Helping patients to reduce the risk of transmitting HIV to others is an important aspect of medical care for HIV-infected individuals. Most people with HIV infection want to prevent others from being infected with HIV, but they may practice sexual or injection drug behaviors that put others at risk of infection. Most HIV-infected patients also want to protect themselves from acquiring sexually transmitted infections. This chapter offers recommendations for discussing HIV transmission and prevention with HIV-infected patients, with the goal of reducing HIV transmission. This aspect of care is often referred to as "prevention with positives" (PWP). Taking responsibility for preventing HIV transmission is an important concern for most people with HIV, as well as for their health care providers. In fact, many HIV-infected individuals report that they want to discuss prevention with their health care providers. It is clear that information alone, especially on subjects such as sexual activity and drug use, cannot be expected to change patients' behavior. However, health care providers can help patients understand the transmission risk of certain types of behavior and help patients establish personal prevention strategies (sometimes based on a harm-reduction approach) for themselves and their partners. Some patients may have difficulty adhering to their safer sex goals. In these cases, referrals to mental health clinicians or other professional resources such as prevention case management may be helpful. Patient-education needs are variable and must be customized. Providers must assess the individual patient's current level of knowledge as part of developing a prevention plan. All the information that a patient needs cannot be covered during a single visit. A patient's prevention strategy should be reinforced and refined at each visit with the clinician. Clinicians also should ask patients questions to determine life changes (eg, a new relationship, a breakup, or loss of a job) that may affect the patient's sexual or substance use practices. If the patient can read well, printed material can be given to reinforce education in key areas, but it cannot replace a direct conversation with the clinician. Patient educators, nurses, peer counselors, social workers, and mental health providers also may be used to discuss prevention strategies with patients.  | Sexual Transmission and Prevention of HIV | | Begin the education process by learning what the patient and his or her immediate family (if the family is aware of the patient's HIV status) believe about HIV transmission. Also be sure the patient understands how the virus is not transmitted (eg, sharing plates and eating utensils or using the same bathrooms) to allay any unnecessary fear. Advise the patient not to share toothbrushes, razors, douche equipment, or sex toys to avoid transmitting HIV via blood or sexual secretions. This also will help prevent the transmission of other bloodborne or sexually transmitted infections, including hepatitis C, from coinfected patients. The patient should not donate blood, plasma, tissue, organs, or semen because these can transmit HIV to the recipient. There is no reason why a person with HIV cannot have an active, fulfilling, and intimate sex life. However, the patient must be counseled properly about the risk of transmission. This discussion between the provider and patient, should be client centered. This means that the provider should let the patient guide the discussion, starting from the patient's current point of knowledge and practice, always addressing any presenting concerns the patient may have prior to proceeding with a discussion about sexual transmission and risk. The provider should ask open-ended questions, in a nonjudgmental manner, to elicit information about the patient's relationships, sexual behaviors, and current means of reducing transmission risk. It is important to recognize that not every patient seeks the complete elimination of risk (eg, via abstinence) but rather a reduction in risk, chosen after the options are discussed with the provider. The clinician may help the patient select and practice behaviors that are likely to be less risky. There are many methods for reducing risk, including the following:  | Disclosing HIV status | | | Reducing the number of sex partners | | | Using condoms, particularly for anal or vaginal intercourse (insertive or receptive) | | | Having sex only with other HIV-infected partners (serosorting) | | | Avoiding drug use in conjunction with sex | | | Using adequate lubrication to avoid trauma to genital or rectal mucosa | | | Maintaining maximal suppression of HIV through antiretroviral therapy | |
If the patient requires more extensive counseling to support behavioral changes, the provider should refer the patient to support groups or prevention case management to meet those needs. Certainly, if the patient is dealing with a dual or triple diagnosis (including substance abuse or mental illness), a referral to address those needs also is indicated. Several models of PWP are appropriate and realistic for the clinical setting, where prevention discussions must be conducted within severe time constraints. The Partnership for Health model developed by Jean Richardson and colleagues resulted in a 38% reduction in unprotected anal or vaginal sex among patients with multiple and casual partners after the implementation of "consequence frame messaging" in the context of a clinic-wide program. This program is being diffused nationally and soon will be included on the Centers for Disease Control and Prevention (CDC) Diffusion of Effective Behavioral Interventions Web site at: http://www.effectiveinterventions.org. Another model, developed by Fisher and Cornman for use in clinical settings, assesses deficits in HIV information, motivation, or behavioral skills using motivational interviewing techniques, complete with behavioral prescription writing at the
