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HIV infected women in Mexico: vulnerability, missed

opportunities and late diagnosisMARTIN-ONRAET A.3, ALVAREZ-WYSSMAN V.1, VOLKOW-

FERNANDEZ P.3, GONZALEZ-RODRIGUEZ ANDREA2, VELAZQUEZ-ROSAS G.4,RIVERA-ABARCA L.4, TORRES-

ESCOBAR INDIANA5, SIERRA-MADERO J.1 1Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, 2Clínica

Especializada Condesa, 3Instituto Nacional de Cancerología, Mexico City, Mexico, 4

Centros Ambulatorios de Prevención y Atención en SIDA e ITS (CAPASITS) Oaxaca,

5Centros Ambulatorios de Prevención y Atención en SIDA e ITS (CAPASITS) Puebla.

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INTRODUCTION

• HIV in Mexico is a concentrated epidemic driven by infection in MSM

• Late presentation remains the most important challenge

• Women represent 20% of affected population• Detection campaigns focus on high risk groups

that do not include women• The only screening strategy for HIV detection in

women is pregnancy• HIV infected women are particularly vulnerable and

represent a double challenge

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GOALS

• What are the sociodemographic and clinical

characteristics of Mexican women recently diagnosed with HIV infection?

• How are women diagnosed with HIV?

• Are there specific factors reflecting increased vulnerability in women infected with HIV?

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STUDY DESIGN AND SAMPLE

SUBJECTS:

Mexican born HIV-infected women, diagnosed between 2009 and 2013, attending one of 4 HIV care centers of 3 different states:- Oaxaca- Puebla- Mexico City: Instituto de

Nutrición and Clínica Condesa

DATA:

Structured face to face interviews and medical records:- Socio demographics, risk

behavior, history of physical/sexual violence, circumstances of HIV diagnosis and access to medical and prenatal care

- Clinical information from files

• Standard statistical analysis was done with Stata 12.0 • Ethics approval was obtained, informed consent from women• Women were offered legal and psychological counseling

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RESULTS

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SAMPLE

331 women invited

270 women interviewed

30 did not accept

31 accepted file review

301 women included

HIV Care center, n=301 N (%)Clínica Condesa 94 (31.2)Instituto de Nutrición 58 (19.3)Oaxaca 100 (33.2)Puebla 49 (16.3)

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N(%)Indigenous language: - Speaks or understands 39 (14)Education: - illiterate 23 (7.7)- Primary school (incomplete and complete) 70 (23.6)- Secondary school (incomplete and complete) 113 (38.1)- High school/commercial career/incomplete degree 79 (26.6)- Complete degree 12 (4)

Participates in household income 134 (50.1)Woman as the only provider for their family 51 (19.1)Monthly income in USD: - Less than 460 USD 222 (94)

SOCIODEMOGRAPHIC CHARACTERISTICS

31%

31%

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CLINICAL CHARACTERISTICS N (%)

Any comorbidity* 58 (21)Co-infection HCV/HBV 6 (2)History of alcohol abuse 33 (11.5)History of illicit substance abuse 31 (10.8)Initiation of sexual activity in years, median (range) 17 (10-31)Number of pregnancies, median (range) 2 (0-13)Number of sexual partners, median (range) 2 (1-300)Age at first pregnancy, median (range) 20 (12-38)First pregnancy at 18 years or less 63 (28.5)Any sexually transmitted disease other than HIV at diagnosis: 82 (33.6)

- HPV infection 61 (72.6)

- Genital herpes 7 (8.3)

- Syphilis 5 (6)- Other 11 (13.1)

*Diabetes Mellitus (5.3%), arterial hypertension (4.4%), dyslipidemia (14.3), others (7.7%)

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N(%)History of physical violence at home : 126 (47)Who was the aggressor? a - Previous or current partner 97 (69.8)- Parents 22 (15.8)- brother 4 (2.9)- Others 16 (11.5)

History of sexual abuse: 78 (29.7)¿Who was the aggressor? a - Previous or current partner 35 (33.9)- Parents 5 (4.9)- brother 12 (11.6)- Others 51 (47.6)

History of imprisonment: 11 (4)History of living in the US or the borders 16 (6)History of paid sex 26 (9.7)

VULNERABILITY FACTORS

a There might be more than one agressor per woman

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Clinical and socio demographic characteristics in different centers

Condesa Nutrición Oaxaca Puebla P

Age at diagnosis <30 yo, n (%) 29 (30.8) 20 (34.5) 48 (48) 24 (49) 0.04**

Speaks or understands indigenous language, n (%) 8 (9.6) 4 (9.5) 25 (25.2) 2 (4.2) 0.001**

Number of sexual partners, median (range) 3 (1-300) 2 (1-40) 2 (1-99) 2 (1-45) 0.018*

History of paid sex, n (%) 12 (14.8) 1 (2.5) 9 (9.3) 4 (8.3) NS

History of illicit substance use, n(%) 16 (18.8) 5 (9.4) 7 (7.2) 3 (6.12) 0.04**

History of sexual abuse, n (%) 32 (39) 14 (36) 20 (21) 12 (25.5) 0.04**

Baseline CD4 count, median (range) 217 (3-1341)

111 (1-913)

298 (14-1138)

194 (6-929)

<0.001*

Reasons for diagnosis, n(%):

Recently diagnosed partner or offspring 34 (42.5) 14 (35) 36 (36.3) 16 (33.3)

Symptoms 26 (32.5) 19 (47.5) 31 (31.3) 19 (39.6)

Pregnancy 8 (10) 1 (2.5) 16 (16.2) 4 (10.9) NSa

* Kwallis test, ** χ2 testa There were statistical differences between INCMNSZ and Oaxaca, for diagnosis through pregnancy (p=0.02)

