Chapter 4
Prevention Of HIV In The Clinical Care Setting

Michael P. Johnson, MD, MPH

Rationale for HIV Prevention in Primary Care   TOP

Why is HIV prevention important in the HIV clinical care setting?

Why rob banks?…
Because that is where the money is!

There is growing awareness that the majority of people living with HIV are having sex and that active substance abuse, often with needle-sharing behavior, remains common in the setting of HIV infection (see Chapter 13: Management of Substance Abuse). The HIV clinical care setting provides an opportunity to work with patients to reduce their risk of transmitting HIV to others. Studies are under way to measure the effectiveness of comprehensive clinical care in preventing the spread of HIV. Until those results are available, one should assume that interventions to reduce HIV concentrations in the body through antiretroviral therapy (ART) combined with behavioral counseling to reduce high-risk sexual behaviors and, when indicated, drug abuse treatment are important approaches to decreasing the incidence of HIV infection.

Do most primary care providers incorporate HIV prevention into their care?

Experienced providers, and even HIV specialists, often do not conduct screening and assessment of behavioral risk or offer prevention counseling for their HIV-infected patients. The degree to which these are neglected is startling. Nationwide, approximately a third of HIV-infected patients report that their providers have never counseled them about HIV prevention; in some settings as many as three quarters of HIV medical care providers do not ask about sexual behavior and as many as half do not ask about drug use (Marks et al, 2002; Natter et al, 2002). Results of an unpublished study suggest that HIV specialists are less likely than primary care physicians to engage clients in discussions about sexual and drug-using behaviors. Barriers of time, training, and comfort level contribute to this missed opportunity for HIV prevention.

What factors are associated with high-risk behaviors of people living with HIV?

People living with HIV often practice high-risk sexual and drug-using behaviors in association with poor adherence to clinical care in general and to ART regimens in particular (Wilson et al, 2002). This is of particular concern given the risk of viral resistance with poor medication adherence, which may subsequently result in transmission of resistant viral strains to others. Also, both adherence to HIV prevention practices and adherence to medication regimens appear to be related to mental health problems, which are common among people with HIV (Kalichman et al, 2002). In particular, depression and anxiety disorders are common and should be assessed in patients who report continued high-risk sexual and drug-using behaviors. Any of these conditions should alert the provider to probe for problems in the other conditions or behaviors; addressing underlying issues can lead to improvements in several important behaviors.

What behavioral interventions work to prevent people living with HIV from transmitting HIV?

The earliest behavioral interventions provided factual information and generated fear of AIDS to motivate people to reduce high-risk behavior. Most experts now agree that these interventions do not effectively reduce high-risk behaviors of persons at greatest risk for acquiring HIV, and that generating fear of AIDS most likely increases stigmatization of people living with HIV infection.

A number of counseling interventions have been found to be more effective than providing knowledge alone. Among these effective approaches are brief, provider-delivered counseling messages, which can be delivered within the context of a clinical encounter (Kamb et al, 1998; CDC, 2001). Several theoretical behavioral models have been used to guide counseling interventions. Some common elements of these theory-based counseling approaches include:

• Establishing dialogue and rapport with the client and providing ongoing services in an understanding and nonjudgmental manner, often with the support of trained peers to supplement the provider-based counseling
• Understanding and addressing client needs, situations, and pressures for sexual and drug-using behavior (eg, mental health needs), with emphasis on issues that might be perceived by the client as more pressing than HIV prevention (eg, food, housing, employment), and external barriers to the adoption of safer behaviors (eg, domestic violence)
• Addressing the client's high-risk behavior in a step-wise manner, understanding the readiness and motivation for a change in each specific high-risk behavior, and building the client skills for implementing such changes

These elements are the basis for the assessment and counseling recommendations discussed below, which can be implemented in the clinical setting, along with planning and mobilization of supportive services.

What is the role of drug abuse treatment in preventing HIV transmission?

