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HIV Basics Mary Beth Donica, MD Program Director, MATEC at University of Cincinnati March 2021 1 This conference is supported by the Health Resources and Services Administration (HRSA) of the U.S. Department of Health and Human Services (HHS) as part of an award totaling $3,139,511.00 with 0 percentage financed with nongovernmental sources. The contents are those of the author(s) and do not necessarily represent the official views of, nor an endorsement, by HRSA, HHS or the U.S. Government. Disclosures I have no disclosures to report. 3 LEARNING OBJECTIVES Review the epidemiology of HIV in Ohio and the USA. Discuss stigma around HIV and LGBTQ+. Describe the basic biology and transmission of HIV. Describe clinical manifestations of HIV infection. List tests used to monitor chronic HIV infection. Review basics of outpatient care for PLWHA. 4 EPIDEMIOLOGY 5 HIV Epidemiology in US: 2018 1.1 million people in the USA have HIV 15% of people with HIV are unaware of their HIV status. 37,968 people were newly diagnosed with HIV in 2018 From 2014-2018, new HIV diagnoses decreased by 7%, although the incidence increased in some groups. Men who have sex with men (MSM), particularly black/African American MSM, are most affected by the HIV epidemic. In 2018, there were 15,280 deaths in people with HIV. 6 6 Note. Estimates were derived from a CD4 depletion model using HIV surveillance data. Estimates rounded to the nearest 100 for estimates >1,000 and to the nearest 10 for estimates 1,000 to reflect model uncertainty. Estimates for the year 2018 are preliminary and based on deaths reported to CDC through December 2019. Estimates for Alabama, Oklahoma, and South Carolina should be interpreted with caution due to incomplete death ascertainment. Total estimate for the United States does not include data for Puerto Rico. Estimated HIV Prevalence among Persons Aged 13 years, by Area of Residence 2018United StatesTotal = 1,173,900 This map presents estimates of HIV prevalence for persons aged 13 years in the United States for 2018. HIV prevalence was highest in California, Florida, Georgia, Illinois, Maryland, New York, New Jersey, North Carolina, Pennsylvania, Texas, Ohio, and Virginia. Five states accounted for 50% of persons living with HIV infection: California, Florida, Georgia, New York, and Texas. Estimates for the year 2018 are preliminary and based on deaths reported to CDC through December 2019. Estimates for Alabama, Oklahoma, and South Carolina should be interpreted with caution due to incomplete death ascertainment. Estimates were derived from a CD4 depletion model using HIV surveillance data. Estimates were rounded to the nearest 100 for estimates >1,000 and to the nearest 10 for estimates 1,000 to reflect model uncertainty. Estimates with a relative standard error of 30%50% are preceded by an asterisk (*) and should be used with caution. Estimates for the following jurisdictions should be interpreted with caution because they do not have laws requiring complete reporting of laboratory data or have incomplete reporting. Areas without laws: Idaho, New Jersey, and Pennsylvania. Areas with incomplete reporting: Arizona, Arkansas, Connecticut (2018 only), Kansas, Kentucky, Nevada (2017 only), Vermont, and Puerto Rico. All data presented in this slide set are from the same dataset (reported to CDC through December 2019) and CD4 model used for the HIV Supplemental Surveillance Report "Estimated HIV Incidence and Prevalence in the United States 20142018". Please see the Commentary and Technical Notes for information on the methods used to produce the estimates. The report can be found at: https://www.cdc.gov/hiv/library/reports/hiv-surveillance.html 7 HIV in Ohio 2019 There are 24,558 people with HIV in Ohio. In 2019, there were 973 new diagnoses of HIV. The rates of new diagnoses were over 7 times higher for black/African American people when compared to white people. Over half of the new diagnoses are in people between the ages of 20 and 34. Male to male sexual contact is the risk factor for 58% of males newly diagnosed. Heterosexual contact is the risk factor for 68% of females. 8 HIV in Selected Ohio Counties 2019 County Rate per 100,000 New Infection Rate per 100,000 Butler 127.6 6.5 Clermont 83.3 5.8 Cuyahoga 410.1 16.1 Franklin 405 16.4 Hamilton 402.8 20.6 Montgomery 294.9 17.9 odh.oh.gov accessed 9/28/2020 Counties in Ohio with the highest rate of HIV. These are all urban areas. People with HIV/AIDS live in EVERY county in Ohio. However, not all counties in Ohio reported new HIV infections in 2014. 