end of the visit. This model involves a process that takes 5-10 minutes to complete. More information about the model is available at http://www.chip.uconn.edu/interventions/k-options.pdf. Finally, a model (called Act, Screen, Intervene) was generated from a work group developed in collaboration with the national HIV/STD Prevention Training Centers and the AIDS Education and Training Centers, based on the guidelines "Incorporating HIV Prevention into the Medical Care of Persons Living with HIV" developed by the CDC, Health Resources and Services Administration, and HIV Medical Association. The new curriculum, with the same title, includes 4 modules designed to guide the clinician in implementing prevention and partner notification into clinical work. This model has been pilot tested in 5 U.S. cities and also is being diffused nationally. The guidelines can be found at http://www.cdc.gov/mmwr/preview/mmwrhtml/rr5212a1.htm. Any of these models, or new models that are expected to emerge from the Special Projects of National Significance, may assist the provider in implementing prevention work in the context of clinical care. | |
| Partner Notification | | A good way to begin a discussion about HIV prevention and transmission is with an inquiry about any previous experiences disclosing to partners. The provider then can ask whether the patient currently has a need to disclose to one or more partners and whether he or she is ready and motivated to share information about HIV status. The provider should prompt patients to consider several questions about disclosure, including how they might approach the discussion, how their partners might react, what information they might offer their partners, whether partners are likely to keep their status confidential, and whether they have any concerns about personal safety (eg, if they fear a violent reaction). If patients fear a violent reaction or are not ready to share their status but want their partners to know, the provider may offer assistance with partner notification, for example through the local health department, in a confidential manner. As an alternative,
patients may want the provider to talk with their partners, and that option can be offered as well. See the U.S. Department of Veterans Affairs HIV Web site at http://www.hiv.va.gov/vahiv?page=sex-01-00 for a patient-oriented discussion of partner notification. | |
| Helping Patients Reduce the Risk of Sexual Transmission | | | Standard Condom Use | | Make sure that the patient understands how HIV is transmitted and which types of sexual acts are more and less risky than others. For vaginal or anal sex, correct use of latex or polyurethane condoms reduces the risk of HIV transmission considerably. Patients should be encouraged to use condoms as much as possible. For HIV-infected individuals, condom use is also is effective in reducing the risk of contracting another illness (such as hepatitis C or another sexually transmitted disease) and the (apparently low) risk of becoming reinfected with another strain of HIV. It should be noted that condoms are less effective in reducing the transmission of organisms such as human papilloma virus (HPV) and herpes simplex virus (HSV), which may result from viral shedding from skin. In the event of allergy to latex or other difficulty with latex condoms, polyurethane male or female condoms may be substituted. "Natural skin" or "lambskin" condoms are not recommended for
HIV prevention. Of course, condoms must be used correctly to be highly effective in preventing HIV transmission. Be sure that the patient knows exactly how to use a condom. Table 1 provides instructions for condom use. |
 | | Instructions for Use of Standard Condoms | | Use a new latex or polyurethane condom with each act of sex (oral, anal, or vaginal). Make sure that the condom is undamaged, and that its expiration date has not passed. | | | Carefully handle the condom to avoid damage from fingernails, teeth, etc. | | | Being sure that the condom roll faces out, unroll the condom onto the erect penis before any genital contact with partner. | | | Ensure that the tip of the condom is pinched when applying it to the top of the penis, to eliminate air in the tip that could cause breakage during ejaculation. | | | Use only water-based lubricants with latex condoms. Oil-based lubricants (such as mineral oil, cooking oil, massage oil, body lotion, and petroleum jelly) can weaken latex or cause it to break, although they are fine with the use of polyurethane condoms. Adequate lubrication during intercourse helps reduce the risk of condom breakage. | |
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Advise patients to avoid using nonoxynol-9 (N-9) spermicides. Recent data suggest that N-9 may increase risk of HIV transmission during vaginal intercourse and can damage the rectal lining. N-9 should never be used for anal intercourse. For patients who complain about lack of sensitivity with condom use, the following techniques may help: | Apply a drop of lubricant inside the condom (not more, because it increases the risk that the condom will come off). | | | Use polyurethane condoms instead of latex because they conduct heat and may feel more natural. | | | Use insertive (female) condoms, which are not as restrictive to the penis. | | | Use specially designed condoms that do not restrict the top of the penis (eg, Inspiral, Xtra Pleasure). | |
