Prevention and Education

Helping You In The Prevention
of Human Immunodeficiency Virus (HIV),
Sexually Transmitted Infections, and Viral Hepatitis

Definition of Harm Reduction
Harm reduction is a practice that encourages minimization of harm to individuals and the community at large. Harm reduction strategies develop from an ideology of Health promotion. The health care provider and the client have equal power in the relationship. The client is valued as an expert in regards to his/her own life. By incorporating a set of strategies and tactics, individuals gain access to the tools that promote health. Harm reduction can be applied to any behavior in which the focus is on reducing risk. (e.g. rock climbing with a harness is less risky than free style climbing). Harm reduction views risk reduction as a continuum that moves back & forth – the steps towards lessening harm may be made in very small increments. It recognizes the client's coping skills have been carefully constructed over their lifetime and new skills can only be integrated as they become relevant. Clients are provided with alternative options, which help them to make positive steps towards healthier lives.

Harm Reduction has Four Major Components:
• Raising awareness of the issues
• Making contact with populations
• Providing the means for behavior change
• Endorsing the harm reduction measures being proposed or implemented

Goals of Harm Reduction
• Creating safe and open environments
• Exchanging information with no conditions applied.
• Improving health status physically, emotionally, and spiritually
• Empowering and advocating for both user and health car provider.
• Minimizing the risk of harm, illness, or disease
Harm Reduction Practice
• It is an alternative to the traditional disease, moral and abstinence based models
• Any positive change the style of which is ego building, not ego breaking can reduce harm
• Risk is a natural part of life; harm is considered in the context of the person's life
• Focuses on all the complexities of a persons life and not solely on one behavior in isolation

Programs

Men’s Health Project

• Sexy Summer Campaign
• Sexy Survey

Provincetown Needle Exchange Program

The Provincetown Needle Exchange is one of four needle exchange programs in Massachusetts. Needle exchange is a scientifically proven intervention that significantly reduces the spread of blood borne diseases such as HIV and Hepatitis C. Our program operates from a Harm Reduction Model.

Step One
To participate in Massachusetts pilot needle exchange program you must enroll. Enrollment is anonymous. Enrollment gives you the legal right to possess a syringe in Massachusetts without a prescription from a physician. Once you have enrolled in the Massachusetts Needle Exchange program you will be given a program participation card with a code on the back. This code represents you and is your only proof of legal participation. This is how the registration code is assigned and how it protects your identity. We use the first three letters of your mother’s first name and your birth date. So if your mother’s first name was Mary and your birth date was March 16, 1982 your code would be MAR031682. This code is then registered with the Massachusetts department of public health as a participating member of the Needle Exchange Program. You do not have to give us your name, address or any other personal information. Once registered you can exchange syringes legally at any of the four exchange sites in Massachusetts.

Step Two
Carry your exchange card with you any time you have syringes on your person. Since it is an anonymous program your registration card is the only proof you have that you are enrolled in the Massachusetts needle exchange program legally.

Lost Card or Arrest
If you loose your registration card we are able to replace the card based on the code and date of registration. It is important to use the formula mentioned above when registering so that if for any reason you need a replacement card or proof that you are a member of the Massachusetts Needle exchange program we will be able to provide you with a duplicate card or a letter verifying your legal participation in this program and right to carry a syringe without a prescription. In cases of arrest the Massachusetts Department of Public Health will provide you with a letter of legal participation. The letter will state your code and the date of enrollment. It is very important to use the formula described in step one when enrolling. It makes your code easy to remember and that unique combination of the first three letters of your mother’s first name and your birth date is the only way we can provide proof of your legal participation in this program.

Anonymous HIV Counseling & Testing

Why Get Tested?

Have you done an HIV personal risk reality check lately? Do you know where you stand? Are you: a man who has had unprotected sex with men?STD’s.

Knowing whether you are HIV positive or negative.

An estimated 8,000 -10,000 Massachusetts residents are infected with HIV and do not know it.

