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Prevention for Positives

for Health Care Providers

Prevention for Positives

Note: Some medications mentioned in this chapter may not be available on the VHA National Formulary. Consult VA pharmacists for alternatives.

Key Points

  • HIV prevention should be a focus of routine HIV primary care.
  • Prevention interventions should emphasize patients' own health and the health of their partners.
  • Assessment of sexual and substance-use behaviors and discussion of risk reduction interventions can be brief: 5-10 minutes per visit over a series of visits.
  • Elements of the prevention evaluation and intervention include:
    • A detailed HIV transmission risk assessment, including the patient's sexual practices with each partner, and needle-use practices, if applicable
    • Screening and testing for STIs
    • Assessment of pregnancy intentions and pregnancy testing if appropriate
    • Identification and correction of misconceptions
    • Tailored prevention messages
    • Individualized interventions
    • Referrals
    • Periodic reevaluation
  • Antiretroviral therapy (ART) with maximal virologic suppression sharply decreases risk of sexual transmission of HIV, and can be an important component of an overall prevention strategy.

Background

Basic Epidemiology of HIV Transmission in the United States: The Role of Prevention for Positives

There are an estimated 50,000 new HIV infections each year in the United States, almost all attributable to risky sexual and drug-use behaviors. Each new infection originates with someone already infected with HIV, and nearly all are preventable. Assessing patients' behaviors and promoting healthy changes can decrease the risk of HIV transmission. This chapter will focus on performing sexual risk assessment and making simple interventions to prevent transmission of HIV infection; this, in turn, can protect patients and their sexual and drug-sharing partners from other sexually transmitted and bloodborne pathogens, and possible HIV superinfection.

Veterans with HIV*

Alcohol use disorder: 33%

Illicit drug use: 30%

Other and unspecified drug use: 22%

*Veterans in the VA HIV Clinical Case Registry in care in 2007 who had an ICD-9 code corresponding to these conditions

Transmission route for persons diagnosed with HIV infection in the United States in 2010:

  • Men: approximately 67% sex with other men (MSM); 15% high-risk heterosexual contact; 12% injection drug use (IDU), 6% MSM and IDU
  • Women: approximately 77% heterosexual sex; 21% IDU

Source: CDC, 2010; Diagnoses of HIV Infection and AIDS in the United States and Dependent Areas, 2010. Estimated numbers of new HIV diagnoses in adults and adolescents in 40 states and 5 U.S. dependent areas with confidential name-based HIV reporting. See References.

Helping Patients Adopt and Maintain Safer Sexual Behaviors

The HIV clinic is an important setting for prevention efforts, to help patients decrease the risks of:

  • Transmitting HIV to others via sexual or IDU behaviors
  • Acquiring and transmitting an STI
  • Acquiring a bloodborne infection (for injection drug users)
  • HIV superinfection (note: this appears to occur rarely, but can adversely affect clinical status and treatment options)
  • Unintended pregnancy

Nevertheless, studies have shown that many HIV providers do not assess transmission risks with or provide prevention messages to their patients.

For some patients, decreasing HIV transmission risks requires them to make small changes in sexual and drug-use behavior; for others, significant changes are needed. Although behavior changes can be difficult to make and to maintain, they should be encouraged. Several studies have shown that assessment of HIV transmission risk followed by brief prevention interventions initiated by the care provider can be effective. Various risk reduction interventions in primary care and STI clinics have resulted in:

  • Increased condom use
  • Safer IDU practices
  • Fewer STIs
  • Increased use of ART

As with any behavior change intervention (eg, smoking cessation, dietary modification), HIV prevention interventions need to be reevaluated and reinforced regularly. Over time, primary care providers can have a significant impact on their patients' behaviors. Clinicians often underestimate how seriously patients take their recommendations.

Addressing patients' health behaviors, particularly in the realms of sex and drug use, can be challenging or uncomfortable for some medical providers. Learning how to conduct a partner-by-partner risk assessment can reduce this discomfort. Given the preventable nature of HIV infection, HIV risk assessment and the delivery of individualized prevention messages should be routine and ongoing aspects of HIV care that are performed at the initial evaluation and periodically thereafter.