9 What is Stigma? A process of devaluation of people either living with or associated with HIV and AIDS Stigma is perpetuated by myths about what HIV is, how it's transmitted, and who people living with HIV are Types of stigma include: Enacted stigma Internalized stigma Institutional stigma Before we get started talking about HIV, we need to unpack what makes HIV unique. Thanks to advances in treatment and prevention, there is nothing about HIV that should uniquely disadvantage people living with it, compared to people living with, say, diabetes. But people living with HIV face The main causes of stigma include: (https://www.icrw.org/wp-content/uploads/2016/10/Understanding-and-Challe...) Insufficient knowledge, misbeliefs and fears about how HIV is transmitted and the life potential/capacity of PLWH Moral judgments about people who we assume have been sexually promiscuous Fears about death and disease Lack of recognition and stigma The main forms of stigma include: Physical and social isolation from family, friends, and community Gossip, name calling, and condemnation Loss of rights and decision-making power Self-stigma blaming and isolating themselves Stigma by association Stigma by looks/appearance/type of occupation Stigma may arise from two sources, stigma enacted by society, and stigma arising from within the individual who is part of a stigmatized group. Enacted stigma is the stigma that one experiences from external sources such as individuals and organizations. It is manifest in the interactions one has with others. It is stigma that emanates from, and is applied to, an individual who is part of the stigmatized group. Internalized stigma occurs when a member of the stigmatized group comes to believe and integrate the stigma that is held by society. The messages that are conveyed by the dominant culture are absorbed by the individual and then become a part of how that individual sees themselves and their place within the greater society. Institutional stigma occurs when institutions such as hospitals, community based organizations, schools, and courts come to believe and integrate into their policies and procedures the messages about the stigmatized group. It is the stigmatization of a particular group through the use of formal and informal policies and procedures enacted by those within the organization. 11 Impact of Stigma Major barrier to HIV screening and testing Negative impact on health of PLWH Poor access to healthcare Treatment interruptions Failure to disclose status (Dowshen et al., 2009; Eaton, et al, 2015; Fontenberry, et al., 2002; Halkitis, Wolitski, & Millett, 2013; Overstreet et al., 2012; Sayles et al., 2009) Healthcare providers and staff can hold outdated beliefs about HIV. Despite advances in treatment and knowledge about HIV, stigmatizing attitudes and behaviors persist and present barriers to testing, treatment adherence, and retention in care (Stringer, Turan, McCormick, Durojaiye, Nyblade, Kempf, Lichtenstein, & Turan, 2016). A study conducted in 2008 found that over 50% of nursing staff, 25% of cosmetic surgeons, and nearly half of all obstetricians surveyed refused to provide services to patients living with HIV (Sears, 2008). Other surveys and studies have found, time and time again, that people living with HIV report experiencing stigma from their healthcare providers (Stringer, et al., 2016). This can take the form of patient avoidance, taking extreme precautionary measures, refusing to do a physical exam, violating confidentiality, or refusing treatment altogether (Stringer, et al., 2016). In the context of HIV testing, stigma can contribute to failing to recommend testing for everyone, based on the provider's perception of how a person with HIV looks or behaves. For example, a nurse may not offer an older married woman an HIV test, because it is assumed she is in a safe, monogamous sexual relationship. On the other hand, the fear of judgment and stigma can lead to the patient having anxiety and refusing to receive an HIV test, as well as ignoring their risk factors and not being honest with their provider (Nyblade, Stangl, Weiss, & Ashburn, 2009).Patients may feel that accepting an HIV test, or being honest about their risk factors, may negatively impact how the provider perceives them or interacts with them. (Young, Monin, & Owens, 2009). This can stem from an unconscious desire many patients feel to please their providers, since they see them as authority figures. This feeling can be heightened especially with providers who make value judgements and say things like, "good for you!" when a patient says they only have one sex partner. One study found that people who imagined having a stigmatized disease felt they would be seen as an immoral person if they were to be associated with that disease (Young, et al., 2009). 