An old medical student joke says that if you tell your patient to lose weight by diet and exercise and he does lose, you should work him up for cancer. Certainly, we all know how hard it is to get people to change behavior. The behaviors that increase the risk for HIV transmission are particularly hard to change. However, in the chapter on Prevention With Positives , the New York State Department of Health AIDS Institute guideline for preventing the transmission of HIV by patients known to be infected, there are many useful suggestions.
Perhaps the key to the guideline is establishing a dialogue that allows the patient to be frank about his or her ongoing risky behaviors. Clinicians need to use open-ended, nonjudgmental language in asking about alcohol and drug use as well as sexual behavior. Educating and counseling HIV-infected patients about risk reduction is effective only if the patient feels safe in disclosing his or her risky behaviors to the clinician.
Prevention efforts need to be part of all clinician/patient encounters: they can be done by the provider or other members of the care team. In addition to counseling, clinicians should have prevention messages prominently displayed in posters, handouts, and bowls of condoms.
Screening the patients’ partners for HIV and counseling discordant couples on safer sex, including condom use and avoiding the riskiest behaviors, is also key. Patients should be encouraged to use the partner notification program of their local health department if there are partners with whom they have lost contact.
Other ways to reduce transmission include: screening for and treating other sexually transmitted infections (STIs) because they enhance the risk for transmission; screening for and treating addiction, including problematic alcohol use; and providing clean needles or referral to needle exchange programs for injection drug users who decline referral for treatment.
Testing all pregnant women for HIV is essential. The reduction of mother-to-child transmission has been one of the great prevention successes of the last 30 years. Without treatment, 20%-25% of infants born to HIV-infected women are infected; with screening of all pregnant women and treatment of those with HIV infection, that rate is now less than 1%.
The Prevention With Positives guideline recommends treatment of patients in serodiscordant relationships (ie, patients with an uninfected partner, even when the infected patient has a high CD4 cell count).
The guideline was developed just before the release of a key study supporting this concept. The HPTN 052 study was an international cooperative effort in which heterosexual patients with CD4 counts of 350-550 cells/mm3 and an uninfected partner were randomly assigned to antiretroviral therapy or observation. A total of 1763 serodiscordant couples were enrolled.
The trial was stopped early when the data and safety monitoring board noted that there was a relative reduction of 96% in the number of linked HIV-1 transmissions resulting from the early initiation of antiretroviral therapy as compared with delayed therapy.
Although the magnitude of the effect is very high, the results should come as no surprise because virtually every study of transmission has found that higher viral loads in an HIV-infected person increase the risk for transmission to an uninfected person. This is true whether the route of transmission is by sexual contact, needlestick exposure of a healthcare worker,1 or transmission from mother to baby. Therefore, it is reasonable to consider reducing the source patient’s viral load as a way to reduce transmission by any route, particularly sexual.
Prevention efforts generally have had mixed results, but there have been some real successes as can be seen in the CDC epidemiologic chart (Figure).1
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