April 2003

Current Knowledge

Despite significant advances in the treatment of HIV infection, the estimated number of annual new HIV infections in the United States has remained at 40,000 for nearly 10 years.¹ Historically, HIV prevention in this country has generally focused on persons who are not HIV-infected, to help them avoid becoming infected. However, further reduction of HIV transmission will require new strategies, including an increased emphasis on preventing transmission by HIV-infected persons aware of their status.^2,3 This may be a highly cost-effective strategy in that prevention is targeted directly to potential sources of new infections. After testing positive for HIV, many people reduce behaviors that may transmit HIV to others.^4,5 However, recent studies suggest that such behavioral changes are not maintained by all HIV-infected persons and that some continue to engage in behaviors that place others at risk for HIV infection.^6,7

Routine HIV prevention programs and support are needed to help HIV-infected persons reduce behavioral risks and maintain safer behavior in the years after the diagnosis of HIV infection. Studies have tested interventions in this population and have demonstrated significant reductions in risky sexual and drug-use behaviors. For example, in a study at public HIV clinics of HIV-infected persons who had multiple sex partners at baseline, the prevalence of unprotected anal and vaginal intercourse was reduced 38% after brief, ongoing prevention counseling from primary care providers.⁸ Successful risk-reduction interventions for HIV-infected persons have also been conducted in group settings.⁹ Further, interventions for HIV-infected persons who inject illicit drugs have reduced illicit drug use and unsafe sex in this population.^{10, 11} A number of studies have demonstrated the beneficial effect of substance abuse treatment, particularly methadone maintenance treatment, on HIV risk behaviors among injection drug users (IDUs).¹² Taken as a whole, the findings strongly suggest that a concerted, sustained effort to provide prevention counseling and appropriate referral to services can greatly benefit HIV-infected persons and help them maintain safer behaviors that prevent others from becoming infected with HIV. However, recent studies suggest the need for targeted physician training on the importance of HIV transmission prevention counseling.

Objectives

The purpose of this document is to assist HIV medical providers, health departments, and community-based organizations (CBOs) to enhance HIV prevention services for HIV-infected persons by

• Increasing the number of positive persons who have information about transmission risks and regularly receive counseling about ways to reduce the risk of transmitting HIV to others
• Increasing the number of sexually active HIV-infected persons who are screened and tested for sexually transmitted diseases (STDs)
• Enhancing the capacity and ability to conduct effective prevention counseling and referral for services (e.g., social, mental health, drug treatment, partner notification)
• Strengthening the linkages among health departments, CBOs, and providers of HIV care to facilitate the referral of HIV-infected persons to needed services