For those patients who are unable or unwilling to use condoms, the following suggestions may help reduce HIV transmission risk: | Use plenty of lubricant to reduce friction and microtrauma, which create portals of entry for the virus. | | | Avoid spermicides that damage the vaginal or anorectal linings. | | | Avoid douching products. | | | Avoid recreational drugs, especially methamphetamine, which impair the ability to maintain "safer" sex behaviors. | | | Avoid the use of drugs such as nitrates (poppers) that enhance blood flow to the genitals. | |
For HIV-infected women, consider avoiding hormonal birth control methods because of a possible increase in the risk of HIV viral shedding. | |
| Insertive (Female) Condom Use | | The insertive "female" condom (Reality) may be used for vaginal or anal intercourse. It is a thin polyurethane pouch with a flexible ring at the opening, and another unattached flexible ring that sits inside the pouch to keep it in position in the vagina (for use in the anus, the inner ring must be removed and discarded). The female condom may be an option for women whose male partners will not use male condoms or for couples who do not like standard condoms. Female condoms are more expensive than male condoms, but may be procured at a lower cost at some health departments or Planned Parenthood clinics. They generally are less well known to patients and may be unacceptable to some women whose culture or religion prohibits or discourages touching one's own genitals. Note that the female condom cannot be used at the same time as a male condom. Be sure the patient knows how to use the insertive condom before she or he needs it; after teaching, encourage practice when alone at home and unhurried. Women who have used the diaphragm, cervical cap, or contraceptive sponge may find it easy to use the female condom. Illustrated directions are included in each box of insertive condoms. Table 2 gives instructions on the use of insertive condoms. |
| | Instructions for Use of Insertive (Female) Condoms | | Vaginal Intercourse | | | Open the pouch by tearing at notched edge of packet, and take out the female condom. Be sure that the lubricant is evenly distributed on the inside by rubbing the outsides together. | | | Find a comfortable position, such as standing with one foot on a chair, sitting with knees apart, or squatting. Be sure the inner ring is inside, at the closed end of the pouch. | | | Hold the pouch with the open end hanging down. While holding the outside of the pouch, squeeze the inner ring with your thumb and middle finger. Still squeezing, spread the labia with your other hand and insert the closed end of the pouch into the vagina. | | | Now, put your fingers into the pouch itself, which should be inside the vagina, and push the inner ring and the pouch the rest of the way up into the vagina with your index finger. Check to see that the front side of the inner ring is just past the pubic bone. The back part of the inner ring should be up behind the cervix. The outer ring and about an inch of the pouch will be hanging outside the vagina. | | | Until you and your partner become comfortable using the female condom, use your hand to guide the penis into the vagina, keeping it inside the pouch. If, during intercourse, the outer ring is getting pushed up inside the vagina, stop, remove the female condom, and start over with a new one. Extra lubricant on the penis or the inside of the female condom may help keep this from happening. | | | After intercourse, take out the condom by squeezing and twisting the outer ring to keep the semen inside the pouch. Throw away in a trash can; do not flush. Do not reuse. | | | If there are problems, call the manufacturer's toll-free customer assistance line at 800-274-6601, #230. | | | More information is available on the manufacturer's Web site at: http://www.femalehealth.com. | |
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| Anal Intercourse | | | Remove the inner ring and discard it. Put the female condom on the penis of the insertive partner and insert the condom with the penis, being careful not to push the outer ring into the rectum. The outer ring remains outside the anus, for ease of removal after ejaculation. | |
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| Prevention with Positives and Oral Sex | | Although there is evidence that some people have become infected through receptive oral sex, the risk of HIV transmission via oral sex, in general, is much lower than the risk of transmission by vaginal or anal sex. Thus, most public health and prevention specialists focus their attention on riskier sexual and drug-use behaviors. However, because HIV transmission can occur with oral sex, clinicians should address this issue with patients and help them make informed decisions about risk reduction. Sores or lesions in or around the mouth or on the genitals may increase the risk of HIV transmission, as may a concurrent sexually transmitted infection. Patients (and their partners) should avoid oral-genital contact if they have these conditions. Similarly, patients and partners can further reduce risk by not brushing or flossing teeth before oral sex. Individuals who wish to reduce further the risk of HIV transmission during oral sex may use barriers such as