Clinicians can greatly affect patients' risks for transmission of HIV to others via the following actions:

  • Performing a brief screening for HIV transmission risk behaviors
  • Communicating tailored prevention messages
  • Discussing sexual and drug-use behavior
  • Positively reinforcing changes toward safer behavior
  • Referring patients for services such as substance abuse treatment
  • Facilitating partner notification, counseling, and testing
  • Identifying and treating other STIs
  • Initiating and supporting ART, where appropriate

These measures also may decrease patients' risks of acquiring other STIs and bloodborne infections (eg, viral hepatitis).

Adapted from CDC, HRSA, NIH, and HIVMA. See References.

Doing prevention work with HIV-infected patients can be divided into evaluation steps and management steps.

Evaluation:

  1. Establish rapport and conduct a quick, detailed behavioral risk assessment.
  2. Assess for the presence of symptomatic and asymptomatic STIs.
  3. Assess for use of ART (with virologic suppression).

Management:

  1. Locate patient's risk behavior along the risk continuum.
  2. Correct misinformation, answer questions, and educate.
  3. Assess patient's readiness for behavior change.
  4. Work toward risk reduction with an individualized prevention message based on the patient's risk behaviors and readiness to change.
  5. Treat STIs and supply medications, condoms, and lubricant if needed.
  6. Agree on what patient will do to reduce risk.
  7. Agree to address prevention at future visits.

The rest of this chapter will focus on these steps in more detail.

Evaluation

HIV transmission risk assessment should be performed at the initial evaluation and periodically thereafter. For patients with significant ongoing risk factors for HIV transmission, it should be part of every visit, if possible.

Sexual risk assessment

  • Should include an evaluation of risks of HIV transmission and risks of acquisition and transmission of other STIs (including HBV and HCV infections).

Drug and alcohol risk assessment (see also Alcohol Misuse and Substance Use)

  • Illicit drug use (particularly methamphetamine use) and alcohol misuse are associated with unsafe sex practices, and with STI and HIV acquisition and transmission.
  • Sharing of nonsterile injection equipment can itself cause transmission of HIV and other bloodborne pathogens (including HBV and HCV).

Mental health assessment (see also Depression)

  • Serious mental illness, posttraumatic stress disorder, and depression increase the likelihood of risky sexual and drug- and alcohol-use behaviors.

STI screening/testing

  • The presence of an STI indicates risky sexual practices and increased risk of HIV transmission, and the potential for acquisition of different HIV strains.
  • Coinfection with an STI (eg, gonorrhea, chlamydia, syphilis, chancroid, herpes simplex virus [HSV], and trichomoniasis) can increase HIV transmission risk and is deleterious to the patient's own health.

Sexual risk assessment: In order to provide appropriate and specific recommendations, it is important to understand the patient's risk behaviors and why he or she is engaging in them. A basic assessment should include questions about a variety of topics (see box below). Because a patient's sexual activities may vary substantially with different partners or in different circumstances, asking follow-up questions to explore the circumstances of unsafe behaviors is crucial to targeting specific risk behaviors for intervention. One very helpful way of organizing an efficient but detailed risk assessment is to ask patients to make a mental list of their most recent partners, and then explore their risk behaviors with each partner (see Table 1 for questions to ask).

Note: Veterans may be particularly reluctant to acknowledge same-sex sexual activities or IDU.

When interviewing patients, it is important to establish rapport in order to elicit truthful and complete responses and to establish a context for behavioral interventions. It often is helpful to normalize the questions as a routine part of primary care, and these topics should be discussed openly in a nonjudgmental manner.

Providers often find that systematically evaluating risk in a partner-by-partner fashion makes the risk assessment more clinical, less emotionally charged, and more comfortable for them and their patients.

Reassuring patients about the confidentiality of their responses to questions about risky behavior is a key component for establishing rapport and trust and obtaining truthful responses. The confidentiality of HIV-related information in the VA system is explicitly and specifically protected by federal law; it may be helpful at a patient's initial visit to clarify his or her confidentiality rights.

