Empowering Women to Take Control of their Sexual Health

Two weeks ago, I attended a powerful and motivating summit hosted by Florida International University (FIU) Robert Stempel College of Public Health and Social Work on empowering women to take control of their sexual health through knowledge of biomedical HIV prevention methods, connecting to community resources, and mobilizing key community stakeholders and providers.

What was most unique about this summit was the rawness of the various conversations. These conversations included voices of state congresswoman Frederica Wilson and Ileana Ros-Lehtinen, community women and activists, a panel of diverse physicians and nurse practitioners, researchers, and LGBT and minority women working across different sectors in the HIV prevention field. When it comes to empowering women surrounding their sexual health, pre-exposure prophylaxis (PrEP) is viewed as the driving vehicle. The problem is that there is a lack of awareness among women particularly LGBT and minority women, and providers about PrEP and post-exposure prophylaxis (PEP). During the engaging providers panel comprised of various physicians working in South Florida, a Haitian physician expressed that before the conference he decided to call several of his provider friends that practice within the local Haitian community and asked them if they have heard of PrEP. How many do you think said, “Of course, I know about PrEP”? The answer is…0. Not one single doctor whom was asked said they have heard of PrEP. We have a lot left to do. The work has not yet been done!

Miami’s HIV Epidemic

So maybe you are wondering…well why host this conference? The county of Miami-Dade continues to lead the nation in new HIV infections. Not too far away is the neighboring county of Broward which continues to compete with Miami when it comes to high prevalence rates as well.

Due to the rising rates of HIV in Miami-Dade County, city officials have responded to the epidemic with the development of a “Getting to Zero” task force comprised of city commissioners and individuals representing various public health agencies throughout Miami-Dade County as well as the state of Florida. The task force devised a multi-pronged action plan with priority goals for the next two years. The plans include to (1) reduce the rates of reported AIDS cases, (2) reduce the percentage of newly diagnosed HIV cases among residents aged 13-19 (3) increase the percentage of newly identified HIV-infected persons who are linked to care within 90 days of diagnosis and are receiving appropriate preventive care and treatment services in Miami-Dade County and (4) reduce the number of newly reported HIV cases in Miami-Dade County (http://www.miamidade.gov/releases/2016-09-29-mayor-getting-to-zero.asp).

Prep around the globe

PrEP has served as a vehicle for prevention and is being used worldwide. Countries such as the United States has large scale PrEP programs while others are still in the stages of development and some have not implemented as of yet. There has been many PrEP initiatives enacted. The US Agency for International Development (USAID) is currently supporting 5 Microbicide Product Introduction Initiative (MPii) projects in Kenya, South Africa, Zimbabwe, Malawi, and Uganda from 2015-2020 focused on gender-based violence, drug resistance, creating demand, introducing new products, and models for delivering services. Another program is the DREAMS (Determined, Resilient, Empowered, AIDS-free, Mentored and Safe) initiative, a collaborative effort between US President’s Emergency Plan for AIDS Relief (PEPFAR), Bill & Melinda Gates Foundation, Girl Effect, Johnson & Johnson, Gilead Sciences and ViiV Healthcare. DREAMS aims to reduce the incidence of HIV by 40% among adolescent girls and young women by 2020 in the highest HIV burden countries including Kenya, Lesotho, Malawi, Mozambique, South Africa, Swaziland, Tanzania, Uganda, Zambia and Zimbabwe. Of the 10 countries, 5 have included PrEP for adolescent girls and young women in their strategic plans to address HIV. Recent data from PEPFAR shows significant declines in new HIV diagnoses among adolescent girls and young women. In the 10 African countries implementing PEPFAR’s DREAMS partnership, the majority of the highest HIV-burden communities or districts achieved greater than a 25 percent–40 percent decline in new HIV diagnoses among young women (https://www.usaid.gov/what-we-do/global-health/hiv-and-aids/technical-areas/dreams). In other areas of the globe such as Latin America and the Caribbean, a combination of biomedical, structural, and behavioral interventions is greatly needed in order to reach target objectives and goals and ultimately increase HIV prevention efforts. I am excited to see the future of PrEP.