condoms, dental dams, or flexible plastic kitchen wrap. Individuals who smoke crack cocaine often develop open burns, cracked lips, or damaged mucous membranes inside the mouth and thus may be at elevated risk of HIV transmission via oral sex. HIV-infected crack users should be counseled about the risk of transmitting HIV to uninfected partners through those portals of entry during oral sex and should receive risk-reduction counseling. In addition, they (or their partners) may benefit from techniques such as insulating the end of the crack pipe to reduce burns while smoking (eg, with a rubber band or spark plug cap) and avoiding the brittle or sharp-edged copper scrubbing pads used as screens in the crack pipe. | |
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| Influence of Substance Use on Sexual Behavior | | Alcohol and drug use can contribute significantly to the risk of sexual transmission of HIV, because of behavioral disinhibition. While intoxicated, substance users may, for example, forgo condom use, practice riskier sexual behaviors, have multiple partners, or use erectile dysfunction agents to sustain sexual activity. Addressing substance use issues is an important aspect of PWP. Patients should be assessed for HIV transmission risks associated with alcohol and injection or noninjection drug use, including crystal methamphetamine, in the context of their sexual behaviors (for injection drug use, see below). As always, it is important to approach the patient in a nonjudgmental manner. If alcohol or other drugs are posing barriers to practicing safer behaviors, the provider should counsel the patient to reduce or avoid substance use before engaging in sex, or refer the patient to prevention case management for more specialized risk reduction. Often, the provider
can help the patient identify methods for reducing HIV transmission risk, including means that do not require abstaining from alcohol and drug use. | |
| Injection Drug Use and Prevention of HIV | | Clinicians should discuss substance use, including steroid use, and reinforce the patient's understanding of the adverse effects that these drugs can have on the body and the immune system. Assess whether referral for treatment is appropriate, and be knowledgeable about referral resources and mechanisms. If the patient is using injection drugs, emphasize the fact that HIV is readily transmitted by sharing needles and other injection equipment and that reusing or sharing needles and syringes can cause additional infections (eg, endocarditis, hepatitis C). Assess the patient's readiness to change his or her drug injection practices, and refer to drug treatment programs as appropriate. Refer to an addiction counselor for motivational interviewing or other interventions, if available. After completion of substance abuse treatment, relapse prevention programs and ongoing support will be needed. If the patient continues to use needles, discuss safer needle-use
practices (Table 3) and refer to a needle exchange program, if one is available, so that syringes and needles are not reused. A partial listing of needle exchange sites may be found at: http://www.nasen.org, although many states either do not have or cannot list their facilities. Local harm-reduction activists may be aware of specific programs for obtaining clean needles and syringes. Patient-education flyers on safer injection practices, safer stimulant use, overdose prevention, and other topics are available on the Midwest AIDS Education and Training Center's Web site at http://www.uic.edu/depts/matec/resource.html. |
| | Needle Use Practices to Reduce Risk of Infection and HIV Transmission | | Never reuse or share needles, syringes, water, or drug preparation equipment. If there is a need to reuse syringe equipment, it should be cleaned properly with bleach or water, with care taken not to share the materials (eg, container, water) used for cleaning. | | | It is best to use only sterile syringes obtained from a reliable source (pharmacy, needle exchange program). In addition, reusing one's own syringes can lead to various bacterial infections, abscesses, etc. | | | Use sterile or boiled water to prepare drugs. If unavailable, use clean water from a reliable source, such as fresh tap water. | | | Use a new or disinfected container (cooker) and a new filter (cotton) to prepare drugs. Cooking the drugs before injecting can reduce the chances of transmitting HIV when sharing equipment. | | | Clean the skin around the injection site with a new alcohol swab before injecting, and use a sterile or clean cotton pad to stop the blood flow after injecting. Also, using a tourniquet when injecting can help reduce damage to veins and assist the user in controlling the shot and avoiding overdose. | | | Safely dispose of syringes after one use, either in a specially made sharps container, or a clean detergent container. Many pharmacies offer disposal programs for used syringes. | | | For patient flyers on safer injection practices, safer stimulant use, overdose prevention, and other topics, go to http://www.uic.edu/depts/matec/resource.html. | |
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| Tattoo, Piercing, and Acupuncture Equipment | | Patients should be aware of the risk of contamination of tattoo equipment, inks, and piercing equipment, and avoid situations where they might either transmit HIV or pick up other bloodborne pathogens. Acupuncturists generally use sterile needles, but clients should verify this before using their services. | |
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