We recommend daily emtricitabine/ tenofovir disoproxil fumarate for pre-exposure prophylaxis in the cases of those at high risk for HIV. For persons who inject drugs, harm reduction services should be provided, including needle and syringe exchange programs or supervised injection. They should also have access to medically assisted therapies, including opioid agonists and antagonists, and low-threshold detoxification and drug cessation programs. Post-exposure prophylaxis is recommended for all persons who have sustained a mucosal or parenteral exposure to HIV from a known infected source, and this should be initiated as soon as possible.
CONTRACEPTION FOR WOMEN LIVING WITH HIV OR WITH A PARTNER WITH HIV
If a woman is concerned about becoming infected with HIV, counsel her to use condoms. If she is HIV-positive, hormonal contraception does not increase the risk of complications of HIV and should be offered as needed.
MANAGING URINARY TRACT INFECTIONS
Our expert is Thomas M. Hooton, MD, Associate Chief of Staff, Miami Veterans Healthcare System and Professor of Clinical Medicine at the University of Miami Miller School of Medicine. His specialty is infectious diseases.
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URINARY TRACT INFECTIONS (UTIs) ARE COMMON
UTI is the most common bacterial infection encountered in the ambulatory care setting in the United States. By age 32, half of all women report having had at least one UTI, and among young, healthy women with cystitis, the infection will recur in 25% of them within six months. The recurrence rate increases when there’s more than one prior UTI.
BACTERIAL CULTURE USUALLY NOT NEEDED FOR UNCOMPLICATED UTI
We define an uncomplicated UTI as one involving a healthy, ambulatory, non-pregnant woman with no history of genitourinary, anatomic, or functional abnormalities. UTIs in everyone else are considered complicated. In the case of an uncomplicated UTI, there is such a high correlation between the typical UTI symptoms and laboratory confirmation of infection that a bacterial culture is usually not needed. If you do perform a urine culture in these cases, you may be wasting two or three days waiting for the results and meanwhile, your patient is suffering. Our recommendation for women with typical UTI symptoms is: treat her immediately with antibiotics, and have her call you if she doesn’t get better. An exception to this is if she’s sexually active and has a history of STDs, you might want to culture for chlamydia. If your patient is hospitalized or in a nursing home or using a catheter or has symptoms or signs of kidney infection (e.g., fever), or is otherwise thought to have a complicated UTI, we recommend, across the board, having a culture taken.
E. coli causes 90% of UTIs, and in women the voided urine culture is highly predictive of bladder infection when it comes to finding E. coli bladder infections. On the other hand, there’s a risk that the lab culture will give a false negative for E. coli, given that most laboratories do not routinely report colony counts less than 104 CFU/ml. Such laboratories will miss as many as 20- 30% of symptomatic UTIs. Further complicating interpretation, enterococci and group B streptococci in voided urine may represent urethral contamination rather than bladder infection. If a woman is not symptomatic, even when bacteria are found in the culture, it is not necessary to treat.
AIM TO REDUCE ANTIMICROBIAL USE
There is an increase in antimicrobial resistance worldwide. As just one example, between the years 2000 and 2010, the Surveillance Network reports that urinary E. coli resistance for ciprofloxacin increased from 3% to 17%. In this regard, antibiotic resistance prevalence varies by uropathogen, but for commonly used oral drugs it may be as low as 5% for nitrofurantoin to >50% for amoxicillin. Because resistance complicates treatment, we need to practice antimicrobial stewardship. In cases where the UTI symptoms are mild, the infection may clear on its own. Randomized trials using placebos show that most patients tend to get better over time and that the body’s own immune system can take care of most infections. In the case of a very mild UTI, a reasonable strategy for handling it, if your patient is agreeable to this approach, is to increase fluids, take a urinary analgesic, and delay antibiotics for a couple of days and see if the UTI clears on its own. In cases where antibiotic therapy is needed, choose a short course treatment. There are no first-line recommended regimens that would last seven days.