When people know that they are infected with HIV, they are more likely to take care of themselves, get timely medical treatment, and avoid passing the virus to others.

A negative result is usually a huge relief and provides strong motivation for taking action to remain HIV-free.

In 2000-2004, almost one third of those found to be infected with HIV in MA were unaware of their HIV status until they developed full blown AIDS.

Early detection of HIV allows for the monitoring and support of the immune system to prevent AIDS.

Types of HIV Tests

The most common test for HIV is the antibody test (called ELISA). It can be done using a sample of blood, oral fluid or urine. Results can take from as little as 20 minutes to as long as two weeks, depending on which test you take:

-- Regular ELISA blood test: Blood is taken from a vein in your arm. The blood draw is quick and not very painful. Results take one to two weeks.

-- Rapid ELISA blood test (OraQuick): Your finger is pricked and a small drop of blood is used. Results usually take less than an hour.*

-- ELISA home collection kit: Over-the-counter kits are available that allow you to collect your own blood sample, send it to a lab and receive the results by phone anonymously in three to seven days. (Only “Home Access” brand is approved.)

-- Regular ELISA oral fluid test (OraSure): A swab is placed between your cheek and gum to collect fluid from your mouth. Results take one to two weeks.

-- Rapid ELISA oral fluid test (OraQuick): Same as above but results usually take less than an hour.*

-- Regular ELISA urine test: A urine sample is used. Results take one to two weeks.

If any of the above ELISA tests are positive, another test, called the Western blot, is done to confirm the results. (*If you have taken a rapid test, it will take additional time, probably one to two weeks, to get the Western blot results.)

Confidential versus Anonymous Testing

If you go to a testing site that offers anonymous testing, your counselor will assign you a number which only you can link to your test results. No record is made of your name.

However, some sites only offer confidential testing where your name identifies your test sample and your results. Even then your information is kept confidential by law and test results cannot be communicated to anyone but you.

What If My Test Is Negative?

A negative test means that no antibodies to the Human Immunodeficiency Virus were found. Assuming that at least 6 weeks have passed since your last risky contact, a negative result means you are most likely not infected. However, if fewer than 6 weeks have passed since your last risky encounter, retesting at a later date is advisable.

If your most recent risk was profound (e.g. unprotected vaginal or anal intercourse with an HIV-infected partner) and your initial test is negative, retesting 3 and 6 months after the encounter is advised.

A negative test may well produce tremendous relief. At the same time, unexpected feelings may surface. If you have friends or family members who have been infected with the virus, you may experience sadness, anger, and guilt as well. It is important to honor these feelings which are part of your affection and loyalty.

A negative result, is a perfect time to look at your personal HIV risk and, if necessary, make changes that will insure your continued good health. Your counselor can help you plan your strategy.

What If My Test is Positive?

A positive test indicates that HIV antibodies were detected in your sample. A blood sample taken from your arm is unlikely to produce a false positive. However, if you have no known risk factors, repeat the test for certainty.

Despite the accuracy of the oral and rapid (finger stick) tests, positive results are considered “preliminary”. Confirmation using a blood sample from your arm is the next step to identify your antibody status with certainty.
A positive test is a crisis for most people. You might feel absolutely crushed, afraid, terrified, angry, relieved (to confirm what you have suspected) – or numb. Despite everything you know about HIV, you may fear that death is right around the corner.

Your counselor is there to support you. Most counselors offer immediate access to medical evaluation and case management (to deal with issues such as health insurance, medication access, mental health, chemical dependency treatment, and so on). For some, taking immediate action feels healthy and powerful. Others need days or weeks to adjust to the notion of having a chronic, contagious disease. They will want to take time to think, sit with their feelings, do some research, or talk with friends or family before taking action. It is rarely necessary to do anything immediately. We understand that this news is often overwhelming. We want you to know that, a) there is ample life after acquiring HIV and, b) that you are not alone.

Reporting Positive HIV Results to the State

MA uses a “unique identifier” which is a code instead of a name to report individuals who have tested positive. This code cannot be traced to you. Reporting allows public health officials to track the course of the HIV epidemic.