Table 1. Components of a Detailed Risk Assessment

* Serosorting, whereby an HIV-infected person has unprotected sex only with HIV-infected partners, likely reduces HIV transmission in settings where the HIV status of the partner is definitively known. Serosorting does not affect the risk of acquiring other STIs, including HBV and HCV infections, or the risk of reinfection with drug-resistant or more pathogenic strains of HIV.

For a more complete risk assessment questionnaire, see the Risk Assessment Battery (University of Pennsylvania and Philadelphia Veterans Administration Medical Center), reproduced in the VA Prevention Handbook; see References

(Print table)

  • Number of recent sex partners
  • Sex of each partner
  • Type of relationship with each partner (eg, main, casual, anonymous)
  • HIV status of each partner
  • Whether patient discloses his/her HIV status to partners or potential partners
  • Type of sexual activity engaged in with each partner
  • Safer and less-safe sexual activities engaged in with each partner
  • Use of any risk reduction techniques (eg, condoms, serosorting,* disclosure)
  • Consider asking questions such as:
    • "What made it more difficult for you to use condoms during this sexual encounter/with this partner?"
    • "What made it easier for you to use condoms during this sexual encounter/with this partner?"
  • Substance use (including alcohol) associated with sex
  • Circumstances of risky sex behaviors (eg, while intoxicated or high, with anonymous partners, in particular settings)
  • Risky drug-use practices (eg, sharing injection equipment or nasal straws)
  • Barriers to "safer" sex (and drug-use) practices
  • STI symptoms
  • Women: current pregnancy, desire or intention for pregnancy, contraception
  • Men with female sex partners: intentions for conception or fathering, contraception
  • Use of ART, with virologic suppression

How to start the conversation

Sometimes, the hardest part of doing prevention for positives is simply starting the conversation. The CDC HIV Prevention Guidelines present examples of screening and follow-up questions that may be used in interviewing patients:

Open-end question by clinician, similar to one of the following:

  • "What are you doing now that you think may present a risk of transmitting HIV to a partner?"
  • "Tell me about the people you've had sex with recently."
  • "Tell me about your sex life."

Screening questions* (checklist; should take approximately 4 minutes):

  • "Since your last checkup here," or, if first visit, "Since you found out you are infected with HIV ..."
  • "Have you been sexually active; that is, have you had vaginal, anal, or oral sex with a partner?"
    • If yes:
    • "Have you had vaginal or anal intercourse without a condom with anyone?"
    • If yes:
    • "Were any of these people HIV negative, or are you unsure about their HIV status?"
    • "Have you had oral sex with someone?"
    • If yes:
    • (For a male patient) "Did you ejaculate into your partner's mouth?"
  • "Have you had a genital sore or discharge, discomfort when you urinate, or anal burning or itching?"
  • "Have you been diagnosed or treated for an STI?
    • Do you know whether any of your sex partners have been diagnosed or treated for an STI?"
  • "Have you shared drug-injection equipment (needle, syringe, cotton, cooker, water) with others?"
    • If yes:
    • "Were any of these people HIV negative, or are you unsure about their HIV status?"

These questions may be used in a face-to-face interview, or with a self-administered questionnaire.

*Adapted from CDC, HRSA, NIH, and HIVMA. See References.

STI Screening

  • The presence of an STI suggests behaviors that may result in HIV transmission.
  • In addition to the morbidity associated with the STI itself, the presence of an STI increases the risk of HIV transmission; diagnosis and treatment of STIs may therefore decrease HIV transmission, as well as prevent transmission of the STI.
  • Screen all patients at baseline and regularly thereafter, depending on their risk factors (eg, every 3-6 months in patients with a new sex partner or a partner who is an injection drug user); do specific tests according to sites of possible exposure; see below.
  • Routinely ask patients whether they have symptoms of an STI; perform diagnostic testing for all symptomatic patients, and treat as indicated.
Table 2. Screening for STIs
STIScreening Test

Adapted from CDC. Sexually Transmitted Disease Treatment Guidelines--2010. See References.
* * NAAT is not currently approved for this indication by the FDA. There is evidence that NAAT can accurately diagnose pharyngeal and rectal gonorrhea and rectal chlamydia, and many local public health departments and commercial laboratories have obtained Clinical Laboratory Improvement Amendment (CLIA) waivers to perform NAAT on pharyngeal and rectal swabs.