STRATEGIES TO REDUCE RISK OF UTI RECURRENCE
In older women, topical vaginal estrogens have been helpful. Cranberry is a widely used OTC product, but there is conflicting evidence as to whether or not it is effective in decreasing UTI risk. Another OTC product, D-mannose, a natural sugar, inhibits the attachment of E. coli to urinary mucosa, which means that the bacteria can be flushed out when voiding. We don’t have a lot of data on D-mannose yet, but absence of data doesn’t mean it doesn’t work. Fortunately, both cranberry and D-mannose can be obtained without a prescription. Another strategy is avoiding using either a diaphragm or a spermicide-coated condom for birth control (if another method can be used), since both of these have been shown to increase the risk of UTI. There are also behavioral changes that may be effective, such as drinking more water and not delaying going to the bathroom to urinate. Of course sexual intercourse is the strongest risk factor for UTI, so reducing its frequency, if feasible, should be effective in reducing the risk of UTI.
INVITE YOUR PATIENT WITH RECURRING UTI TO KEEP A DIARY
There are several strategies that haven’t been tested, but they may work for your individual patient. Ask her to see what in her daily routine seems to correlate with recurrent UTI. As noted above, if cranberry or D-mannose seem to work, then by all means encourage their use. See if increasing the amount of fluids consumed daily makes a difference. Some have suggested an association with tight-fitting underwear versus looser cotton underwear, and shower versus tubs baths. If the patient thinks something they have tried works, then encourage its use as long as it seems safe. Antibiotics are highly effective but should be discouraged until antibiotic-sparing approaches have been tried and used only in patients with frequent recurrences of bothersome symptomatic UTIs.
Menopause and Cardiovascular Disease
Our expert is Virginia M. Miller, PhD, Professor of Physiology and Surgery at the Mayo Clinic, where she is Principal Investigator of a Specialized Center for Research of Sex Differences and Research Director for Building Interdisciplinary Research Careers in Women’s Health. Dr. Miller’s work includes studying how estrogen affects progression of atherosclerosis and changes in brain structure and cognition at menopause. If there is a medical topic that you would like to see explored here, please let me know.
MENOPAUSE HAS AN IMPACT ON CARDIOVASCULAR DISEASE
Menopause is associated with dramatic changes in the sex steroid estrogen, and these changes can accelerate the development of cardiovascular disease. Women lag behind men in developing cardiovascular disease until menopause and then the risk for developing cardiovascular disease increases to become about the same as for men.
ESTROGEN TREATMENTS ARE NOT ALL THE SAME
There are benefits and harms associated with the use of estrogen treatment for menopausal symptoms and one of the major issues that needs to be addressed, both by scientists and clinicians, is the tendency to lump all estrogen treatments together. The Women’s Health Initiative, which showed adverse cardiovascular consequences for hormone replacement therapy, used conjugated equine estrogen (CEE) for women without a uterus and, in women with a uterus, the estrogen was used with a synthetic progestogen. However, other estrogen preparations, such as oral estradiol and transdermal estrogen, have different and more favorable risk profiles.
ONE SIZE DOES NOT FIT ALL
It is important to keep in mind the age and underlying health conditions of the women who are using these products. Data from observational and epidemiological studies and the Women’s Health Initiative show that attention needs to be given to the health status of women when prescribing hormone replacement therapy. Those who are at low risk for a cardiovascular disease may do well with hormone replacement therapy, in contrast to those who have higher cardiovascular risk factors.
HRT NEEDED FOR PREMATURE OR SURGICALLY INDUCED MENOPAUSE
Another very strong case of one size not fitting all is women who have either had premature menopause or a surgically induced menopause. After the Women’s Health Initiative study, it seemed as if hormone replacement therapy was bad for everyone, but in these two cases, the benefits clearly outweigh the harm. Depriving these women of HRT increases the risk of mortality. Women in these two categories benefit if they receive HRT until natural menopause would have occurred.