Procedures
Steps for HIV care providers

1. HIV prevention counseling should become a standard in the care for persons infected with HIV who continue to engage in behaviors that lead to HIV transmission. Providers of HIV care should assess the current level and characteristics of their prevention efforts, including allocation of resources, staffing, materials, and time devoted to this activity. The assessment should be used to guide planning and training needed to meet the diverse prevention needs of HIV-infected men and women.
2. HIV clinics should display in waiting and exam rooms prevention posters and other printed materials (e.g., brochures describing partner counseling and referral services and other prevention behaviors) that convey the importance of safer sex and safer substance-use behaviors. Prevention materials should emphasize the importance of abstinence, safer sex behaviors, and reducing or abstaining from drug use to protect partners as well as one’s own health. Examples of prevention messages and ways to reduce risk are presented in Attachment 1.
3. HIV care programs should provide patients with written information (e.g., brochures or brief pamphlets) about:
   1. Behaviors that increase and behaviors that decrease transmission risks
   2. Role of STDs in increasing HIV transmission and the need to be tested and treated for STDs at the first sign or suspicion of infection
   3. Importance of disclosing one’s HIV infection status to sex partners
   4. Viral load and transmission risk emphasizing that having an undetectable or low viral load does not mean that one cannot transmit HIV
   5. Drug use and its potential role in increasing sexual risk behaviors
4. At each visit, health care providers should ask patients about behaviors associated with HIV transmission using a straightforward, nonjudgmental approach. At the initial clinic visit, patients should be questioned about symptoms and screened for laboratory evidence of STDs. Decisions about subsequent testing should be guided by behavioral screening and the patient’s symptoms manifestations. See Attachments 2 and 3 for tests for detecting asymptomatic STDs.
5. The primary care provider (e.g., physician, physician assistant, nurse practitioner) should conduct a 3-5 minute counseling session each time a patient is seen. Providers should have a one-page sheet for personal use that outlines the intervention process (see intervention schematic below) that can be referred to as a tool and reminder for delivering the intervention. Providers are encouraged to emphasize a partnership or team approach. Providers could say the following: “The health care providers here are dedicated to helping our patients stay as healthy as possible. We must work as a team to do this; this means that you and I make a commitment to do all we can to keep you well and stop the spread of this disease. My role is to give you expert medical care, support you in making choices about your care and answer your questions. But your health really depends most on your own actions and behaviors. The two of us have to work together as a team to keep you as healthy as possible.”
6. The primary care provider should verbally state prevention messages to the patient (see Attachment 1) and initiate a discussion of behavioral goals. For some patients, the goal will be to continue to be abstinent, for other patients the goal will be to continue to practice safer sex. For other patients, the goal(s) will be to reduce risk behavior(s) (e.g., always using a condom, reducing number of sex partners). The goals should be recorded in the patient’s medical chart on a form designed to track the prevention intervention. This form should include a place for the provider to indicate that counseling was given on a specific date.
7. Prevention messages can be reinforced at subsequent visits by other care providers, social workers or health educators; patients may be more receptive to the messages if they are conveyed by more than one person.
8. At the next visit, the provider should inquire about progress toward goals and again convey prevention messages orally to the patient. The provider should reinforce (i.e., praise) healthy behavior and, if needed, discuss new ways to overcome barriers. The provider and patient should reset goals for next visit.
9. During a counseling session it may become apparent that a patient needs more intensive counseling or needs a referral to address a personal issue that cannot be handled by the medical provider (e.g., substance use, domestic violence, depression, needs for housing or shelter). Each provider should have on hand a list of referral resources (including addresses, telephone numbers, and names of contact persons) in the clinic, medical center, and community. In making a referral, the provider (or other clinic staff) should attempt to link a patient immediately by helping schedule an appointment before the patient leaves the clinic. 
   
   
   
10. Providers should prepare for making patient referrals by
    1.  Learning about local HIV prevention and supportive social services, including those funded by the Ryan White CARE Act
    2. Learning about available resources and having a referral guide listing such resources
    3. Contacting staff in local programs to facilitate other referrals. Referral guides and other information can usually be obtained from local and state health department HIV/AIDS prevention and care programs

A brief summary for effective referral is attached in the Appendix.

Steps for health departments and CBOs

The following recommendations are offered to help refine and expand services for HIV-infected persons in health departments and CBOs. Some of the preceding recommendations for HIV care providers are also applicable to health departments and CBOs, such displaying posters and providing printed materials to cue patients to the importance of safer sex (item 2 above), providing risk-reduction information (item 3 above) and prevention messages (Attachment 1), and refining referral mechanisms (items 8, 9 above).

