The estimated number of annual new human immunodeficiency virus (HIV) infections in the United States has remained at 40,000 for >10 years. Reducing the rate of transmission will require new strategies, including emphasis on prevention of transmission by HIV-infected persons. Medical care providers can affect HIV transmission by screening HIV-infected patients for risk behaviors, communicating prevention messages, discussing sexual and drug-use behaviors, reinforcing changes to safer behavior, referring patients for services such as substance abuse treatment, facilitating partner counseling and referral, and identifying and treating other sexually transmitted diseases. The Centers for Disease Control and Prevention (CDC), the Health Resources and Services Administration (HRSA), the National Institutes of Health (NIH), and the HIV Medicine Association (HIVMA) of the Infectious Diseases Society of America (IDSA) have recently collaborated to develop evidence-based recommendations for incorporating HIV prevention into the medical care of persons living with HIV. This article summarizes key aspects of the recommendations.
The estimated number of annual new HIV infections in the United States has remained at 40,000 for over 10 years . Reducing the rate of HIV transmission will require new strategies, including increased emphasis on preventing transmission by persons living with HIV [2, 3]. Clinicians providing medical care to HIV-infected persons can play a key role in helping their patients reduce risk behaviors and maintain safer sexual and drug-using practices and can do so with a feasible level of effort, even in constrained practice settings. The Centers for Disease Control and Prevention (CDC), the Health Resources and Services Administration (HRSA), the National Institutes of Health (NIH), and the HIV Medicine Association (HIVMA) of the Infectious Diseases Society of America (IDSA) have recently collaborated to develop recommendations for incorporating HIV prevention into the medical care of persons living with HIV . The recommendations were developed using an evidence-based approach (table 1). The strength of each recommendation is indicated on a scale of A (strongest recommendation for) to E (recommendation against); the quality of available evidence supporting the recommendation is indicated on a scale of I (strongest evidence for) to III (weakest evidence for), and the outcome for which the recommendation is rated is provided. The recommendations are categorized into 3 major components: (1) screening for HIV transmission risk behaviors and sexually transmitted diseases (STDs); (2) providing, and referring for, behavioral risk-reduction interventions and related services; and (3) facilitating notification, counseling, and testing of infected persons' partners. This article summarizes key aspects of the recommendations for readers of this journal.
Risk screening, a brief assessment of behavioral and clinical factors associated with transmission of HIV and other STDs, can be used to identify patients who should receive more in-depth risk assessment, HIV risk-reduction counseling, other risk-reduction interventions, or referral for other services (e.g., substance abuse treatment) (table 2). Screening methods include asking patients about behaviors associated with transmission of HIV and other STDs, eliciting patient reports of symptoms of other STDs, and laboratory testing for other STDs.
Behavioral risk screening should address both sex-related and injection drug—related behaviors (table 3). Screening can be done with brief, self-administered, written questionnaires; computer-, audio-, and video-assisted questionnaires; structured face-to-face interviews; and personalized discussions [5–16]. Screening questions can be either open-ended or closed (directed) (table 4). Open-ended questions avoid simple “yes” or “no” responses and encourage patients to discuss personal risks and the circumstances in which risks occur [6, 17, 18]. Clinicians who receive training are more likely to perform effective behavioral risk screening [8–11]. Screening for behavioral risks can be done by ancillary staff before the patient is seen by the clinician or by the clinician during the medical encounter. Provider reminder systems (e.g., computerized reminders) increase the likelihood that recommended screening is done regularly .
The presence of new STDs often suggests recent or ongoing sexual behaviors that may result in HIV transmission. Also, substantial evidence suggests that many STDs enhance risk for HIV transmission or acquisition [20–24]; therefore, early detection and treatment of bacterial STDs may reduce risk for HIV transmission . Clinicians should routinely ask patients about STD symptoms; the presence of such symptoms should always prompt diagnostic testing and, when appropriate, treatment. However, clinical symptoms are not sensitive for identifying many infections, because most STDs are asymptomatic [26–33]; therefore, laboratory screening (i.e., testing on the basis of risk estimation, regardless of clinical indications for testing) of HIV-infected persons is a cornerstone of identifying persons at risk for transmitting HIV and other STDs to others (tables 5 and 6) [34–37].
Women of childbearing age should be questioned during routine visits about the possibility of pregnancy. Women who suspect pregnancy or have missed their menses should be tested for pregnancy. Early pregnancy diagnosis would benefit even women not receiving antiretroviral treatment, because they could be offered treatment to decrease risk for perinatal HIV transmission.
Behavioral interventions are strategies designed to change the knowledge, attitudes, behaviors, or practices of individuals to reduce their personal health risks or their risk of transmitting HIV to others (table 7). Behavioral change can be facilitated by environmental cues in the clinic or office, messages delivered to patients by clinicians or other qualified staff on-site, or referral to other persons or organizations providing prevention services.