CLINICIANS NEED TO REQUEST ADDITIONAL STUDIES
The cardiovascular system of women differs greatly from that of men, primarily because of the need to adjust to pregnancy. This leads to the assumption that treatment results will not be the same for women as for men. Although there have been some published studies on the differences in response to different treatments, more women are needed in clinical trials, and clinical trial data analysis needs to be done by sex. To develop the guidelines for what treatments are effective for women, more data are needed to provide useful information for clinicians to use in their practices. We need a groundswell of clinicians asking for these kinds of studies.
Preventing Unintended Pregnancy
Our expert is Jeffrey F. Peipert, MD, PhD, Professor of Obstetrics and Gynecology at Washington University School of Medicine. He is Vice Chair of Clinical Research for the Department of Obstetrics and Gynecology and is a recognized expert in reproductive epidemiology, sexually transmitted diseases, and family planning.
Please don’t hesitate to let me know if there is a topic relating to women’s health that you would like to see explored in this blog.
THE CONSEQUENCES OF UNINTENDED PREGNANCIES ARE SEVERE
In the United States, of the 6.4 million pregnancies each year, 49% are unplanned and, of these, 40% will end in abortion. In this country $11 billion is allocated to unplanned pregnancies and abortions. In addition, unintended pregnancies often carry higher risks, and the outcomes for the neonates are often poorer. There is also a higher risk of partner violenceand, for the individual woman, an unintended pregnancy can disrupt her education and her career plans.
MORE EFFECTIVE FAMILY PLANNING WOULD SAVE LIVES
Effective family planning could prevent as many as one in every three maternal deaths. It would prevent unintended pregnancies and abortions, enable the healthy spacing of births, and it would prevent the risks to mothers and to the children of very young mothers. It would also stop childbearing when the desired family size has been reached.
LARC METHODS ARE THE MOST EFFECTIVE REVERSIBLE CONTRACEPTION
Long-acting reversible contraception (LARC) methods include IUDs and implants. They are 20 times more effective than pills, patches, and rings, and even though they are reversible, they rival sterilization in their effectiveness. They have high satisfaction and continuation rates and, of major importance, these methods are not dependent on compliance or adherence. They are immediately effective and, when removed, there is a rapid return to fertility. These methods work by preventing fertilization, either by preventing ovulation and/or thickening the cervical mucus and making it difficult for sperm to ascend to meet the egg. The subdermal implant provides protection for up to 3 years, the LNG-IUS lasts up to 5 years, and the copper T IUD, is effective for up to 10 years.
PROVIDERS AND PATIENTS ARE INSUFFICIENTLY AWARE OF LARC CHOICES
Given the very high satisfaction rates for existing users, coupled with the high effectiveness rates for LARC methods, more women would be expected to choose these methods if they were made aware of them. The use of IUDs declined drastically in 1971 when the Dalkon Shield was the subject of litigation and people worried about disease and possible infertility. However, we know, today, that the fears of disease, as long as the woman doesn’t already have an STD, are ungrounded. In addition, the return to fertility is rapid after the IUD has been removed.
LARC METHODS ARE VALUABLE FOR MOST WOMEN OF REPRODUCTIVE AGE
LARC methods are useful to women during their reproductive years. However, LARC methods are not suitable for everyone. The best method for an individual is the one that she is most likely to use consistently and correctly and that is compatible with her reproductive life plan, including her desire for pregnancy and her preferred spacing of pregnancies. Although fertility declines significantly after age 35, LARC methods are important in the premenopausal period because pregnancies that do occur in this age group are at higher risk for genetic anomalies such as Down syndrome and other pregnancy risks.
SOME WOMEN ARE NOT GOOD CANDIDATES FOR INTRAUTERINE CONTRACEPTION
Women with the following conditions are poor candidates for IUDs:
Known or suspected pregnancy
Immediate post-septic abortion
Cervical or endometrial cancer
Uterine fibroids that interfere with placement
Current purulent cervicitis, chlamydia, or gonorrhea
INFORMATION AND RESOURCES
The following two websites provide useful information, materials, and resources related to LARC methods and their use and the Contraceptive CHOICE Project: www.larcfirst.com andwww.choiceproject.wustl.edu
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Protein Consumption, Exercise, and the Elderly
Our expert is Wayne Campbell, PhD, Professor of Nutrition Science at Purdue University. He is a member of the 2015 Dietary Guidelines for Americans Advisory Committee appointed by the USDA and the HHS. An important focus of Dr. Campbell’s current research is changes in older people relating to protein metabolism, body composition, and glucose metabolism.