1. Health departments in collaboration with the Health Resources and Services Administration’s (HRSA) AIDS Education and Training Centers (AETC) or the STD/HIV Prevention Training Centers funded by CDC should facilitate the training of, and support for, HIV primary care providers to conduct HIV prevention counseling with patients during routine medical examinations.
2. Directors of HIV/AIDS prevention programs at health departments should establish or confirm already established working relationships with CBOs and with medical directors of public and private HIV clinics. These relationships should be formalized in a written agreement. Each party should have a working knowledge of the services provided by the other. This relationship will facilitate coordinated efforts to provide prevention services, referral mechanisms, and medical care to HIV-infected persons. It is important that health departments and CBOs strive to link HIV-infected persons to medical care if they are not already in care, and that providers of HIV care should strive to make prompt and appropriate referrals for prevention or social services that cannot be provided at the clinic.
3. Health departments and CBOs should also provide an array of services for HIV-infected persons. Health departments and particularly CBOs should offer prevention case management (PCM), which includes client-centered prevention counseling to help people adopt and maintain risk-reduction behaviors and access needed medical, psychological, and social services. 14 Needs may include treatment for drug or alcohol abuse; mental health services; intervention for sexual or physical abuse (victim or perpetrator); housing or transportation; nutritional, financial, and legal matters; and insurance coverage. Health departments should have staff and procedures for conducting partner notification services. All HIV-infected persons seen at health departments and CBOs should receive information on ways to reduce HIV transmission and receive prevention messages (Attachment 1).

Working with Partners and Integration into Existing Services

1. Health departments and medical directors at HIV clinics should consult with HRSA and local HIV/STD Prevention Training Centers to arrange assistance for training clinic medical staff to assess transmission risk and do prevention counseling.
2. HIV clinics, health departments, and CBOs should work with local community planning groups to design, implement, and evaluate interventions that address the local needs determined by the community planning group.
3. Successful referral should be confirmed by contacting the referred person and the agency to which the referral was made. This includes linking HIV-infected persons to prevention and social services as well as to medical care. See Appendix for further guidance on the referral process.

Programmatic Considerations

1. Staff at HIV clinics, health departments, and CBOs should meet within their respective settings to discuss ways to integrate prevention into their services for persons who are HIV positive. These services must be offered and advertised in a way that does not stigmatize persons who are HIV positive or single out any particular group as responsible for new infections.
2. It is important that all interventions, including behavioral and STD screening, discussions of sexual and drug-use behaviors, and referrals, be conducted with cultural sensitivity.

Vignette
The Partnership for Health (PfH) intervention, conducted at six public HIV clinics in California, is an example of a successful behavioral intervention.8 The intervention was conducted mostly by primary care providers at the clinic after relatively brief training. The theme conveyed the importance of a patient-provider team approach in addressing the medical and behavioral dimensions of care to help HIV-infected patients stay as healthy as possible. The intervention included the following: (a) Printed information (brochure) introduced the partnership theme, stated messages emphasizing the importance of safer sex, and gave examples of specific risk-reducing behaviors. At later clinic visits, patients received flyers containing prevention information. (b) Posters in the clinic waiting room conveyed the PfH theme, and posters in each exam room emphasized a specific prevention message. (c) Brief (3-5 minutes) counseling was conducted by the primary care provider who stated the importance of the partnership, communicated prevention messages, and discussed behavioral goals with patients (e.g., risk reduction, maintaining safer behaviors). Results indicated that the intervention significantly reduced sexual risk behavior among patients whose profiles at baseline indicated risky behavior patterns.

Monitoring Implementation

CDC grantees receiving HIV prevention funds that work with HIV care providers to incorporate prevention in medical settings will be required to routinely report the following indicators to monitor implementation.

CDC’s HIV Prevention Program Performance Indicators*:

1. Percentage of the intended number of HIV infected individuals to be reached who were actually reached with a prevention message (H.2)
2. Percentage of HIV infected persons who, after a specific period of participation in prevention counseling, report a reduction in sexual or drug using risk behaviors or maintain protective behaviors with seronegative partners or with partners of unknown status (I.2)

Other program measures that will require collaboration with health care providers providing prevention in care settings:

3. Number of persons with HIV who are referred for further prevention services, including partner counseling and referral services (PCRS) and prevention interventions for persons living with HIV.
4. Number of persons with HIV who use the prevention services to which they are referred
5. Number of persons with HIV who have a new STD diagnosis in a specified period
6. Collection of HIV transmission risk data in accordance with CTR Guidelines
7. Brief surveys of providers in HIV clinics before and after training to demonstrate the extent to which providers feel more prepared to conduct prevention counseling with patients
8. Brief surveys of patients at HIV clinics to assess the proportion that received prevention messages, how the messages are being received, the proportion that received prevention counseling, how prevention counseling is perceived, and whether changes in risk behavior are reported.