Sharing of drug-injection paraphernalia is directly related to HIV transmission through the transmission of infected blood. Drug and/or alcohol abuse indirectly lead to HIV transmission through the exchange of sex for drugs and enhanced sexual risktaking under the influence of these substances. Drug abuse treatment is an important intervention in the setting of HIV clinical care (see Chapter 13) and should be considered as an important and effective means of HIV prevention among persons with HIV who abuse drugs and/or alcohol.

What is known about the role of antiretroviral therapy in preventing HIV transmission?

Effective ART leads to a decline in plasma viral load, which reduces the risk of maternal-infant HIV transmission. The risk of sexual transmission of HIV is strongly correlated with plasma HIV levels (Quinn, 2000) (see Figure 4-1). There is also a strong correlation between changes in plasma viral load and the HIV viral load in genital secretions (Ball et al, 1999); however, HIV can be present in genital secretions when plasma HIV is suppressed below the level of detection. While it is highly likely that effective ART leads to a significant reduction in HIV infectivity, from a behavioral standpoint an increase in high-risk sexual behavior because of a sense of lower risk to others has been observed in persons being treated with ART (Dukers, 2001; Scheer, 2001). For this reason, HIV prevention counseling remains important for those on effective ART, and it is particularly important when viral loads rise, eg, due to interruption of therapy and/or emergence of viral resistance.

Figure 4-1. Associations of HIV Plasma Viral Load and
Sexual Transmission of HIV

Source: Quinn TC, Wawer MJ, Sewankambo N, et al. Viral load and heterosexual transmission of human immunodeficiency virus type 1. N Engl J Med. 2000;342:921-929. Copyright 2000 Massachusetts Medical Society. All rights reserved. Reprinted with permission.

What is the role of nonoccupational postexposure prophylaxis (nPEP) in the prevention of HIV infection?

Nonoccupational postexposure prophylaxis (nPEP) refers to the use of ART to prevent HIV after a significant sexual exposure to HIV (eg, after sexual assault or condom breakage during intercourse between a discordant couple). A complete review of postexposure prophylaxis (PEP) can be found in Chapter 11: Postexposure Prophylaxis. In summary, a 28-day course of ART may be considered for prevention of nonoccupational HIV transmission if therapy is initiated within 72 hours after a significant exposure from a person with known or suspected HIV infection. This approach will be addressed in upcoming US Public Health Service (PHS) guidelines for nPEP (watch the AIDSInfo website listed in Suggested Resources for these guidelines).

Interventions for HIV Prevention   TOP

What can the provider do to enhance prevention practice in the clinical setting?

Primary care interventions to assess and reduce the risk that HIV-infected persons will transmit the virus to others can be conducted at the level of 1) medical care, 2) other care (eg, case management, social services), and 3) clinic structure. Ideally, interventions at all 3 levels are combined to maximize the opportunities for HIV prevention, and each clinic will structure its interventions differently according to its configuration and resources. The following recommendations are directed primarily to the medical provider, although there are often other clinic staff members who support and reinforce these risk assessment and counseling interventions. Training can enhance the skills and motivation for providers to integrate these activities into their routine practice (see Suggested Resources and Chapter 18: Keeping Up-to-Date: Sources of Information for the Provider).

How can the provider identify a patient's risk behaviors?

A brief history should be taken at each regularly scheduled clinic visit to identify knowledge of HIV transmission, sexual and drug-using behavior, and symptoms of an STD (eg, urethral or vaginal burning or discharge, dysuria, genital or anal ulcers, inter-menstrual bleeding, or lower abdominal pain in women). History-taking methods include written, audio, and computerized questionnaires and face-to-face interviews, using either structured or open-ended questions (see examples in Table 4-1). Studies suggest that patients may provide more honest and detailed responses to questionnaires not administered face-to-face. Also, physicians trained in discussing sensitive sexual and drug-using issues are likely to perform better than those who are not. Providers should give positive reinforcement to patients when the screening questions indicate no high-risk sexual and drug-using behaviors. Conversely, indications of high-risk behavior should trigger a medical/laboratory evaluation for STDs, behavioral risk assessment and counseling interventions, and referral and contact notification, as indicated. For more detailed discussion, see the section on Risk Assessment and Counseling in Chapter 2: Approach to the Patient as well as the screening questions for drug abuse in Chapter 13: Management of Substance Abuse.