Women’s Perspectives

During the women’s perspectives breakout sessions, workshops were broken down into specific focus groups including African American, Latina and Haitian. Amongst the African American women breakout session, some key topics that were addressed included stigma, specifically communication between the medical provider and client such as clear language on how to ask questions during the appointment while also considering time constraints, policy, and the need for funding toward effective behavioral interventions for HIV negative black women in the community.

Sistas Organizing to Survive (SOS) is a grassroots mobilization of black women in the fight against HIV and AIDS. In Florida, one in 68 non-Hispanic black women are known to be living with HIV/AIDS and has been the leading cause of death among black women aged 25-44 years within the state. (http://www.floridahealth.gov/diseases-and-conditions/aids/administration/minority-initiatives.html)

Call to Action

Miami is the #1 city in the United States with new HIV infections. This is a huge public health issue. We have a call to action to advocate for ourselves and others when it comes to ending the epidemic. We have made significant strides, but the work has not yet been done. Sexual health including HIV prevention should be something that we freely discuss with our family, colleagues, peers, physicians, and anyone that we come in contact with that is willing to listen. It is these conversations that we can decrease stigma surrounding HIV. Women across the counties of Broward, Miami-Dade, and Palm Beach have answered the call to action by organizing and advocating for all women. We have accepted the call to action together that we can get Miami to Zero!

“A future where new HIV infections are rare, and when they do occur, every person, regardless of age, gender, race/ethnicity, sexual orientation, gender identity, or socio-economic circumstance will have unfettered access to high quality, life-extending care, free from stigma and discrimination.”

–Quote from the National HIV/AIDS Strategy Updated to 2020: Strategy Vision

For additional information, please visit http://www.who.int/hiv/topics/prep/en/ http://amp4health.org/ and http://getting2zeromiami.com/

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Is Zika still a thing? My experiences as a Zika Case Manager in the field (South Florida)

Zika was a hot topic, but now it seems like it is a thing of the past. People always ask me…”Is Zika still is a thing?” And my response is, “Of course! Just because it has declined, certainly does not mean that it isn’t still a public health threat.”

Interesting enough, comments like “Is Zika still a thing” come from physicians and various public health professionals as well as individuals living in regions with active Zika transmission. Those that express more of a concern include individuals that have planned future travel to the state of Florida and are planning to conceive, or a close family member of someone who is currently pregnant.

What is Zika?

Perhaps you never heard of Zika, or still quite aren’t sure what Zika is exactly. Zika can be described as a virus that spreads to people primarily through the bite of an infected Aedes species mosquito. It is closely related to other flaviviruses such as Zika can also be transmitted sexually from a person that has Zika to their partner as well as from a pregnant woman to her developing fetus, which can result in serious birth defects. Want to learn more about Zika? Check out some other IH section blog posts about Zika here.

My role, criteria for testing, testing/funding limitations

I was hired as one of two Zika Case Managers within my local county health department through funding allocated to the state of Florida by the CDC. One of my duties is to coordinate the testing of suspected local, or travel cases, pregnant women, and any infant born to a potentially exposed pregnant woman. The testing criteria for pregnant women include those who traveled to a Zika-active transmission area, had sexual exposure during pregnancy, or 8 weeks prior regardless of the mother’s testing status, as well as those with any abnormal ultrasound results. Testing is also recommended if the mother was not previously tested. Just like other reportable infectious diseases, it takes effective communication between health professionals at all levels to get quality information across regarding Zika. In order to get the job done, we collaborate with infection control practitioners of local hospitals, nurses, physicians, and other public health clinicians to get samples of babies collected at birth for Zika testing while also making sure that a head ultrasound and hearing test are performed on the baby. This is very important because once the baby leaves the hospital it is almost impossible to get samples collected. A majority of the pediatric clinics don’t have the means to ship the specimens to the state laboratories. Some of the general responses we have received from these clinics include not knowing how to properly prepare the specimens for shipping, having the money to do so, and lack of knowledge about billing the patient’s insurance for the procedure. Although the county health department has the access and ability to ship specimens, it would be a liability for us to ship the specimens if another facility collected the samples.