12 HIV Compared to Other Diseases Disease Stigma Level What people say about the person How the person feels Reasons for stigma HIV High Deserves it Got it from bad behavior Stay away Shame and loss of self-esteem Scared to die Associated with sex and drugs Deadly disease Fear of contagion Other STI Medium Bad person Promiscuous Embarrassment Shame Associated with sex Cancer Low Unlucky Loss of hope Scared to die Deadly disease Not contagious Diabetes Low Lazy Self-blame Not associated with sex Not contagious Cancer: no transmission to others + no moral blame = no stigma Leprosy: transmission to others + no moral blame = low stigma HIV: transmission assumed + strong moral blame = high stigma Are there times when stigma is higher for cancer and diabetes? http://www.hivpolicy.org/Library/HPP001877.pdf 13 How can we combat stigma? People First Language Stigmatizing vs. Preferred Language Opt-out testing Trauma-informed care People First language: People First Language puts the person before the illness or medical condition and describes what a person has, not who a person is. Using a diagnosis as a defining characteristic reflects prejudice, and also robs the person of the opportunity to define him or herself. We want to promote understanding, respect, and dignity for all people.(https://www.poz.com/article/vickie-lynn-valerie-wojciechowicz-28210-9008) Have you ever heard a person living with HIV describe themselves as "I am HIV"? Do the words "infection" or "infected" feel negative to you? Are you offended when you are referred to by your health condition first, instead of as a person first? (https://www.thewellproject.org/hiv-information/why-language-matters-faci...) 14 Stigmatizing Preferred HIV patient, AIDS patient AIDS or HIV carrier Person living with HIV Full-blown AIDS There is no medical condition for this phrase simply use the term AIDS, or Stage 3 HIV Contaminated or infected Person living with HIV Unprotected sex Condomless sex Compliant Person taking medications as prescribed HIV infected Living with/diagnosed with HIV, contracted/acquired HIV BIOLOGY OF HIV: A BRIEF OVERVIEW 16 Characteristics of HIV Human Immunodeficiency Virus. RNA virus. Classified as a retrovirus. Must live inside a human cell to survive. Spread from person to person by contact with certain body fluids: semen, blood, vaginal fluids, breast milk. 17 Characteristics of HIV con't Weakens the immune system of a person by replicating inside a type of white blood cell call T cells (CD4 cells). The T cells are destroyed during this process. Once established, infection with HIV is chronic. HIV is the virus that causes AIDS. 18 HIV Life Cycle Courtesy of the Howard Hughes Medical Institute https://www.youtube.com/watch?v=PlSvywlLuNw HIV: TRANSMISSION & ACUTE INFECTION 20 HIV is in: Blood Semen Vaginal fluids Breast milk HIV is NOT in: Tears Sweat Insect bites Utensils Furniture, toilets Behaviors which risk for contracting HIV: Men having sex with men (MSM). Multiple sex partners. Substance misuse/abuse. Sharing needles for tattoos or piercing. Sex partner of a person with high risk behavior. Mother to fetus transmission if mom has HIV. Breastfeeding if mom has HIV. Pre-masticated food from parent to child. Reducing Risk Safer sex with each encounter. Clean needles & equipment when injecting drugs. Test all pregnant women for HIV, including those who are in labor and whose HIV status is unknown. Avoid breastfeeding if mom has HIV. Treatment as prevention: U=U. PrEP. We will take a deeper dive into some of these prevention methods later in this presentation. 23 Acute HIV Infection HIV usually starts replicating within 11 days of transmission During acute infection, virus levels in the bloodstream are very high. Individuals are highly infectious during this time. ~ 50% of individuals will feel ill during acute infection. Acute Retroviral Syndrome Non-specific symptoms: fever, headache, fatigue, rash, sore throat, myalgias, swollen lymph nodes, diarrhea. Can be mild, moderate or severe. May require hospitalization. Neurologic problems such as meningitis or paralysis can occur. Can be associated with a severely weakened immune system and opportunistic infections. Serum Markers in Early HIV Infection National HIV Curriculum Section 1 www.hiv.uw.edu accessed 4/19/18 Types of HIV Tests Rapid Tests Test for HIV antibodies Results in 30 minutes Test may not be positive for 3-6 weeks after exposure to HIV 4th Generation Testing Tests for antigens and antibodies Very accurate Allows for earlier diagnosis (2-3 weeks after infection) If positive, must be followed by a confirmatory test Must perform test to differentiate HIV-1 from HIV-2 There are two main types of the HIV virus HIV -1 and HIV- 2. Of the approximately 37.9 million people in the world who have HIV, approximately 1 to 2 million have HIV-2. HIV-2 is seen most commonly in West Africa, France, Spain, Portugal, Brazil, India, Angola and Mozambique. Management of HIV-2 may require different medications than HIV-1; treatment with an expert skilled in HIV is usually recommended. Individuals may be infected with both HIV-1 and HIV-2. 