What medical and laboratory screening should be done?

Symptoms or signs of an STD or known exposure to STDs should prompt immediate physical and laboratory examinations. However, because STDs are often present without symptoms, every patient should be screened for laboratory evidence of syphilis, trichomonads (women only), gonorrhea, and chlyamdia at the initial visit and at least annually (see Table 4-2). Some experts also recommend type-specific testing for herpes simplex virus type 2 because of its association with a higher risk of HIV transmission and possible need for enhanced counseling. More frequent screening for STDs is appropriate with evidence or suspicion of high-risk sexual behavior (eg, sex with a new partner, sexual activity without consistent and correct condom use); however, there are no data to guide the precise frequency. More frequent screening might also be appropriate in asymptomatic men who have sex with men (MSM) and younger women because of a higher STD prevalence among these demographic groups. The local prevalence of these infections might guide frequency of screening. Laboratory screening for drug abuse is addressed in Chapter 13.

What behavioral assessment and counseling interventions should the provider implement?

Specific suggestions for assessment and counseling are presented in Table 4-3 and in Chapter 2. Each clinic must decide which aspects of HIV prevention assessment and counseling are best done by the primary provider, by other clinical providers with whom the patient interacts, or some combination of both. Brief interventions by physicians have been found to be effective with other conditions, including smoking cessation, improving dietary behavior, and reduction of alcohol consumption. Thus, while data are limited on the topic of HIV prevention, physicians should provide such counseling until studies suggest alternate and improved approaches.

How can clinic staff other than the primary medical provider enhance HIV prevention practice?

In most medium-sized and larger clinics, staff members other than the primary medical provider are responsible for referral, contact notification, and quality improvement, which can all be used to enhance prevention practice, as discussed below. In addition, specific structural interventions (eg, arranging client flow to ensure interaction with clinic staff who conduct prevention counseling, use of video, written handouts or other educational media, and distribution of condoms) can strengthen the role of other clinic staff in prevention activities.

What role does referral to community resources play in HIV prevention?

Some complex patient issues and conditions fall beyond the scope of a primary care clinic and must be addressed before risky behavior can be reduced or eliminated. These include drug abuse, mental health issues, domestic violence, and assistance with needs such as housing, food, and employment. Each clinic should have established relationships with community resources to address these issues, and staff members should have thorough knowledge of the available services as well as mechanisms in place to ensure that patients can access the services. Finally, followup should be done to be certain that the referrals are utilized and are effective for each patient. It is unlikely that persons at highest risk for transmitting HIV to others can effectively reduce such behavior without access to a comprehensive array of services and supports.

What are key elements of contact notification?

Contact notification is an effective way to identify additional HIV-infected persons through HIV counseling and testing, bring them into care, and provide support to help them avoid transmitting HIV to others. Health departments traditionally conduct contact notification; in some States providers are required by law to report to the health department known sexual or drug-equipment-sharing contacts of persons infected with HIV. The standard method is to inform the patient's contacts that they have been placed at risk and need HIV testing without identifying the source.

How can HIV prevention be made a part of routine clinic practice?

HIV prevention, often neglected as a component of HIV clinical care, is more likely to be a part of routine clinic practice if it is part of the clinical continuous quality improvement activities (see Chapter 17: Quality Improvement). While the most effective indicators for prevention practice in the clinical setting are not known, considerations include medical record documentation of risk assessment history, prevention counseling, medical/laboratory examination for STDs, establishment of a prevention plan, and completion of referrals. There should be regular assessment of whether such tasks are completed and regular feedback to staff members regarding the success rates of completing these interventions. Finally, training interventions should be guided by data from these quality improvement activities (see Chapter 18).