If you do not wish to inform your sexual or needle-sharing contacts of your positive status yourself, the MA Department of Public Health does an excellent job of notifying your contacts without divulging your name.

Positive Prevention

Positive Prevention seeks to keep people living with HIV/AIDS (PLWHA) from developing opportunistic infections, to prevent their infection from progressing to AIDS, and to keep them from spreading HIV to others.

Positive Relationships is a program for small groups of people living with HIV/AIDS. Knowing that the lives of persons living with HIV/AIDS are stressful, the program aims to build coping skills to reduce stress.

These skills involve:
• Solving problems
• Making decisions
• Negotiating choices

These skills are applied to three life areas:
• Disclosing HIV status to family and friends
• Disclosing to sex partners
• Building healthy and safer relationships

Positive Relationships does not tell people that they should disclose. Group members use the skill to make informed decisions about disclosure and sexual behaviors.

Positive Relationships is:
• Interactive
• Fun
• Educational
• Stress-reducing
• A time to share common experiences and learn decision –making skills

Positive Relationships is not:
• Lectures
• Classes
• Forums
• 12-step program

Please contact Max Sanduski or Rick Shaw at (508) 487-8311 for more information.

HIV

Statistics (People Living With HIV)

• World Wide: 44,000,000 (estimate)
• United States: 1,185,000 (estimate)
• Massachusetts 15,698 (as of 11.1.05)

Transmission Categories
o Men Who Have Sex With Men (MSM): 34%
o Injection Drug Users (IDU): 28%
o Heterosexual Contact: 29%
o MSM/IDU: 3%

Gender:
o Male: 71%%
o Female: 29%

HIV Infection and AIDS: An Overview

INTRODUCTION
AIDS (acquired immunodeficiency syndrome) was first reported in the United States in 1981 and has since become a major worldwide epidemic. AIDS is caused by HIV (human immunodeficiency virus). By killing or damaging cells of the body's immune system, HIV progressively destroys the body's ability to fight infections and certain cancers. People diagnosed with AIDS may get life-threatening diseases called opportunistic infections, which are caused by microbes such as viruses or bacteria that usually do not make healthy people sick.
More than 900,000 cases of AIDS have been reported in the United States since 1981. As many as 950,000 Americans may be infected with HIV, one-quarter of whom are unaware of their infection. The epidemic is growing most rapidly among minority populations and is a leading killer of African-American males ages 25 to 44. According to the Centers for Disease Control and Prevention (CDC), AIDS affects nearly seven times more African Americans and three times more Hispanics than whites. In recent years, an increasing number of African-American women and children are being affected by HIV/AIDS. In 2003, two-thirds of U.S. AIDS cases in both women and children were among African-Americans.

TRANSMISSION
HIV is spread most commonly by having unprotected sex with an infected partner. The virus can enter the body through the lining of the vagina, vulva, penis, rectum, or mouth during sex.
Risky behavior
HIV can infect anyone who practices risky behaviors such as
• Sharing drug needles or syringes
• Having sexual contact, including oral, with an infected person without using a condom
• Having sexual contact with someone whose HIV status is unknown

Infected blood
HIV also is spread through contact with infected blood. Before donated blood was screened for evidence of HIV infection and before heat-treating techniques to destroy HIV in blood products were introduced, HIV was transmitted through transfusions of contaminated blood or blood components. Today, because of blood screening and heat treatment, the risk of getting HIV from such transfusions is extremely small.

Contaminated needles
HIV is frequently spread among injection drug users by the sharing of needles or syringes contaminated with very small quantities of blood from someone infected with the virus.
It is rare, however, for a patient to give HIV to a health care worker or vice-versa by accidental sticks with contaminated needles or other medical instruments.