27 CDC Revised Recommendations 2006for HIV Testing Routine, voluntary HIV screening for persons aged 13-64 in all health care settings, not based on risk factors. Screen persons at known risk at least once a year. Screen all pregnant women each pregnancy. Separate signed consent or counseling should not be required. 28 HIV:CHRONIC INFECTION 29 How does HIV affect the body? HIV depletes the number of T cells (CD4 cells) in the host and destroys the body's natural immunity. HIV can directly affect cell function of some organs. Brain, kidney, neuropathy (impaired nerve sensation in hands and feet). Chronic inflammation from immune system being ramped up. This may the risk of heart disease and stroke. Once acquired, HIV is a lifelong infection There is no cure for HIV, but the infection can be controlled with daily medications. With treatment, the life expectancy of people with HIV is nearly the same as those who do not have HIV. Without treatment, most people living with HIV infection will go on to develop AIDS. Blood tests to monitor HIV infection T cells (CD4 cells) Type of white blood cell. Normal is 500-1500. Protects from certain infections. Monitored every 6-12 months. Viral Load Measures amount of virus in the bloodstream. Also called RNA test. Monitored every 3-6 months. Ideal value is undetectable'. Undetectable does not mean that there is no virus in the body. It means that the amount of virus circulating in the bloodstream is so low that a commercial lab can't detect any virus. 32 Acquired Immunodeficiency Syndrome(AIDS) People with HIV go on to develop AIDS if their immune system becomes very compromised and has an impaired ability to fight infections. Criteria for Diagnosis of AIDS: CD4 count falls to 200 or below (or < 14%). or Patient develops an indicator condition such as tuberculosis, pneumocystis pneumonia, Kaposi's sarcoma, disseminated fungal infection, lymphoma, invasive cervical cancer, recurrent pneumonias, wasting syndrome. 34 www.aidsetc.org May 2014 Natural History of Untreated HIV Infection Common Illnesses in people with HIV Sinus infections Bronchitis Bacterial infections Diarrhea Fatigue Weight loss Folliculitis Seborrhea Vaginal infections Illnesses That Can Occur in Patients with HIV Toxoplasmosis Cryptococcal meningitis Progressive multifocal leukoencephalopathy Encephalopathy Cytomegalovirus Candidiasis Pneumocystis carinii/jiroveci pneumonia (PCP) Pneumonia (recurrent) Tuberculosis (TB) Histoplasmosis Cytomegalovirus Cryptosporidiosis Mycobacterium avian complex Salmonella septicemia (recurrent) Isosporiasis Genital Herpes Vaginal Candidiasis Cervical cancer (invasive) Kaposi's sarcoma Herpes simplex (severe) Lymphoma Wasting disease Coccidioidomycosis BRAIN LUNGS GENITALS EYES MOUTH/THROAT GUT SKIN OTHER Information adapted from the U.S. Department of Health and Human Services' HIV and Its Treatment: What You Should Know (December 2009) accessed at http://www.aidsinfo.nih.gov/contentfiles/understandinghivprevention_fs_en.pdf on Oct. 20, 2010. 37 TREATMENT & WELLNESS CARE FOR THE PERSON WITH HIV 38 Initial Clinic Visits Educate about HIV disease progression, transmission, treatment options. Discuss safe sex & risk reduction. Avoid exposure to different strains of HIV that have different sensitivity patterns to HIV meds. Identify other chronic health conditions, including psychiatric illness. Start antiretroviral meds ASAP. You may hear the term "rapid initiation of ART". This means starting medications to control HIV as soon as possible. 