• The HIV clinical care setting offers an ongoing opportunity to work with patients to reduce their risk of transmitting HIV to others.
• Common elements of behavioral interventions to reduce HIV risktaking include establishing rapport with the patient, addressing immediate patient needs (eg, mental health problems, substance abuse, housing), and working in small steps to build motivation and skills for change.
• A brief history of patient risk behaviors and HIV prevention counseling should be parts of each patient visit.
• Besides HIV prevention counseling, the following are important components of HIV prevention in the clinical setting: contact notification, drug abuse treatment, screening for STDs, decreasing the patient's viral load through ART, and nPEP
  
• Structural interventions for HIV prevention include making available educational materials and condoms, establishing strong referral relationships with social service and substance abuse services, and incorporating prevention indicators into quality improvement activities.
  

Suggested Resources   TOP

Institute of Medicine/Committee on HIV Prevention Strategies in the United States. No time to lose: getting more from HIV prevention. Ruiz MS, Gable AR, Kaplan EH, Stoto MA, Fineberg HV, Trussell J, eds. Washington DC: National Academy Press. 2001.

Centers for Disease Control and Prevention. Advancing HIV prevention: New strategies for a changing epidemic - U.S. 2003. MMWR. 2003;52:329-332.
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Centers for Disease Control and Prevention. Incorporating HIV prevention into the medical care of persons living with HIV. MMWR. 52(RR12):1-24. July 18, 2003.

WEBSITES

AIDSInfo: Accessed 11/03.

HIVInsite: Accessed 11/03.

References   TOP

Ball JK, Curran R, Irving WL, Dearden AA. "HIV-1 in semen: determination of proviral and viral titres compared to blood, and quantification of semen leukocyte populations." J Med Virol. 1999;59:356-363.

Centers for Disease Control and Prevention. Revised guidelines for HIV counseling, testing and referral. MMWR. 2001;50
(RR-19):1-57.

Dukers NH, Goudsmit J, de Wit JB, Prins M, Weverling GJ, Coutinho RA. Sexual risk behavior relates to the virological and immunological improvements during highly active antiretroviral therapy in HIV-1 infection. AIDS. 2001;15:369-378.

Kalichman SC, Rompa D, Luke W, Austin J. "HIV transmission risk behaviors among HIV positive persons in serodiscordant relationships." Int J STD/AIDS. 2002;13:677-682.

Kamb ML, Fishbein M, Douglas JM, et al. "Efficacy of risk-reduction counseling to prevent human immunodeficiency virus and sexually transmitted diseases; a randomized, controlled trial." Project RESPECT Study Group. JAMA. 1998;280:1161-1167.

Marks G, Richardson JL, Crepaz N, et al. Are HIV care providers talking with patients about safer sex and disclosure?: A multi-clinic assessment. AIDS. 2002;16:1953-1957.

Natter J, Fiano T, Gamble B, Wood RW. "Integrating HIV prevention and care services: the Seattle 'Collaboration Project.'"J Public Health Manag Pract. 2002 Nov;8:15-23.

Quinn TC, Wawer MJ, Sewankambo N, et al. "Viral load and heterosexual transmission of human immunodeficiency virus type 1." N Engl J Med. 2000;342:921-929.

Scheer S, Chu PL, Klausner JD, Katz MH, Schwarcz SK. "Effect of highly active antiretroviral therapy on diagnoses of sexually transmitted diseases in people with AIDS." Lancet. 2001;357:432-435.

Wilson TE, Barron Y, Cohen M, et al. "The Women's Interagency HIV Study. Adherence to antiretroviral therapy and its association with sexual behavior in a national sample of women with human immunodeficiency virus." Clin Infect Dis. 2002;34:529-534.