* The CDC Technical Assistance Guidelines for Health Department HIV Prevention Program Performance Indicators provides information on setting baseline, target, and indicator specification including appropriate data sources, calculations and reporting issues. Note: Performance indicators may have been modified to reflect specific population or setting characteristics.

References

1. Centers for Disease Control and Prevention. Guidelines for national human immunodeficiency virus case surveillance, including monitoring for human immunodeficiency virus infection and acquired immunodeficiency syndrome. MMWR 1999;48(RR-13):1-29.
2. Janssen RS, Holtgrave DR, Valdiserri RO, Shepherd M, Gayle HD. The serostatus approach to fighting the HIV epidemic: Prevention strategies for infected individuals. Am J Public Health 2001;91:1019-24.
3. 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, editors. 2001. National Academy Press, Washington, D.C.
4. Valleroy LA, MacKellar DA, Karon JM, Rosen DH, McFarland W, Shehan DA, Stoyanoff SR, LaLota M, Celentano DD, Koblin BA, Thiede H, Katz MH, Torian LV, Janssen RS. HIV prevalence and associated risk in young men who have sex with men. JAMA 2000;284:198-204.
5. Allen S, Serufilira A, Bogaerts J, Van de Perre P, Nsengumuremyi F, Lindan C, Carael M, Wolf W, Coates T, Hulley S. Confidential HIV testing and condom promotion in Africa: Impact on HIV and gonorrhea rates. JAMA 1992;268:3338-43.
6. Centers for Disease Control and Prevention. Resurgent bacterial sexually transmitted disease among men who have sex with men — King County, Washington, 1997 – 1999. MMWR 1999;48:773-7.
7. 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;16:135-49.
8. Richardson JL, Milam J, McCutchan A, Stoyanoff S, Bolan R, Weiss J, Kemper C, Larsen RA, Hollander H, Weismuller P, Marks G. Effect of brief provider safer-sex counseling of HIV-1 positive patients: A multi-clinic assessment. Under review.
9. Kalichman SC, Rompa D, Cage M, DiFonzo K, Simpson D, Austin J, Luke W, Buckles J, Kyomugisha F, Benotsch E, Pinkerton S, Graham J. Effectiveness of an intervention to reduce HIV transmission risks in HIV-positive people. Am J Prev Med 2001;21:84-94.
10. Sorensen JL, Copeland AL. Drug abuse treatment as an HIV prevention strategy: A review. Drug and Alcohol Dependency 2000; 59:17-31.
11. Margolis AM, Avants SK, Warburton LA, Hawkins KA, Shi J. A randomized clinical trial of a manual-guided risk reduction intervention for HIV-positive injection drug users. Health Psychology 2003; 22:223-8.
12. Gibson DR, Flynn NM, McCarthy JJ. Effectiveness of methadone treatment in reducing HIV risk behavior and HIV seroconversion among injecting drug users [editorial review]. AIDS 1999;13:1807-18.
13. Duffas WA, Barragan L, Metsch CS, et.al. Effect of physician specialty on counseling practices and medical referral pattern among physicians caring for disadvantaged human immunodeficiency virus-infected populations. Clinical Infectious Diseases 2003; 36:1577-84
14. Centers for Disease Control and Prevention. HIV prevention case management guidance. U.S. Department of Health and Human Resources, September 1997.
15. Centers for Disease Control and Prevention. Sexually transmitted diseases treatment guidelines 2002. MMWR 2002;51(No. RR-6):1-82.
16. Centers for Disease Control and Prevention. HIV prevention through early detection and treatment of other sexually transmitted diseases – United States recommendations of the Advisory Committee for HIV and STD prevention. MMWR 1998;47(RR-12):1-24.
17. Collis TK, Celum CL. The clinical manifestations and treatment of sexually transmitted diseases in human immunodeficiency virus-positive men. Clin Infect Dis 2001;32:611-22.