39 Initial Lab Tests CD4 Count (T cells) Viral Load Genotype Complete Blood Count Baseline Chemistries Hepatitis A, B and C testing Syphilis, Chlamydia and Gonorrhea tests Tuberculosis screening with QuantiFERON Gold or T-SPOT tests. Quantiferon Gold and T-SPOT are blood tests used to screen for tuberculosis. They are more reliable than the PPD skin test. 40 Genotype Test Analyzes for mutations in the HIV virus that can affect its sensitivity to anti-retroviral medications. HIV virus without mutations is called wild-type. A genotype test should be done at time of diagnosis. Repeat genotype if antiretroviral meds are not working (treatment failure). Anti-retroviral Medications Highly active anti-retroviral therapy. Acronyms: HAART or ART. Controls infection; does not eradicate it. Goals: Slow viral replication. Stop disease progression and keep person as healthy as possible. Maintain or increase CD4 count. Prevent opportunistic infections. Prevent transmission of HIV to others. Who Should Be on Anti-Retrovirals? DHHSAdult and Adolescent ARV Guidelinesrecommend initiation of antiretroviral therapy for all persons with HIV to reduce morbidity and mortality associated with HIV infection and to prevent HIV transmission to others. In addition, antiretroviral therapy should be started immediately, or as soon as possible, after the HIV diagnosis is confirmed. 43 Anti-retroviral Medications 5 FDA approved categories of anti-retrovirals: HIV entry inhibitors Nucleoside reverse transcriptase inhibitors (NRTIs) Non-nucleoside reverse transcriptase inhibitors (NNRTIs) Integrase strand inhibitors (INSTIs) Protease inhibitors (PIs) Recommended Initial ART Regimens The choice of the initial antiretroviral regimen depends on multiple patient factors, including medical and psychiatric comorbidities, patient preferences, and drug interactions. In theAdult and Adolescent ARV Guidelines, the Recommended Initial Regimens for Most People with HIV consists ofan INSTI anchor drug plus a 2-drug NRTI backbone. Other effective regimen options are available for use in certain clinical situations. 45 Comorbidities are other illnesses that a person may have in addition to HIV. Refer to the DHHS guidelines (at HIV.gov) on antiretroviral medications to find out additional information about appropriate medications to use to treat HIV. 45 Single Tablet Regimens Genvoya Biktarvy Delstrigo Juluca Stribild Triumeq Atripla Complera Odefsey Symtuza Single tablet regimens combine several different anti-retroviral medications into one pill. This makes it much easier for people to take ARTs. 46 Monthly Injection ART On Jan 21, 2021 the FDA approved Cabenuva (cabotegravir and rilpivirine, injectable formulation) to use once a month as a complete treatment regimen for HIV. Indicated for patients whose HIV is well controlled with an oral ART regimen. Must take one month of oral cabotegravir and rilpivirine before starting injections to ensure tolerability of medications. 47 Use of Viral Load to Guide HIV Treatment Decisions Viral Load (RNA) monitoring 2-4 weeks (not more than 8 weeks) after start or change of ART, then every 4-8 weeks until suppressed to <200 copies/mL. Every 3-4 months with stable patients; may consider every 6 months for stable, adherent patients with VL suppression >2 years. Isolated "blips" may occur (transient low-level RNA, typically <400 copies/mL); these are not thought to predict virologic failure. Virologic Failure Defined as a HIV RNA level of >200 copies/ml confirmed on multiple test dates. Assess patient's ability to take medication as prescribed. Requires an assessment of multiple issues: HIV meds, non-HIV meds, other medical problems, social issues. Order a genotype. Change medications as indicated by tolerability and genotype. Wellness Care Proper nutrition; maintain ideal body weight. Keep immunizations up to date. Annual tuberculosis screening for most patients. Avoid alcohol and substance misuse. Annual lipid tests and assessment for risk of heart disease and strokes. Annual screening for syphilis and other STIs according to risk factors. Annual screening for Hepatitis C in certain patients. Screen for osteoporosis CONCURRENT ILLNESSES IN PEOPLE WITH HIV 51 Examples of Concurrent Illnesses Diabetes Mellitus Hypertension Hyperlipidemia Heart Disease Stroke Hepatitis Substance Use Disorders 52 Hepatitis C RNA virus. Can cause hepatitis, cirrhosis, liver failure, hepatocellular carcinoma. Transmitted via: Exposure to blood products (i.e. sharing street drug paraphernalia). Organ transplantation. Condomless sex. Perinatal (mother to newborn). 53 Hepatitis C con't 15 to 30% of people with HIV may also have hepatitis C. As compared to people without HIV, individuals with HIV may have a more aggressive and rapid course of infection with hepatitis C. There are a number of anti-viral medications that treat hepatitis C. Can cure hepatitis C. Can be prescribed for people with HIV. Drug drug interactions with ARTs can occur. Re-infection can occur. Test yearly in high risk individuals. 