Mother to child
Women can transmit HIV to their babies during pregnancy or birth. Approximately one-quarter to one-third of all untreated pregnant women infected with HIV will pass the infection to their babies. HIV also can be spread to babies through the breast milk of mothers infected with the virus. If the mother takes certain drugs during pregnancy, she can significantly reduce the chances that her baby will get infected with HIV. If health care providers treat HIV-infected pregnant women and deliver their babies by cesarean section, the chances of the baby being infected can be reduced to a rate of 1 percent. HIV infection of newborns has been almost eradicated in the United States due to appropriate treatment.
A study sponsored by the National Institute of Allergy and Infectious Diseases (NIAID) in Uganda found a highly effective and safe drug for preventing transmission of HIV from an infected mother to her newborn. Independent studies have also confirmed this finding. This regimen is more affordable and practical than any other examined to date. Results from the study show that a single oral dose of the antiretroviral drug nevirapine (NVP) given to an HIV-infected woman in labor and another to her baby within 3 days of birth reduces the transmission rate of HIV by half compared with a similar short course of AZT (Azidothymidine). For more information on preventing transmission from mother to child, go to http://aidsinfo.nih.gov/guidelines.

Saliva
Although researchers have found HIV in the saliva of infected people, there is no evidence that the virus is spread by contact with saliva. Laboratory studies reveal that saliva has natural properties that limit the power of HIV to infect, and the amount of virus in saliva appears to be very low. Research studies of people infected with HIV have found no evidence that the virus is spread to others through saliva by kissing. The lining of the mouth, however, can be infected by HIV, and instances of HIV transmission through oral intercourse have been reported.

Scientists have found no evidence that HIV is spread through sweat, tears, urine, or feces.

Casual contact
Studies of families of HIV-infected people have shown clearly that HIV is not spread through casual contact such as the sharing of food utensils, towels and bedding, swimming pools, telephones, or toilet seats.
HIV is not spread by biting insects such as mosquitoes or bedbugs.

Sexually transmitted infections

If you have a sexually transmitted infection (STI) such as syphilis, genital herpes, chlamydial infection, gonorrhea, or bacterial vaginosis appears, you may be more susceptible to getting HIV infection during sex with infected partners.

EARLY SYMPTOMS OF HIV INFECTION
If you are like many people, you will not have any symptoms when you first become infected with HIV. You may, however, have a flu-like illness within a month or two after exposure to the virus. This illness may include
• Fever
• Headache
• Tiredness
• Enlarged lymph nodes (glands of the immune system easily felt in the neck and groin)
These symptoms usually disappear within a week to a month and are often mistaken for those of another viral infection. During this period, people are very infectious, and HIV is present in large quantities in genital fluids.
More persistent or severe symptoms may not appear for 10 years or more after HIV first enters the body in adults, or within 2 years in children born with HIV infection. This period of "asymptomatic" infection varies greatly in each individual. Some people may begin to have symptoms within a few months, while others may be symptom-free for more than 10 years.
Even during the asymptomatic period, the virus is actively multiplying, infecting, and killing cells of the immune system. The virus can also hide within infected cells and lay dormant. The most obvious effect of HIV infection is a decline in the number of CD4 positive T (CD4+) cells found in the blood-the immune system's key infection fighters. The virus slowly disables or destroys these cells without causing symptoms.
As the immune system worsens, a variety of complications start to take over. For many people, the first signs of infection are large lymph nodes or "swollen glands" that may be enlarged for more than 3 months. Other symptoms often experienced months to years before the onset of AIDS include
• Lack of energy
• Weight loss
• Frequent fevers and sweats
• Persistent or frequent yeast infections (oral or vaginal)
• Persistent skin rashes or flaky skin
• Pelvic inflammatory disease in women that does not respond to treatment
• Short-term memory loss
Some people develop frequent and severe herpes infections that cause mouth, genital, or anal sores, or a painful nerve disease called shingles. Children may grow slowly or be sick a lot.