Resources

AIDS Education and Training Centers (AETCs)

CDC/HRSA/HIVMA of the IDSA recommendations for incorporating HIV prevention into the medical care of HIV-infected persons.

National Alliance of State and Territorial AIDS Directors (NASTAD)

National Prevention Information Network (NPIN; 1-800-458-5231)

STD/HIV Prevention Training Centers (PTCs)

CDC. Technical Assistance Guidelines for CDC’s HIV Prevention Program Performance Indicators.

CDC. Sexually Transmitted Diseases Treatment Guidelines 2002.

Attachment 1 – Prevention in Medical Care Settings

Examples of Prevention Messages

1. Unsafe sex may make it harder for you to keep yourself healthy
2. Unsafe sex also exposes other people to HIV infection
3. Unsafe sex may expose you to sexually transmitted diseases (STDs) (such as syphilis or gonorrhea) or strains of HIV that are not easily treated
4. Not having sex will prevent any possibility of infecting another person
5. Injecting illicit drugs or taking them orally puts your health at risk
6. Sharing injection needles with others exposes other people to HIV infection and may expose you to diseases such as hepatitis
    
7. If you and a sex partner don’t use latex condoms or latex barriers while having sex
   • You do not show that your own health and the health of your partner come first
   • You are more likely to get STDs that may be difficult for us to treat
   • You may get other strains of HIV that may be difficult to treat
   • You make it harder for your medical provider to care for you
   • You may worry about infecting your partner and feel guilty after having sex
     
8. There are a variety of ways to reduce risks to yourself and a sex partner. Many people with HIV use one or more of the following strategies
   • Choose not to have sex at all
   • Choose safer behaviors, such as mutual masturbation
   • Choose to have sex with a partner who is HIV-infected and to use protection (a condom) with this partner
   • Choose less risky behaviors such as oral sex, and use latex barriers during oral sex
   • Choose to have anal or vaginal sex, but always use a condom to reduce the risk of transmission
   • Choose to limit the number of people with whom you have sex
   • Choose to stop using alcohol and other drugs because being under the influence of drugs may lead to unsafe sex

Attachment 2 - Prevention in Medical Care Settings

Examples of Laboratory Tests to Detect Asymptomatic Sexually Transmitted Diseases in Persons Who Are Asymptomatic

These recommendations apply to persons without symptoms or signs of STDs. Patients with symptoms (e.g., urethral or vaginal discharge; dysuria; intermenstrual bleeding; genital or anal lesions; anal pruritus, burning, or discharge; and lower abdominal pain with or without fever) or known exposure should have appropriate diagnostic testing regardless of reported sexual behavior or other risk factors.

First Visit
For all patients

• Test for syphilis: Nontreponemal serologic test, such as rapid plasma reagin (RPR) or Venereal Disease Research Laboratory (VDRL) test
• Test for urogenital gonorrhea: urethral (men) or cervical (women) specimen for culture; or urethral/cervical specimen or first-catch urine nucleic acid amplification test (NAAT) for Neisseria gonorrhoeae
• Test for urogenital chlamydial infection: urethral (men) cervical (women) specimen or first-catch urine (i.e., the first 10-30 cc of urine voided after initiating the stream should be used; men and women) specimen for NAAT for Chlamydia trachomatis

For women

• Test for trichomoniasis: wet mount examination or culture of vaginal secretions for Trichomonas vaginalis
• Test for urogenital chlamydia: cervical specimen for NAAT for Chlamydia trachomatis should be performed for all sexually active women 25 years of age or younger, and other women at increased risk, even if asymptomatic.