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SOURCE OF HIV INFECTION

N(%)Likely source of infection: - Stable partner (current or partner) 201 (75)- I don’t know 28 (10.5)- Casual partner 24 (9)- Other reasons* 15 (5.5)Had ever done an HIV test previously 65 (24.3)Suspicion of being HIV infected before doing the test 62 (23)- Of those who suspected, how many had done a test before 29 (46.7)* tatoo (1), rape (5), sharing needles (1), transfusion (5), working accident (3)

Reasons to get tested: N(%)Health care provider recommendation 175 (65.3)Other reasonsa 93 (34.7)

aTesting campaigns, donation, prenuptial studies, getting to a lab

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Infected partner/offspring (n=101)

Symptoms (n=92) Others (n=44) Pregnancy (n=28)0

5

10

15

20

25

30

35

40

45

38.134.7

16.6

10.6

CIRCUMSTANCES OF HIV DIAGNOSIS %

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CLINICAL STAGE AT PRESENTATION

Age at diagnosis, median (range) 32 (16.5-75)CD4 count at presentation, median (range) 203 (1-1341)CD4<200 , n(%) 133 (49.3)CD4 <100, n(%) 77 (28.5)

AIDS defining events at diagnosis, n(%) 80 (27.5)

Number of AIDS defining events: 111 (there were more than one per patient) Waisting syndrome (48), Cytomegalovirus disease (9), extrapulmonary tuberculosis (9), Candida

esophagitis (8), P.jiroveci pneumonia (8), atypical mycobacterial disease (3), pulmonary tuberculosis (5), cryptococosis (3), others (18)

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MEDICAL CARE PRIOR TO DIAGNOSIS

68% of women diagnosed through symptoms had sought medical care before

40%

60%

Sought medical care for HIV symp-toms before diagnosis?*

Yes No

* Symptoms such as weight loss, fever, chronic diarrhea, oral candidiasis, herpes

0 1-2 3-4 5 or more0

10

20

30

40

50

60

7061

13.2 14.411.4

Number of medical contacts prior to HIV diagnosis

%

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Partner diagnosed (n=83)

Child diagnosed (n=11)

Symptoms (n=86)

Pregnancy (n=20)

Others (n=40)

Median of CD4 (range)

267 (14-1341) 132 (30-659) 108 (1-726) 322 (6-1138) 198 (18-683)

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# of medical contacts None (n=141) 1-2 (n=34) 3-4 (n=35) 5 or more (n=26)

Median of CD4 (range) 256 (1-1341) 217 (7-1138) 187 (3-726) 31 (10-289)

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Characteristics associated to late stage disease at diagnosis (CD4 count <200)

Univariate analysis Multiple logistic regression

CD4<200 CD4>=200 OR (CI95%) P OR (CI95%) P

Age at diagnosis:

<30 years 38 (36.5) 66 (63.5) 1 1

>= 30 years 95 (57.3) 71 (42.8) 2.32 (1.4-3.8) 0.001 1.89 (1.07-3.3) 0.02

Diagnosis through pregnancy:

Yes 5 (25) 15 (75) 1 1

No 111 (50.4) 109 (49.6) 3 (1.07-8.6) 0.02 1.8 (0.6-5.4) 0.2Number of consultations prior to diagnosis:

0-2 69 (39.4) 106 (60.6) 1 1

3 or more 44 (72.1) 17 (27.9) 3.97 (2.1-7.5) <0.001 3.56 (1.85-6.8) <0.001

NS: Physical violence, sexual abuse, speaking indigenous language, illegal substance abuse,study degree

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PRENATAL CARE

All pregnancies Some pregnancies None of the pregnancies

Not applicable0

10

20

30

40

50

60

70

11.6 13.6

61.2

13.6

HIV test offered during prenatal care %

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CONCLUSIONS

• Women recently diagnosed with HIV in Mexico have vulnerability factors such as a high prevalence of physical and sexual violence, low level of education, pregnancies at young age, low incomes and acquiring HIV mainly through their stable partner

• Women are detected late, except for women diagnosed through pregnancy

• Most women (73%) are diagnosed because of an infected partner/offspring or being symptomatic

• Missed opportunities of earlier diagnosis and low rates of HIV testing were detected, during medical and prenatal care

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Consequences and perspectives

• Late diagnosis in women seems to be the result of a deficient health care system and lack of risk perception both from health care workers and women, in a context of high vulnerability and the absence of screening policies for non-pregnant women

• Strategies for early detection need to be reevaluated for women in countries with concentrated epidemics such as the one in Mexico

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ACKNOWLEDGMENTS

• Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán:

– Juan Sierra Madero– María de Lourdes Guerrero Almeida– Juan Calva Mercado– Brenda Crabtree Ramírez– Rigoberto Aramburo García

• Clínica Especializada Condesa:– Andrea González Rodríguez– Jesús Casillas Rodríguez– Carlos Magis Rodríguez– Florentino Badial Hernández– Ubaldo Ramos Alamillo– Victoria Alvarez Wyssmann– Ricardo Niño Vargas

• Instituto Nacional de Cancerología:– Patricia Volkow Fernández– Diana Vilar Compte

• Hospital general Manuel Gea González

– Rafael Valdez Vázquez– Patricia Rodriguez Zulueta– Daniel Aguilar Zapata

• CAPASITS Oaxaca– Gabriela Velázquez Rosas– Lesvia Rivera Abarca– Yuko Nakamura López

• CAPASITS Puebla– Indiana Torres Escobar– Tayde Pérez reyes