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HIV PREVENTION: "Survival sex" and substance abuse may hinder HIV prevention efforts
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Health & Medicine Week
December 29, 2003
Even after receiving risk-reduction counseling, some individuals who knowthey are HIV-positive are engaging in high-risk behavior that could transmittheir infection, according to a new study.
Interviews with 256 people who attended a New York City HIV clinic revealedthat 41% engaged in unprotected sex after learning they were HIV-positive,the study reported.
Trading sex for drugs or money was an important factor associated withhigh-risk behavior, particularly for women. Lead author Dr. Joseph P.McGowan of the Bronx-Lebanon Hospital Center in New York said HIV-positivewomen may be more likely to have unprotected sex because of a "lack ofempowerment or low self-esteem. For example, does the woman have the abilityto say no if the man doesn't use a condom?" Often, said McGowan, the womenhave a history of exchanging sex for money or drugs, which probably led themto become HIV-positive initially. Such "survival sex" is adifficult-to-change habit fueled by both economic need and addiction.
The findings are published in the January 1, 2004, issue of ClinicalInfectious Diseases, now available online.
Highly active antiretroviral therapy (HAART) patients were more likely tohave unprotected sex than those who did not receive the treatment, perhapsbecause HAART patients believed they would not transmit HIV to theirpartners. However, said McGowan, although HAART can help decrease the riskof HIV transmission, the risk is not eliminated. In fact, a patientreceiving HAART may transmit a drug-resistant form of HIV.
Reducing transmission of HIV is an intricate problem, said McGowan. In thestudy, McGowan and his colleagues concluded that ongoing risk-reductioncounseling and substance abuse treatment for HIV-infected people must bepart of the solution. "I think what we need to do is make a safe-sexcounseling message an ongoing part of clinical care," he said, "notcounseling once a year. We need to do it much more often in a proactiveway." McGowan also noted that monotonous warnings can lead to patient"fatigue," in which risky behavior increases as the message wears off. "Weneed to develop some motivational interviewing skills and techniques whichinclude the patient in the process to set achievable goals," McGowan said."Rather than telling a patient to stop using drugs, you would ask, 'Do youthink you can cut back on your drug use?'"
Finally, the counseling should not be separate from the cure. "Preventionand treatment have to go hand in hand," said McGowan.
To help medical caregivers better incorporate prevention into theirtreatment of HIV-infected people, the January 1 issue of Clinical InfectiousDiseases will also include a summary of recommendations. The summary isauthored by Dr. Kenneth H. Mayer of the HIV Medicine Association (HIVMA),part of the Infectious Diseases Society of America (IDSA). Therecommendations were developed by HIVMA, the U.S. Centers for DiseaseControl and Prevention, the Health Resources and Services Administration,the National Institutes of Health and the HIV Prevention in Clinical CareWorking Group.
ORIGINAL ARTICLE
Risk Behavior for Transmission of Human Immunodeficiency Virus (HIV) among HIV-Seropositive Individuals in an Urban Setting
Clinical Infectious Diseases 2004;38:122-127
Joseph P. McGowan,1 Sanjiv S. Shah,1 Camelia E. Ganea,1 Steve Blum,1 Jerome A. Ernst,2 Kathleen L. Irwin,3 Noemi Olivo,2 and Paul J. Weidle3
1Department of Medicine, Bronx-Lebanon Hospital Center, Bronx, and 2Community Research Initiative on AIDS, New York, New York; and 3Centers for Disease Control and Prevention, Atlanta, Georgia
ABSTRACT
We conducted interviews with 256 human immunodeficiency virus (HIV)infected patients who attended an HIV clinic in New York City to assess ongoing risk behaviors for HIV transmission.
After learning that the result of an HIV test was positive, 106 subjects (41%)had unprotected sex, 63 (25%) had a new sexually transmitted disease diagnosis, and 38 (15%) used injection drugs. Unprotected sex was reported by 50% of women, 29% of heterosexual men (P = .006, compared with women), and 42% of men who have sex with men, and it was reported more often by persons with a history of trading sex for money or drugs (P < .001). In multivariate analysis, unprotected sex was associated with a history of trading sex for money or drugs (adjusted odds ratio [AOR], 4.0; 95% confidence interval [CI], 2.27.0) and use of highly active antiretroviral therapy (AOR, 1.8; 95% CI, 1.13.1).
Ongoing risk-reduction counseling and substance abuse treatment for HIV-infected persons are needed to reduce behaviors associated with HIV transmission.
BACKGROUND
Because HIV-seropositive persons are the source of transmission of HIV, it is important to characterize the type and extent of their risk behaviors for HIV transmission. It has been estimated that approximately one-third of HIV-infected persons in the United States are unaware of their HIV serostatus. Although these individuals may indeed be the source of transmission for many new cases of HIV infection, HIV-seropositive individuals who are aware of their infection and who engage in high-risk activity may also pose a significant risk for transmission in the community. Indeed, recent outbreaks of sexually transmitted diseases (STDs) among persons with long-standing HIV infection suggest that there are ongoing risk behaviors among some groups. Because many HIV-infected persons are receivingantiretroviral therapy, risk behavior for HIV transmission among HIV-seropositive persons may not only lead to the spread of HIV infection but would likely account for the transmission of drug-resistant HIV.