Sexually Transmitted Infections

Gonorrhea

Although the overall rate of infection with gonorrhea is going down is countries like the United States, the rate of gonorrhea has recently begun to rise specifically among American gay men. Between men, gonorrhea is transmitted primarily through unprotected anal intercourse and giving oral sex. Gonorrhea can be found in the penis, the rectum and the throat. The rise in gonorrhea rates among gay men indicates an increase in high-risk sexual behavior.
Centers for Disease Control (CDC) reported cases for the years 2001-2004.
2001 Cases of Gonorrhea in U.S. actually reported = 361,705
2002 Cases of Gonorrhea in U.S. actually reported = 351,852
2003 Cases of Gonorrhea in U.S. actually reported = 335,104
2004 Cases of Gonorrhea in U.S. actually reported = 330,132
The number of CDC reported cases is believed to be only half the number of actual cases of Gonorrhea in the U.S. each year.
Gonorrhea is a curable sexually transmitted infection (STI) caused by bacteria called Neisseria Gonorrheal. These bacteria can infect the genital tract, mouth, and rectum of both men and women.

SYMPTOMS

The bacteria are carried in semen and vaginal fluids and cause a discharge. Symptoms usually appear within 2 to 10 days after sexual contact with an infected partner. Men have symptoms more often than women, including
• White, yellow, or green pus from the penis with pain
• Burning sensations during urination that may be severe
• Swollen testicles
Symptoms of rectal infection include discharge, anal itching, and occasional painful bowel movements with fresh blood in the feces.
Gonorrhea can also infect eye tissue if infected vaginal or seminal fluid comes in contact with the eye. If eye tissue becomes infected with Gonorrhea bacteria and is not immediately treated the result could cause blindness.
For women, the early symptoms of gonorrhea often are mild. A small number of people may be infected for several months without showing symptoms. In women, the opening to the uterus, the cervix, is the first place of infection. The disease can spread into the uterus and fallopian tubes, resulting in pelvic inflammatory disease (PID). PID affects more than 1 million women in this country every year and can cause tubal (ectopic) pregnancy and infertility in as many as 10 percent of infected women. When women have symptoms, the first ones may include
• Bleeding associated with vaginal intercourse
• Painful or burning sensations when urinating
• Yellow or bloody vaginal discharge
More advanced symptoms, which may indicate development of PID, include cramps and pain, bleeding between menstrual periods, vomiting, or fever.

DIAGNOSIS

Health care providers usually use three laboratory techniques to diagnose gonorrhea.
• Staining samples directly for the bacterium
• Detecting bacterial genes or DNA in urine
• Growing the bacteria in laboratory cultures
Many providers prefer to use more than one test to increase the chance of an accurate diagnosis.
The staining test involves placing a smear of the discharge from the penis or the cervix on a slide and staining the smear with a dye. Then the health care provider uses a microscope to look for bacteria on the slide. You usually can get the test results while in the office or clinic. This test is quite accurate for men but is not good in women. Only one in two women with gonorrhea has a positive stain.
More often, health care providers use urine or cervical swabs for a new test that detects the genes of the bacteria. These tests are more accurate than culturing the bacteria.
The laboratory culture test involves placing a sample of the discharge onto a culture plate and incubating it up to 2 days to allow the bacteria to grow. The sensitivity of this test depends on the site from which the sample is taken. Cultures of cervical samples detect infection approximately 90 percent of the time. The health care provider also can take a culture to detect gonorrhea in the throat. Culture also allows testing for drug-resistant bacteria.

TREATMENT

Health care providers usually prescribe a single dose of one of the following antibiotics to treat gonorrhea.
• Cefixime
• Ceftriaxone
• Ciprofloxacin
• Ofloxacin
• Levofloxacin
If you are pregnant, or are younger than 18 years old, you should not take ciprofloxacin or ofloxacin. Your health care provider can prescribe the best and safest antibiotic for you.
Gonorrhea and chlamydia, another common STI, often infect people at the same time. Therefore, doctors usually prescribe a combination of antibiotics, such as ceftriaxone and doxycycline or azithromycin, which will treat both diseases.
If you have gonorrhea, all of your sexual partners should get tested and then treated if infected, whether or not they have symptoms.