Clinic or office environments can be structured to support prevention. All patients should receive printed information about HIV transmission risks and preventing transmission of HIV to others. Information can be conveyed throughout the clinic; for example, posters and other visual cues containing prevention messages can be displayed in examination rooms and waiting rooms. These materials usually can be obtained through health department HIV/AIDS and STD programs or from the National Prevention Information Network (NPIN) (telephone: 1-800-458-5231; Web site: http://www.cdcnpin.org).
All HIV-infected patients can benefit from brief prevention messages emphasizing the need for safer behaviors to protect their own health and that of their sex or needle-sharing partners. Such messages include discussion of the patient's responsibility for appropriate disclosure of HIV serostatus to sex and needle-sharing partners. These messages can be delivered by clinicians, nurses, social workers, case managers, or health educators. Many patients have inadequate information about factors influencing HIV transmission and methods for preventing transmission. They should understand that the most effective methods for preventing HIV transmission remain those that protect noninfected persons against exposure to HIV. For sexual transmission, the only certain means for HIV-infected persons to prevent transmission to noninfected persons are sexual abstinence or sex only with a partner known to be already infected with HIV. However, restricting sex to partners of the same serostatus does not protect against transmission of other STDs or the possibility of HIV superinfection unless condoms of latex, polyurethane, or other synthetic materials are consistently and correctly used. For injection-related transmission, the only certain means for HIV-infected persons to prevent transmission to noninfected persons are abstaining from injection drug use or refraining from sharing injection equipment (e.g., syringes, needles, cookers, cottons, and water).
Some sexual behaviors have a lower average per-act risk for transmission than others [38–52], and replacing a higher risk behavior with a relatively lower risk behavior may reduce the likelihood that HIV transmission will occur (table 8) [44, 53, 54]. However, risk for HIV transmission is affected by numerous biological and behavioral factors [44, 54, 55], and estimates of the absolute per-episode risk for transmission associated with different activities may be misleading when applied to a specific patient or situation [49, 52]. High viral load is an important risk factor for HIV transmission (table 9) [56–65]. By lowering viral load, antiretroviral therapy may reduce risk for HIV transmission. However, since HIV can be detected in the semen, rectal secretions, female genital secretions, and pharynx of HIV-infected patients with undetectable plasma viral loads [66–70], all patients receiving therapy, even those with undetectable plasma HIV levels, should understand that they may still be able to transmit HIV. Few data are available on efficacy of postexposure prophylaxis for nonoccupational exposure [71–77]; thus, the potential availability of postexposure prophylaxis should not be used to justify risky behavior.
Interventions tailored to individual patients' risks can be delivered to patients at highest risk for transmitting HIV infection and for acquiring new STDs. This includes patients whose risk screening indicates current behaviors that may lead to transmission, who have a current or recent STD, or who mention issues of concern in discussions with the clinician [78, 79]. Any positive results of screening for behavioral risks or STDs should be addressed in more detail with the patient so a more thorough risk assessment can be done and an appropriate risk-reduction plan discussed and agreed upon. At a minimum, an appropriate referral should be made (table 10) and the patient should be informed of risks involved in continuing the behavior. HIV-infected persons who remain sexually active should understand that the only certain means for preventing transmission to noninfected persons is to restrict sex to HIV-infected partners. For mutually consensual sex with persons of unknown or discordant serostatus, consistent and correct use of condoms made of latex, polyurethane, or other synthetic materials can significantly reduce risk for HIV transmission. HIV-infected patients who continue injection drug use should understand the risks of sharing needles and be provided information regarding substance abuse treatment and access to clean needles (table 11) [80–82]. Examples of targeted motivational messages on condom use and needle sharing are provided (figures 1 and 2).
Prevention messages can be reinforced by subsequent longer or more intensive interventions in clinic or office environments by nurses, social workers, or health educators, if feasible [6, 83–108]. Many patients have underlying issues that impede adoption of safer behaviors, and achieving behavioral change is often dependent on addressing such issues. Clinicians will usually not have time or resources to fully address these issues, many of which can best be addressed through referrals for services such as intensive HIV prevention interventions (e.g., multisession risk-reduction counseling) [109–126], medical services (e.g., family planning and contraceptive counseling, substance abuse treatment), mental health services (e.g., treatment for sexual compulsivity), and social services (e.g., housing, protection from domestic violence) (table 10). Patients who have difficulty initiating or sustaining behaviors that reduce or prevent HIV transmission may benefit from prevention case management (PCM). PCM provides intensive, client-centered risk assessment; prevention counseling; and assistance accessing other services to address issues that affect patients' health and ability to change risk-taking behavior.
For IDUs, ceasing injection drug use is the only reliable way to eliminate risk for injection-associated HIV transmission; however, many IDUs are unable to sustain abstinence without substance abuse treatment. Early entry and maintenance in substance abuse treatment programs and sustained abstinence from injecting are important for reducing risk for HIV transmission from infected IDUs [127–143]. Some IDUs are not able or willing to stop injecting drugs; for these persons, once-only use of sterile syringes can significantly reduce risk for injection-related HIV transmission [144–153]. Information on access to sterile syringes and safe syringe disposal may be obtained through health departments or HIV/AIDS prevention programs.