As of March 2017, the department of health has conducted Zika virus testing for more than 13,020 people statewide. At Governor Scott’s direction, all county health departments were mandated to offer a free Zika risk assessment and testing to pregnant women. Unfortunately, due to a decline in cases, and federal funding allocated to state programs winding down, free testing is no longer accessible to the community, and is only provided on a case by case basis. Zika tests can be pretty expensive ranging anywhere from $200 – $400 when conducted at a commercial laboratory and even more in some cases.

State laboratories have just about depleted federal funds received for testing initiatives. If a patient does not meet testing criteria at our department of health, we recommend testing through affiliated commercial laboratories. In addition to the many changes in testing criteria including requiring patients to show proof of insurance, there has been issues with the insurance companies and patients’ have been incorrectly billed over $1000 for their Zika tests when in fact the test was free. This has been a big issue with tests conducted as far back as November and December which we have recently been made aware of. Mosquito control services specifically for Zika efforts provided by our county health department’s Environmental Health program has ended.

Management of Infants with confirmed, or possible Zika Infection

Currently, we have reached the stage where the pregnant women that are case managed have already given birth. We are now tasked with conducting 24 month active follow-ups of all infants exposed to a positive mother via in utero. We conduct follow-up of the infants exposed regardless of whether the infant tested negative, or positive. These infant follow-ups occur at 2, 6, 12, 18, and 24 months. This is because abnormalities can still occur during child development. A majority of our babies being followed are currently between the 12 and 18 month mark.

Out of all the babies we have tested, and are currently following, only one is confirmed to be microcephalic. Looking into the future, at the 18 month follow-up mark, the infants being followed will have to be re-tested in order to confirm if the antibodies are indeed negative or positive. Another complication with testing these babies will be whether the baby has traveled since it has been born. There is a possibility that the baby could have been infected during travel and not in utero. As of July 31st 2018, Zika contracts for our county health department will end and it is unsure who will take on the responsibility for maintaining the case management of these families.

Community Outreach

Best practices we have utilized as a county has been community outreach which we collaborate across the division of communicable diseases. I have been able to work closely with a CDC field assigned Zika Community outreach nurse to assemble and distribute Zika prevention and testing kits with a specific focus on obstetrician-gynecologist and pediatricians. We have been able to identify the gaps in testing and communication among our health department and local hospitals, clinics, and private physician offices. Additional community outreach activities of focus include visiting women, infant, and children (WIC) clinics throughout the county in order to conduct health education on Zika as well as community health fairs primarily within the Haitian population due to Haiti being one of the top countries which we get the most amount of travel related cases. Unfortunately, these outreach efforts will also end at the end of this summer due to the depletion of funds, and our CDC field assigned nurse’s contract ending.

Where we are now

As of right now, Florida still does not have any identified areas with ongoing, active Zika transmission. Florida is a hotspot for vacationers, especially the counties of Miami-Dade and Broward. Since the local transmission of Zika in 2016 in both counties, it seems that very few individuals consider Zika as being a major concern. Very few physicians’ are screening for Zika. Some still aren’t sure what it is exactly, and how it can affect an unborn fetus. Congenital Zika infection is still a global health threat to pregnant women and their infants. Zika is still a fairly new infectious disease, and we are learning as we go, especially the risks after pregnancy. The reality is that Zika is here to stay. Funding for zika prevention and treatment should be a top priority in order to aid in the health and wellbeing of children and families across the United States.