Making SaferSex packages

PREVENTION

The surest way to avoid transmission of an STI is to abstain from sexual contact or be in a long-term mutually monogamous relationship with a partner who has been tested and is known to be uninfected.
By using latex condoms correctly and consistently during vaginal or rectal sexual activity, you can reduce your risk of getting gonorrhea and its complications.

COMPLICATIONS

In untreated gonorrhea infections, the bacteria can spread up into the reproductive tract, or more rarely, can spread into the blood stream and infect the joints, heart valves, or the brain.

The most common result of untreated gonorrhea is PID, a serious infection of the female reproductive tract. Gonococcal PID often appears immediately after the menstrual period. PID causes scar tissue to form in the fallopian tubes. If the tube is partially scarred, the fertilized egg may not be able to pass into the uterus. If this happens, the embryo may implant in the tube causing a tubal (ectopic) pregnancy. This serious complication may result in a miscarriage and can cause death of the mother.

In men, gonorrhea causes epididymitis, a painful condition of the testicles that can lead to infertility if left untreated. Also, gonorrhea affects the prostate gland and causes scarring in the urine canal.

Rarely, untreated gonorrhea can spread through the blood to the joints. This can cause an inflammation of the joints which is very serious.

If you are infected with gonorrhea, your risk of getting HIV infection increases (HIV, human immunodeficiency virus, causes AIDS). Therefore, it is extremely important for you to either prevent yourself from getting gonorrhea or get treated early if you already are infected with it.

It is important to take all of the medication prescribed to cure gonorrhea. Although medication will stop the infection, it will not repair any permanent damage done by the disease. People who have had gonorrhea and have been treated can get the disease again if they have sexual contact with persons infected with gonorrhea. If a person's symptoms continue even after receiving treatment, he or she should return to a doctor to be reevaluated.

The surest way to avoid transmission of sexually transmitted diseases is to abstain from sexual intercourse, or to be in a long-term mutually monogamous relationship with a partner who has been tested and is known to be uninfected.

Latex condoms, when used consistently and correctly, can reduce the risk of transmission of gonorrhea.

Any genital symptoms such as discharge or burning during urination or unusual sore or rash should be a signal to stop having sex and to see a doctor immediately. If a person has been diagnosed and treated for gonorrhea, he or she should notify all recent sex partners so they can see a health care provider and be treated. This will reduce the risk that the sex partners will develop serious complications from gonorrhea and will also reduce the person's risk of becoming re-infected. The person and all of his or her sex partners must avoid sex until they have completed their treatment for gonorrhea.

Division of STD Prevention (DSTDP)
Centers for Disease Control and Prevention
www.cdc.gov/std

Prevention and Education Goals

The primary goals of our Prevention and Education Programs are to inform the public about the benefits of knowing one's HIV status, to provide the community with the information needed to avoid infection (such as the different modes of transmission and high risk factors for infection), and to keep the community current on the medical advancements in the treatment of HIV and AIDS. To meet these goals the department engages in numerous activities in cooperation with a number of medical, educational and social service agencies throughout Cape Cod. Our Provincetown office runs one of the four locally approved Needle Exchange Programs (NEP) in Massachusetts. NEP participants are encouraged both to practice harm-reduction strategies to decrea se their chance of spreading HIV infection and to connect with primary medical care and supportive social services to support and maintain their health.

................

Provincetown:
508.487.8311 (phone)
866.668.6448 (toll free)
508.487.5914 (fax)
askasgcc@verizon.net

Hyannis:
508.778.1954 (phone)
866.990.2437 (toll free)
508.778.4501 (fax)

Richard Shaw
Needle Exchange Coordinator
HIV Counseling & Testing
508.487.8311
rickshaw@asgcc.org

Max Sandusky
Men’s Health Project Program Manager
HIV Counseling & Testing
508.487.8311
maxsandusky@asgcc.org

Linda Decker PA
Mid/Upper Cape Outreach Coordinator
HIV Counseling & Testing
508.778.1954
508.274.5420 (cell)
lindadecker@asgcc.org

© 2008 AIDS Support Group of Cape Cod