54 Psychiatric Illnesses in HIV Patients Major depression Bipolar Illness Schizophrenia Panic Disorder Anxiety Disorder risk for suicide Posttraumatic Stress Disorder Guide for HIV/AIDS Clinical Care, Section 8, pages 557-596 April 2014 US Department of Health and Human Services, Health Resources and Service Administration, HIV/AIDS Bureau 55 ENDING THE HIV EPIDEMIC 56 Methods to Reduce New Infections Needle Exchange Programs Cincy: The Exchange. PrEP nPEP Treatment as Prevention U=U. Reducing mother to baby transmission. PrEP Pre-exposure Prophylaxis. Medication to prevent HIV infection. Who is eligible? Those at risk for HIV: sex partner is known HIV +; multiple sex partners; trading sex for housing, food or drugs; substance abuse disorder. Check Hepatitis B test and kidney function. Daily oral emtricibaine + tenofovir disoproxil fumarate or Daily oral emtricitabine + tenofovir alafenamide or Injection cabotegravir every 8 weeks. Patients should be have appointments every 3 months to repeat HIV test and assess ability to take medication as prescribed. Test for sexually transmitted infections as appropriate. Post-Exposure Prophylaxis (nPEP) Typically administered when there is a defined exposure like unprotected sex or rape. Rapid HIV test must be negative. Must give ART meds within 72 hours of exposure. 28 days of antiretroviral meds. Examples: tenofovir disoproxil fumarate + emtricitabine + dolutegravir OR Tenofovir disoproxil fumarate + emtricitabine + raltegravir Repeat HIV testing at 4-6 weeks and again at 3 months. Treatment as Prevention U=U Individuals with undetectable viral loads are much less likely to transmit HIV to their sex partners or people with whom they share needles with. A few of the research studies showing validity of U = U: HPTN-052 PARTNER-1 & PARTNER -2 studies Opposites Attract Undetectable = Untransmittable U=U Campaign https://www.preventionaccess.org/undetectable Reducing Mother to Child HIV Transmission Test all pregnant women for HIV. Repeat testing in 3rd trimester if woman is at high risk for HIV Pregnant women should be antiretroviral medications; ensure that the viral load is undectable. Undetectable viral load reduces transmission risk from about 25 % to about 1%. HIV exposed neonates should receive antiretroviral medication(s) from an infectious diseases expert and have medical follow-up. RESOURCES 62 Early Intervention Program (EIP) Rapid HIV testing site in the Emergency Department at UCMC. Testing is usually available 24/7. EIP offers HIV risk reduction education. Information materials about sexual and behavioral health. Linkage to HIV care and case management if HIV test is positive. 513-584-0720 63 Caracole Non-profit AIDS service organization for clients in southwest Ohio, northern Kentucky and southeast Indiana. Case Management. Housing: housing stipends as well as on site housing. HIV prevention: HIV testing. Needle exchange & harm reduction. Education about safer sex. 64 OHIV.org 800-332-2437 Private & anonymous info about HIV, STIs, sexual health, testing, HIV prevention (PAPI program). Anyone in Ohio may call or access program online. Phone hotline, online chat, webpage with lists of resources. Health professionals may use the hotline to find resources, testing sites and general care information. 65 Opioid Response Network Free local training and education to professionals addressing the public health crisis of opioid use disorder. Staffed by American Academy of Addiction Psychiatry experts and other national professional organizations with expertise in the prevention, treatment and recovery ofopioiduse disorders. Send request to Opioid Response Network 66 AETC National Clinical Consultation Center HIV Management, COVID-19 800-933-3413 PEPline (post HIV exposure) 888-448-4911 Perinatal HIV Hotline888-448-8765 PrEPline (HIV prevention)855-448-7737 Clinical Substance Use Consultation855-300-3595 Hepatitis C844-497-4636 67 67 Medical Case Management Curriculum Online self learning course for case managers Offered by Southeast AETC Purpose is to improve case managers' health literacy and optimize client-centered communication through improved understanding of the unique structural barriers faced by people with HIV. https://www.seaetc.com/medical-case-management-mcm-curriculum/ 68 Postcard Front QUESTIONS? 70 Source Material cdc.gov odh.ohio.gov National HIV Curriculum www.hiv.uw.edu https://www.preventionaccess.org/undetectable Aidsinfo.nih.gov Slides about stigma are provided courtesy of: Tusday Dudley, M.Ed., Program Director, MATEC Missouri. Contact Information Mary Beth Donica [email protected] 513-584-2422 72