(Print table)

SyphilisNontreponemal tests: RPR (rapid plasma reagin); VDRL (Venereal Disease Research Laboratory test) (some laboratories use a treponemal test as an initial screen, and a nontreponemal test as a confirmatory test)
Chlamydia
  • Urogenital infection: Nucleic acid amplification test (NAAT) on first-void urine (men and women); NAAT on vaginal or cervical swab (women)
  • Pharyngeal infection: Routine screening is not recommended because the prevalence of chlamydia pharyngeal infection is low.
  • Rectal infection: NAAT of rectal swab* (for all who report engaging in anal receptive sex)
Gonorrhea
  • Urogenital infection: NAAT on first-void urine (men and women); NAAT on vaginal or cervical (women) or urethral (men) swab specimen; culture of male urethral or female endocervical swab specimen (For men with symptoms of urethritis, Gram stain of urethral specimen may be done.)
  • Pharyngeal infection: NAAT or culture of oral swab* (for all who report engaging in oral receptive sex)
  • Rectal infection: NAAT or culture of rectal swab* (for all who report engaging in anal receptive sex)
TrichomoniasisWet-mount examination or culture of vaginal secretions (for all women)
HSVSerologic testing for HSV-2; recommended by some experts (for patients not previously diagnosed with HSV). Cell culture and/or HSV PCR are the preferred HSV tests for persons with genital ulcers or other mucocutaneous lesions.

Pregnancy Screening

Screen all women who have a possibility of pregnancy based on sexual history, as well as those with missed menses or other signs or symptoms of pregnancy.

Management

Information and education are important: Many patients have an incomplete or inaccurate understanding of how HIV is transmitted, the risks of various behaviors, and methods to prevent infection of sex partners or needle-sharing partners.

  • Patient education may increase knowledge and provide motivation.
  • Providers may identify and correct misconceptions.
  • It is worth specifically mentioning that ART with maximal virologic suppression appears to substantially decrease HIV transmission risk but does not ensure that patients are noninfectious.
  • However, information alone is not adequate to change patients' behavior.

Brief, tailored interventions and prevention messages delivered by clinicians may help patients reduce their risks of transmitting HIV.

  • These are more effective in achieving behavior change than patient education alone.

There are a number of models for health behavior change and various counseling techniques or programs based on those models (for further information, see the VA HIV Prevention Handbook and References, below). Most involve:

  • Assessing the patient's level of awareness and concern
  • Helping the patient to better understand his or her potentially harmful behavior
  • Determining the patient's readiness for change (see Stages of Change)
  • Working with the patient to target a particular behavior for change
  • Helping the patient bring about the desired change (this may require developing new skills [eg, negotiation])
  • Working toward further specific goals as the patient is ready

(Adapted from AIDS Institute, New York State Department of Health. HIV and Primary Care: Putting Prevention into Practice; 1998.)

In working with patients, it is important to assess their risk, readiness, motivation, and skills around specific behavioral changes and to work with them to prepare for these changes.

Risk Continuum

In interviewing patients, assess their positions on a continuum of risk of HIV transmission (see Table 3). Again, note that the degree or type of risk each person engages in may differ, depending on specific circumstances. Focus on specific behaviors.

Table 3. Relative Risk of HIV Acquisition (per act)
Risk FactorRelative Risk of Acquisition

* Best-guess estimate
# Referent category

Adapted from Varghese B, Maher JE, Peterman TA, et al. Reducing the risk of sexual transmission: quantifying the per-act risk for HIV infection based on choice of partner, sex act, and condom use. Sex Transm Dis 2002;29:38-43. Also adapted from CDC, HRSA, NIH, and HIVMA. Incorporating HIV Prevention into the Medical Care of Persons Living with HIV. MMWR 2003;52:RR-12.