Referrals that match the patient's self-identified priorities are more likely to be successful than those that do not. Discussion with the patient can identify factors that may make it difficult for the patient to complete the referral (e.g., lack of transportation). Patients need specific information to successfully access referral services and may need assistance (e.g., scheduling appointments) to complete referrals. When a clinician does not have the capacity to make all appropriate referrals, or when needs are complex, a case manager can help make referrals and coordinate care. Referral guides and other information usually can be obtained from health department HIV/AIDS prevention and care programs (table 12).
Clinicians can prepare to deliver HIV prevention messages and behavioral interventions by developing strategies for incorporating risk-reduction interventions into patients' clinic visits , obtaining training [155–158], becoming familiar with interventions that have demonstrated effectiveness , and becoming familiar with community resources. Training on risk screening and prevention can be obtained at CDC-funded STD/HIV Prevention Training Centers (http://depts.washington.edu/nnptc) and HRSA-funded AIDS Education and Training Centers (http://www.aids-ed.org). Additional information related to behavioral interventions is available through many health department HIV/AIDS programs. A complete listing of state AIDS directors is available from the National Alliance of State and Territorial AIDS Directors (NASTAD) (http://www.nastad.org). Examples of case scenarios for prevention counseling are provided in tables 13–16.
Partner Counseling and Referral Services, Including Partner Notification
Many HIV-infected persons are not aware of their infection; thus, they cannot benefit from early medical care and do not know they may be transmitting HIV to others. Reaching such persons as early after infection as possible is important for their health and for reducing HIV transmission. Partner counseling and referral services (PCRS), including partner notification, are intended to address these problems by (1) providing services to HIV-infected persons and their sex and needle-sharing partners so the partners can take steps to avoid becoming infected or infecting others, and (2) helping infected partners gain earlier access to medical care and other services (table 17) .
A key element of PCRS involves informing current and past partners that they have been exposed to HIV and advising them to have HIV counseling and testing [161–164]. PCRS is confidential and voluntary. Partners can be reached and informed of their exposure by the infected person, clinicians in the private sector, or health department staff. Notification by the health department appears to be substantially more effective than notification by the infected person . Also, one observational study suggested health department specialists were more successful than physicians in interviewing patients and locating partners . Health departments have staff who are trained to do partner notification and skilled at providing this free, confidential service. These specialists can work closely with public and private sector clinicians who treat persons with HIV and other STDs. Most states and some cities or localities have laws and regulations related to informing partners they have been exposed to HIV. Clinicians should know and comply with such requirements. Additional information related to PCRS is available through health department HIV/AIDS programs.
The HIV Prevention in Clinical Care Working Group
Members of the working group. Sevgi Aral, Samuel W. Dooley, Mary L. Kamb, Jonathan Kaplan, Mary Spink Neumann, Ida M. Onorato, Thomas A. Peterman, Kathryn J. Rauch, Renee Ridzon, and J. Walton Senterfitt (Centers for Disease Control and Prevention [CDC], Atlanta, GA); Barbara Aranda-Naranjo and Michael Johnson (Health Resources and Services Administration [HRSA], Rockville, MD); Christopher M. Gordon (National Institutes of Health, [NIH] Rockville, MD); and, for the HIV Medical Association of the Infectious Diseases Society of America [HIVMA of the IDSA], John Bartlett (The Johns Hopkins University School of Medicine, Baltimore, MD).
Consultants to the working group. Representing the HIVMA of the IDSA: Fredrick Hecht (University of California, San Francisco AIDS Program, San Francisco, California) and Kenneth Mayer (Brown University School of Medicine, Providence, Rhode Island).
Federal government staff: Joanna Buffington, James Buehler, Alan E. Greenberg, Kathleen Irwin, Harold W. Jaffe, Robert S. Janssen, Gary Marks, Allyn Nakashima, Esther Sumartojo, Ronald O. Valdiserri, Jason Urbanowicz, Richard Wolitski, Kimberly Workowski (CDC, Atlanta, GA); Kim W. Hamlett-Berry (Department of Veterans Affairs, Washington, DC).
Other consultants: Bruce D. Agins (New York State Department of Health AIDS Institute, New York, NY), H. Hunter Handsfield (University of Washington and Public Health-Seattle and King County, Seattle, WA) King K. Holmes (University of Washington, Seattle, WA), Thomas C. Quinn (The Johns Hopkins University School of Medicine, Baltimore, MD), Julie M. Scofield (National Alliance of State and Territorial AIDS Directors, Washington, DC), and Dan Wohlfeiler (California Department of Public Health, Berkeley, CA).
The preparers of this article are grateful to P. Lynne Stockton and P. Susanne Justice (CDC, Atlanta, GA), for their editorial assistance, and to Mark R. Vogel (HIVMA of the IDSA, Alexandria, VA), who assisted in coordinating responses from members of the HIVMA of the IDSA.
Figures and Tables
- patient referral
- substance abuse
- centers for disease control and prevention (u.s.)
- united states national institutes of health
- sexually transmitted diseases
- united states health resources and services administration
- hiv infection
- evidence-based practice
- hiv transmission
- hiv prevention
- infectious diseases society of america