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Are your HIV-infected patients putting other persons at risk of infection?
New guidelines incorporate prevention message into HIV care
In your care of HIV-infected patients, are you including information about what they can do to prevent transmitting the virus to others? The Atlanta-based Centers for Disease Control and Prevention (CDC) has just issued new guidance to help you incorporate such prevention messages in your care of those living with the disease.
While research has shown that some people who are aware of their HIV infections tend to reduce risky behavior,1-4 recent reports suggest that such behavioral changes often are not maintained and that a substantial number of HIV-infected persons continue to engage in behaviors that place others at risk for HIV infection.5-6 One such report from California shows that 38% of men with syphilis interviewed said they used the Internet to find sex partners during the first half of 2003.7 About 66% of the men with syphilis said they were HIV-positive, says Terrence Lo, MPH, an epidemiologist with the sexually transmitted disease (STD) control branch of the Berkeley-based California Department of Health Services.
"It is important to focus prevention messages on those living with HIV, their sex and needle sharing partners, and other persons who continue to be at high risk of infection," states Robert Janssen, MD, director of the CDC’s division of HIV/AIDS prevention. "There are an estimated 850,000 to 950,000 people currently living with HIV in the U.S.; one-quarter of infected individuals are unaware of their status and may unknowingly transmit HIV — emphasizing testing will help those people learn their status."
The CDC has developed screening practices including questionnaires and interviews to assess risk behaviors as well as testing for STDs when appropriate.8 The guidelines recommend talking to female patients about the possibility of pregnancy to help prevent mother-to-child HIV transmission.
Many studies have shown that once people learn they are HIV-positive, they take steps to reduce the risk of transmission to their partners, says Janssen.
"These studies suggest that by working with HIV-infected persons, the nation can achieve greater reductions in risk behaviors and HIV transmission," he states. "CDC believes it is important to continue to work with both HIV infected and uninfected persons, especially the partners of those already infected with HIV."
Deliver the message
Help reduce patients’ risk of transmitting HIV through such strategies as delivering prevention messages, providing condoms and printed information, and, when appropriate, referring patients to outside prevention services, advises the CDC.
Display posters and educational material in examination rooms and waiting rooms to get out the prevention messages. These materials usually can be obtained through local or state health department HIV/AIDS and STD programs or from the National Prevention Information Network (NPIN), suggests the CDC. [Dial NPIN’s toll-free number, (800) 458-5231, or visit its web site, www.cdcnpin.org.]
Patients may have misconceptions about HIV transmission, particularly with regard to the risk for HIV transmission associated with specific behaviors, the effect of antiretroviral therapy on HIV transmission, or the effectiveness of post-exposure prophylaxis for nonoccupational exposure to HIV, advises the CDC.8 Use office visits to clear up any confusion on such misconceptions.
Reach the partners
It is important to determine whether patients have notified partners of their infections and then help them contact local health departments to arrange for notification, the new CDC guidelines assert. Interviews of HIV-infected persons in various settings suggest that more than 70% are sexually active after receiving their diagnosis, and many have not told partners about their infection.9
Most states have laws and regulations regarding partner notification. Some health departments require that even if a patient refuses to report a partner, the clinician should report the information to the health department.8 Clinicians should know and comply with any such requirements in the areas in which they practice, advises the CDC.
With the new focus on prevention messages to those already infected with HIV, will the CDC continue to support primary prevention/behavioral risk reduction?
Yes, says Janssen. "CDC’s primary HIV prevention mission — to keep people from becoming infected with HIV — has not changed," he attests. "CDC will continue to support primary prevention and behavioral risk-reduction programs, such as health education risk reduction and prevention case management through programs funded through state and local health departments.
1. Chamot E, Coughlin SS, Farley TA, et al. Gonorrhea incidence and HIV testing and counseling among adolescents and young adults seen at a clinic for sexually transmitted diseases. AIDS 1999; 13:971-999.
2. Valleroy LA, MacKellar DA, Karon JM, et al. HIV prevalence and associated risk in young men who have sex with men. JAMA 2000; 284:198-204.
3. Allen S, Serufilira A, Bogaerts J, et al. Confidential HIV testing and condom promotion in Africa. Impact on HIV and gonorrhea rates. JAMA 1992; 268:3,338-3,343.
4. Cleary PD, Van Devanter N, Rogers TF, et al. Behavior changes after notification of HIV infection. Am J Public Health 1991; 81:1,586-1,590.
5. Stall RD, Hays RB, Waldo CR, Ekstrand M, et al. The gay 90s: A review of research in the 1990s on sexual behavior and HIV risk among men who have sex with men. AIDS 2000; 14(suppl. 3):S101-S114.
6. Crepaz N, Marks G. Towards an understanding of sexual risk behavior in people living with HIV: A review of social, psychological, and medical findings. AIDS 2002; 16:135-149.
7. Lo TQ, Samuel MC, Wong W, et al. Venues where syphilis cases among men who have sex with men reported meeting sex partners, California, 2000-2002. Presented at the 2003 National HIV Prevention Conference. Atlanta; July 2003.
8. Centers for Disease Control and Prevention. Incorporating HIV prevention into the medical care of persons living with HIV: Recommendations of CDC, the Health Resources and Services Administration, the National Institutes of Health, and the HIV Medicine Association of the Infectious Diseases Society of America. MMWR 2003; 52(RR-12):1-17.
9. Marks G, Burris S, Peterman TA. Reducing sexual transmission of HIV from those who know they are infected: The need for personal and collective responsibility. AIDS 1999; 13:297-306.