Print table

Sexual Activity (some popular terms)
Insertive fellatio ("getting head, being blown/sucked")*1#
Receptive fellatio ("giving head, blowing/sucking")*2
Insertive vaginal sex10
Insertive anal sex ("topping")13
Receptive vaginal sex20
Receptive anal intercourse ("bottoming")100
Condom Use
Yes1
No20

Assess readiness for change

Using the Stages of Change model, identify the patient's readiness to change risky sexual behaviors (for more on stages of change, see Alcohol Misuse, Substance Use, and Smoking Cessation).

Figure

Work toward risk reduction: Many people may not want, or may not be willing, to adopt behaviors that entirely eliminate the risk of HIV transmission (eg, abstinence); for most, the goal is to move from riskier activities to less-risky activities (see Table 3). Patients may do this in increments, with the support of clinicians, as they are ready and able.

Interventions may be as brief as 5-10 minutes per session. They should be repeated, refined, and reinforced at follow-up visits. For more extensive support, refer within and outside the VHA (eg, for counseling, psychiatric treatment, and substance misuse treatment).

Individualize prevention messages and interventions. Based on the risk assessment, the clinician can help patients identify behaviors that are less risky, and can target them for intervention. The intervention should be tailored to the individual, and the goal should be attainable. Risk reduction could include:

  • Disclosing one's HIV status
  • ART with maximal suppression of HIV viremia; adherence to ART
  • Asking about partner's HIV status
  • Monogamy
  • Reducing the number of sex partners
  • Using condoms (male or female), particularly for anal or vaginal intercourse
  • Having sex only with other HIV-infected partners (serosorting)
  • Not having sex while intoxicated or under the influence of drugs or alcohol
  • Using adequate lubrication to avoid trauma to genital or rectal mucosa
  • Regular STI testing
  • Referring partners for HIV and STI testing and counseling
  • For drug users: using clean injection equipment; not sharing injection equipment

Using the risk continuum (see Table 3), help the patient identify ways toward less-risky behaviors.

An example of an intervention, based on the Stages of Change theory, is the following:

Response to Risk-Behavior Questions, Corresponding Stages of Behavior Change, and Possible Interventions

Response to Risk-Behavior Questions, Corresponding Stages of Behavior Change, and Possible Interventions

(See full figure)

Providers should give information, education, and support regarding ways to reduce risk.

Practical Supports

Prescribe condoms (male and female condoms are available on the VHA National Formulary). Refer to drug treatment programs as needed, and needle-exchange programs if available.

Refer patients, as needed, to VHA or community resources, for:

  • More intensive risk reduction counseling and intervention
  • Instruction on practical skills (eg, correct condom use, negotiation skills)
  • Substance abuse treatment
  • Mental health treatment
  • Assistance with social problems (eg, lack of money or housing)
  • Case management, social services
  • Support around other problems that contribute to risky behaviors

Follow Up:

  • At each visit, briefly reassess HIV transmission risks
  • Identify and correct misconceptions
  • Answer the patient's questions
  • Reinforce focused prevention messages
  • Give encouragement and positive reinforcement for positive changes in risk behaviors
  • Identify next steps for further risk reduction
  • For patients who continue risky behaviors, elicit their beliefs and attitudes about their behaviors; offer counseling and develop further intervention, based on their motivation and their current stage on the change continuum

Note on Preexposure Prophylaxis (PrEP)

The combination tablet of TDF + FTC (Truvada) has been approved by the FDA for use as PrEP for HIV-uninfected adults at high risk of sexual acquisition of HIV. Dosage is 1 tablet, once daily.

In several studies, TDF + FTC has been shown to be effective in reducing the risk of HIV infection in high-risk MSM and heterosexual men and women. Other studies, however, have not shown efficacy. Effectiveness of this PrEP appears to be strongly correlated with adherence, and it should be noted that, in the studies, PrEP was given in the context of a full array of risk-reduction interventions, including adherence support and risk reduction counseling, condom provision, HIV testing, and STI screening and treatment. The CDC has issued interim guidelines on the use of PrEP in MSM and in high-risk heterosexual adults (see References).

References