Levels of evidence (I-III) and grades of recommendation (A-E) ratings are defined at the end of the Major Recommendations field.
Recommendations for Screening of Human Immunodeficiency Virus (HIV)-infected Persons for HIV Transmssion Risk
HIV-infected patients should be screened for behaviors associated with HIV transmission by using a straightforward, nonjudgmental approach. This should be done at the initial visit and subsequent routine visits or periodically, as the clinician feels necessary, but at a minimum of yearly. Any indication of risky behavior should prompt a more thorough assessment of HIV transmission risks. (A-II, for identifying transmission risk)
At the initial and each subsequent routine visit, HIV-infected patients should be questioned about symptoms of sexually transmitted diseases (STDs) (e.g., urethral or vaginal discharge; dysuria; intermenstrual bleeding; genital or anal ulcers; anal pruritus, burning, or discharge; and, for women, lower abdominal pain with or without fever). Regardless of reported sexual behavior or other epidemiologic risk information, the presence of such signs or symptoms should always prompt diagnostic testing and, when appropriate, treatment. (A-I, for identifying and treating STDs)
At the initial visit
- All HIV-infected women and men should be screened for laboratory evidence of syphilis. Women should also be screened for trichomoniasis. Sexually active women aged <25 years and other women at increased risk, even if asymptomatic, should be screened for cervical chlamydial infection. (A-II, for identifying STDs)
- Consideration should be given to screening all HIV-infected men and women for gonorrhea and chlamydial infections. However, because of the cost of screening and the variability of prevalence of these infections, decisions about routine screening for these infections should be based on epidemiologic factors (including prevalence of infection in the community or the population being served), availability of tests, and cost. (Some HIV specialists also recommend type-specific serologic testing for herpes simplex virus type 2 for both men and women.) (B-II, for identifying STDs)
Screening for STDs should be repeated periodically (i.e., at least annually) if the patient is sexually active or if earlier screening revealed STDs. Screening should be done more frequently (e.g., at 3–6-month intervals) for asymptomatic persons at higher risk. (B-III, for identifying STDs)
At the initial and each subsequent routine visit, HIV-infected women of childbearing age should be questioned to identify possible current pregnancy, interest in future pregnancy, or sexual activity without reliable contraception. They should be referred for appropriate counseling, reproductive health care, or prenatal care, as indicated. Women should be asked whether they suspect pregnancy or have missed their menses and, if so, should be tested for pregnancy. (A-I, for preventing perinatal HIV transmission)
Recommendations for Behavioral Interventions to Reduce HIV Transmission Risk
Clinics or office environments where patients with HIV infection receive care should be structured to support and enhance HIV prevention. (B-III, for enhancing patient recall of prevention messages)
Within the context of HIV care, brief general HIV prevention messages should be regularly provided to HIV-infected patients at each visit, or periodically, as determined by the clinician, and at a minimum of twice yearly. These messages should emphasize the need for safer behaviors to protect their own health and the health of their sex or needle-sharing partners, regardless of perceived risk. Messages should be tailored to the patient’s needs and circumstances. (A-III, for efficacy in promoting safer behaviors)
Patients should have adequate, accurate information regarding factors that influence HIV transmission and methods for reducing the risk for transmission to others, emphasizing that the most effective methods for preventing transmission are those that protect noninfected persons against exposure to HIV (e.g., sexual abstinence; consistent and correct use of condoms made of latex, polyurethane or other synthetic materials; and sex with only a partner of the same HIV serostatus). HIV-infected patients who engage in high-risk sexual practices (i.e., capable of resulting in HIV transmission) with persons of unknown or negative HIV serostatus should be counseled to use condoms consistently and correctly. (A-III, for using brief clinician delivered messages to influence patient behavior)
Patients’ misconceptions regarding HIV transmission and methods for reducing risk for transmission should be identified and corrected. For example, ensure that patients know that 1) per-act estimates of HIV transmission risk for an individual patient vary according to behavioral, biologic, and viral factors; 2) highly active antiretroviral therapy (HAART) cannot be relied upon to eliminate the risk of transmitting HIV to others; and 3) nonoccupational postexposure prophylaxis is of uncertain effectiveness for preventing infection in HIV-exposed partners. (A-III for using brief clinician delivered messages to influence patient behavior)
Tailored HIV prevention interventions, using a risk-reduction approach, should be delivered to patients at highest risk for transmitting HIV. (A-III, for efficacy in promoting safer behaviors)
After initial prevention messages are delivered, subsequent longer or more intensive interventions in the clinic or office should be delivered, if feasible. (A-I, for efficacy of multisession, clinic-based interventions in promoting safer behaviors)
HIV-infected patients should be referred to appropriate services for issues related to HIV transmission that cannot be adequately addressed during the clinic visit. (A-I, for efficacy of HIV prevention interventions conducted in nonclinic settings)
Persons who inject illicit drugs should be strongly encouraged to cease injecting and enter into substance abuse treatment programs (e.g., methadone maintenance) and should be provided referrals to such programs. (A-II, for reducing risky drug use and associated sexual behaviors)
Persons who continue to inject drugs should be advised to always use sterile injection equipment and to never reuse or share needles, syringes, or other injection equipment and should be provided information regarding how to obtain new, sterile syringes and needles (e.g., syringe exchange programs). (A-II, for reducing risk for HIV transmission)
Recommendations for Partner Counseling and Referral, Including Partner Notification
In HIV health-care settings, all applicable requirements for reporting sex and needle-sharing partners of HIV-infected patients to the appropriate health department should be followed. (A-III, for identifying patients who should be referred for partner counseling and referral services [PCRS])
At the initial visit, patients should be asked if all of their sex and needle-sharing partners have been informed of their exposure to HIV. (A-III, for identifying patients who should be referred for PCRS)
At routine follow-up visits, patients should be asked if they have had any new sex or needle-sharing partners who have not been informed of their exposure to HIV. (A-III, for identifying patients who should be referred for PCRS)
All patients should be referred to the appropriate health department to discuss sex and needle-sharing partners who have not been informed of their exposure and to arrange for their notification and referral for HIV testing. (A-I, for increasing partner counseling and referral and voluntary testing of partners)
In HIV health-care settings, access to available community partner counseling and referral resources should be established. (A-III, for establishing a working relationship and increasing understanding about partner counseling and referral procedures)
Definitions:
Strength of Evidence Supporting the Recommendation
- Evidence from at least one properly randomized, controlled trial
- Evidence from at least one well-designed clinical trial without randomization, from cohort or case-controlled analytic studies (preferably from more than one center), or from multiple time-series studies. Or dramatic results from uncontrolled experiments
- Evidence from opinions of respected authorities based on clinical experience, descriptive studies, or reports of expert committees
Strength of Recommendation
- Should always be offered. Both strong evidence for efficacy and substantial benefit support recommendation for use.
- Should generally be offered. Moderate evidence for efficacy — or strong evidence for efficacy but only limited benefit — supports recommendation for use.
- Optional. Evidence for efficacy is insufficient to support a recommendation for use.
- Should generally not be offered. Moderate evidence for lack of efficacy or for adverse outcome supports a recommendation against use.
- Should never be offered. Good evidence for lack of efficacy or for adverse outcome supports a recommendation against use.
