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A
Guide To Primary Care For
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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 Results of an unpublished study suggest that HIV specialists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.
Table 4-1.
Examples of Open- and
Closed-ended Risk-screening Questions
Open-ended
questions
What
do you know about HIV transmission?
What, if anything, are you doing that could result in transmitting
HIV to another person?
Tell me about any sexual activity since your last clinic
visit.
What do you know about the HIV status of each sex partner?
Tell me about condom use during any sexual activity.
Tell me about any drug use or needle sharing since your
last clinic visit.
Closed-ended
questions
Do
you know the facts about how HIV is and is not transmitted?
Have you had sex (vaginal, anal, or oral) with any partner
since your last clinic visit?
For each of your partners, do you know if he/she has HIV
infection, doesn't have HIV infection, or are you not
sure?
Did you use a condom every time, from start to finish
of each sexual encounter?
Have you shared drug injection equipment (including needle,
syringe, cotton, cooker, water) with anyone?
Note: Symptoms of STDs (eg, urethral or vaginal burning
or discharge, dysuria, genital or anal ulcers, inter-menstrual
bleeding or lower abdominal pain among women) are asked
in a closed-ended format, regardless of behavioral question
format.
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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.
Table
4-2. Screening for Sexually Transmitted Diseases
Syphilis
|
Non-treponemal
serologic test
(RPR, VDRL)
|
Gonorrhea
|
Nucleic
acid amplification test
(first-catch urine or urethral [male]/cervical [female]
specimen) or
culture (urethral [male]/cervical
[female] specimen)
|
Chlamydia
|
Nucleic
acid amplification test
(first-catch urine or urethral [male]/cervical [female]
specimen)
|
Trichomonas
|
Wet
mount or culture
(vaginal secretion)
|
Herpes
simplex virus
|
Type-specific
HSV-2
antibody testing
|
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.
Table
4-3. Suggested Counseling Content for Behavioral Risk Reduction
Relative
risk of HIV transmission during sex
|
Most
to least risky activities: receptive anal > receptive vaginal
> insertive anal > insertive vaginal > receptive oral
> insertive oral |
Preventing
HIV transmission during sexual activity
|
Abstinence
(safest behavior).
Correct
condom use (latex or polyurethane condoms, used with water-based,
not oil-based, lubricants, used from start to finish of any
sexual penetration).
Other
means of reducing risk
|
Effect
of drug use on sexual decisionmaking
|
Potential
increase in sexual risk behavior following drug and/or alcohol
use |
Risk
of HIV transmission when
sharing drug-injection equipment
|
Highest
risk for HIV transmission.
Risk
of other disease transmission for either user
Entire works (drug paraphernalia), not only needles, need
to be clean
|
Impact
of viral load level on HIV
transmission risk
|
Greatest
risk of HIV transmission when viral load is elevated (e.g.,
when antiretroviral therapy is stopped or is ineffective).
HIV transmission
still possible during effective antiretroviral therapy (e.g.,
there can be HIV in genital secretions even when plasma viral
load is undetectable)
|
Components
of Assessment and Counseling |
Suggested
Content |
Motivation
for HIV prevention
|
Risk
to self: acquiring non-HIV infectious agent and acquiring
drug-resistant HIV strain.
Risk
to others: transmitting HIV
|
Readiness
and capacity for HIV prevention
|
Patient's
belief about his/her desire, intent, and sense of capacity to
adopt behaviors that prevent HIV transmission |
Barriers
to adopting safer sexual and drug-using behaviors
|
Identification
of barriers, such as mental health needs, substance abuse, domestic
violence, and other social and economic pressures that might
impede the adoption of behaviors to prevent the transmission
of HIV |
Willingness
to accept in-depth counseling and/or referral to overcome
barriers to adopting safer behaviors
|
Identification
of history of past efforts to address the issue impeding the
adoption of safer behavior.
Encouragement
and offering of assistance for more in-depth support through
referral
|
Development
of an HIV prevention plan
|
Creation
of a plan mutually agreeable to patient and provider, written
for both the medical record and the client |
Discussion
of reproductive intentions
|
Assessment
of need for in-depth counseling with HIV-experienced obstetrician
to address risks and benefits of conception |
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.
.
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.
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