For patients who report receptive anal sex

• Test for rectal gonorrhea: anal swab culture for Neisseria gonorrhoeae
• Test for rectal chlamydia: anal swab culture for Chlamydia trachomatis, if available

For patients who report receptive oral sex

• Test for pharyngeal gonococcal infection: culture for Neisseria gonorrhoeae

NOTE: The yield of testing for N. gonorrhoeae and C. trachomatis is likely to vary, and screening for these pathogens should be based on consideration of patient's risk behaviors, local epidemiology of these infections, availability of tests (e.g., culture for C. trachomatis), and cost.

Later Routine Visits

• The tests listed above should be repeated periodically (i.e., at least annually) for all patients who are sexually active or who inject drugs. More frequent testing (e.g., every 3 months or 6 months) may be indicated for asymptomatic persons at higher risk. The presence of any of the following may indicate the need for testing more than once a year:
• Multiple or anonymous sex partners
• Past history of any STD
• Identification of other behaviors associated with the transmission of HIV or other STDs
• Sex or needle-sharing partner(s) with any of the above risks
• Life changes that may lead to an increase in risky behaviors (e.g., dissolution of a relationship)
• High prevalence of STDs in the area or in the patient population.

NOTE: Testing or vaccination for hepatitis, pneumococcal disease, influenza, and other infectious diseases (e.g., screening pregnant women for syphilis, gonorrhea, chlamydia, and hepatitis B surface antigen) should be incorporated into the routine care of HIV-infected persons as recommended elsewhere.^15,16,17
NOTE: Symptomatic and asymptomatic herpes simplex virus (HSV) infection, especially with HSV type 2, is prevalent among HIV-infected persons and may increase the risk of transmitting and acquiring HIV. Therefore, some experts recommend routine, type-specific serological testing for HSV-2. Patients with positive results should be informed of the increased risk of transmitting HIV and counseled regarding recognition of associated symptoms.17 Only tests for detection of HSV glycoprotein G are truly type-specific and suitable for HSV-2 serologic screening.
NOTE: Local and state health departments have reporting requirements for HIV and other STDs, which vary among states. Information on reporting requirements can be obtained from health departments. Clinicians need to be aware of and comply with requirements for the area in which they practice.

Attachment 3 - Prevention in Medical Care Settings

Available Diagnostic Testing for Detection of Sexually Transmitted Diseases

Diagnostic tests are listed in order of preference for recommendation, with most highly recommended test listed first. Alternative tests should be performed if specimen cannot be obtained or if preferred test is not available.

Syphilis

• Darkfield examination or direct fluorescent antibody (DFA) of exudate of lesion
• Serum nontreponemal tests, rapid plasma reagin (RPR), or Venereal Disease Research Laboratory (VDRL) for screening followed by serum treponemal tests such as fluorescent treponemal antibody absorbed (FTA-ABS) or Treponema pallidum particle agglutination (TP-PA)

Trichomoniasis

• Microscopic examination of wet mount or culture of vaginal secretions

Herpes

• Viral culture of genital or other mucocutaneous ulcers

Gonorrhea
Female Genitourinary (GU) tract

• Culture of endocervical swab specimen
• Nucleic acid amplification tests (NAAT) of endocervical swab specimen
• NAAT of urine

Male GU tract

• Culture of intraurethral swab
• NAAT of intraurethral swab
• NAAT of urine

Rectum/pharynx medium specimen

• Culture of rectal or pharyngeal swab specimen with selective

Chlamydia

• NAAT of endocervical swab specimen

Female GU tract

• NAAT of urine
• Unamplified nucleic acid hybridization test, enzyme immunoassay, or direct fluorescent antibody test of endocervical swab specimen
• Culture of endocervical swab specimen

Male GU tract

• NAAT of intraurethral swab specimen
• NAAT of urine
• Non-NAAT or culture of intraurethral swab specimen

Rectum/pharynx

• Culture of rectal or pharyngeal swab specimen
• Direct fluorescent antibody test performed on rectal or pharyngeal swab specimen)

NOTE: NAAT of urine is less sensitive than that of an endocervical or intraurethral swab specimen. Chlamydia trachomatis-major outer membrane protein (MOMP)-specific stain should be used.