As always, if there is a topic that you would like to see covered in the MP Post, please e-mail me.
THE ELDERLY, PARTICULARLY WOMEN, MAY NOT BE GETTING ADEQUATE PROTEIN
Protein intake is remarkably stable throughout our lives and constitutes approximately 15% of total calories. However, as we become older, the number of calories needed to maintain body weight decreases, so if protein intake remains at 15% the absolute number of grams of protein consumed decreases. This means that older adults may not be getting enough protein to maintain muscles and internal organs. Data from a 2013 study of 1,768 adults, by Louise A. Berner, PhD, and colleagues, suggest that approximately 12% of older men and 24% of women over the age of 70 do not consume enough protein.
WHEN REDUCING CALORIES, THE ELDERLY SHOULD CUT BACK ON PROTEIN-POOR AND NUTRIENT-POOR FOODS
Physiologically, and metabolically, most adults are in the elderly category by age 75. If you have an elderly patient who is consuming fewer calories, recommend that she not cut back on protein-rich foods as much as on protein-poor foods. However, it is important to clarify what this means. The protein-poor foods that are candidates for cutting back are desserts or foods made from bleached flour such as white breads. Nutrient-rich foods, such as fruits and vegetables, are still a valuable part of the diet even if protein poor. The protein-rich foods to emphasize are lean cuts of meat, low-fat or fat-free dairy, fish, and eggs, including egg whites. In addition, all the plant-based proteins, such as legumes and soybeans, are good sources of protein, but a variety of these foods should be eaten to obtain all of the amino acids necessary to form a complete protein.
ADEQUATE PROTEIN AND EXERCISE ARE NECESSARY TO SLOW PROGRESSION OF SARCOPENIA
Sarcopenia is age-associated loss of muscle that occurs in everyone. However, it occurs faster in people who do not consume enough protein. Unlike fat and carbohydrates, our bodies do not have a large store of readily available protein. Most of the body’s protein is in lean tissues such as organs and skeletal muscles. When we don’t consume enough protein, the body will take it from somewhere, and muscles will be sacrificed before organs. Anyone who does not eat enough protein will have muscles that shrink in size and decrease in functionality. The good news is that, with a combination of a diet that includes adequate protein and a program of strength training, the progression of sarcopenia can be slowed and even reversed. With adequate protein, combined with strength training exercises, increases in muscle strength of up to 50% are seen, typically, within three months. The increase in strength isn’t entirely from muscle growth as it also includes improvement in the neuromuscular control which in itself results in improved strength.
GET ENOUGH EXERCISE
A minimum of 30 minutes a day of moderately vigorous physical activity or 20 minutes a day of vigorous activity is recommended. For improved physical fitness, 45 minutes to an hour of moderate physical activity is recommended. The exercise does not have to be continuous. Intermittent sessions of fifteen minutes of exercise are still valuable. The goal should be 200 to 300 minutes of exercise per week.
FOR THOSE WHO HAVEN’T BEEN EXERCISING, CREATE SMALL, REALISTIC GOALS
It is important for patients not to be discouraged by their current level of physical activity. Any improvement is good. Often an individual will go to the gym and be intimidated by the fact that others have higher levels of physical activity. The result is that they get discouraged and don’t go back. Tell these individuals that, wherever they are in their goal of improved fitness, they are doing something really positive for themselves as long as they keep trying and set small, achievable goals. Encourage them to feel a sense of accomplishment if, for example, over a couple of weeks they are able to walk for ten minutes instead of the five minutes that had been their previous limit. Any improvement counts and will improve their health. In many cases, elderly patients may want to consult with and work with dietitians and certified strength trainers.
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