Ongoing risk behavior for HIV transmission has been described for men who have sex with men (MSM) and for other populations reporting injection drug use (IDU) as a risk factor for HIV transmission. We report high-risk behavior in a population ofHIV-seropositive persons among whom the predominant risk factors for HIV acquisition were heterosexual contact and IDU. The objectives of this study were (1) to assess ongoing risk behaviors for transmission of HIV among HIV-seropositive persons in primary care who received HIV risk-reduction counseling and education as part of routine practice in our clinic, and (2) to identify associations with ongoing risk behavior.
RESULTS
Four hundred twenty-six patients were evaluated for study eligibility, of whom 256 persons (median age, 40 years; range 2066 years) were recruited into the study during the period of September 1997 through February 1998. Eighty-seven persons did not meet eligibility criteria, and 46 persons were eligible but were not needed in the sampling strata that remained unfilled. Of those persons who wereeligible and needed for sample requirements, 26 refused to enroll and 11 did not return for an interview.
All patients reported having had UPS before knowing that they were HIV seropositive. Of note, heterosexual contact was the onlyreported risk behavior for 118 patients (46%).
UPS after known HIV seropositivity. One hundred six (41%) of 256 patients reported having had UPS after they learned of their positive HIV test result. UPS after knowledge of HIV positivity was reported (1) more by women than by heterosexual men (but not more than by MSM), (2) more by patients who reported trading sex for money or drugs than by those who did not, (3) more by those whoknew their serostatus longer, and (4) more by those who had ever been prescribed HAART than by those who had not. Those who reported having had UPS after learning of a positive HIV test result knew their serostatus an average of 17 months longer than those who did not (P = .001) and had more sex partners before testing positive (median, 40 partners; range, 11500 partners) than did those who did not(median, 12 partners; range, 11000 partners; P = .002). Report of UPS after knowledge of a positive HIV test result was not related to level of education or age category (<35 years, 3549 years, or >49 years).
STDs. One hundred seventy-one (67%) of 256 persons reported having had an STD diagnosed before or after knowledge of their positive HIV test result. Diagnosis of an STD after knowledge of a positive HIV test result was reported by 63 patients (25%), of whom 48 reported diagnosis of an STD both before and after their positive HIV test result, and 15 patients reported an STD diagnosis only after theirpositive HIV test result. Diagnosis of an STD after knowledge of HIV seropositivity was reported (1) more by women (30%) than by heterosexual men (15%; P = .02) but not more than by MSM (27%; P = .8, compared with women; P = .11, compared with heterosexual men); (2) more by those who reported trading sex for money or drugs (45%) than by those who did not (16%; P < .001); and (3) more bythose who knew their HIV serostatus longer (for <1 year, 12%; for 14 years, 21%; for 5 years, 34%; P = .003, by 2 test for trend). Patients who reported receiving an STD diagnosis after learning about their positive HIV test result knew their serostatus an average of 18 months longer than did those who did not report an STD diagnosis during this period (P = .003).
IDU. IDU before knowledge of a positive HIV test result was reported by 104 (41%) of 256 patients, of whom 80 (77%) reported sharing needles. IDU after knowledge of a positive HIV test result was reported by 38 (15%) of 256 patients, of whom 5 (13%) reported sharing needles and/or other injection equipment. Among women, trading sex for money or drugs before testing HIV positive was associated with IDU after knowledge of HIV infection: 12 (67%) of 18 women who reported IDU after knowledge of their positive HIV test result had reported a history of trading sex for money or drugs before they knew they were HIV infected, compared with 41 (40%) of 103 women who denied IDU after their positive HIV test result (P = .03).
Multivariate analysis. After adjusting for the factors described in the Methods, a history of trading sex for money or drugs (adjusted OR [AOR], 4.0) and receipt of HAART (AOR, 1.8) were both statistically associated with UPS after knowledge of HIV status. A second model that included a first-order interaction term between a history of trading sex for money or drugs and HAART use showed that, compared with the subgroup of patients who denied past trading of sex for money or drugs and who had not been prescribed HAART, the patients who reported a history of trading sex for money or drugs and who had been prescribed HAART were more likely to report UPS after they learned that they were HIV seropositive (AOR, 11.0; 95% CI, 4.031.5).
DISCUSSION by authors
In this study of HIV-infected persons whose primary risk behavior for acquiring HIV was heterosexual contact or IDU, sexual behavior that places persons at high risk for HIV transmission to their sex partner was reported by >40% of persons, despite being in ongoing clinical care after they knew they were HIV infected. Proportionately more women than heterosexual men (but not men who have sex with men) reported UPS and diagnosis of an STD after they learned of their positive HIV test result. Our analysis demonstrates that, in this population, this association was largely because women and men who have sex with men were more likely to report a history of trading sex for money or drugs than were heterosexual men.
History of trade of sex for money or drugs was only obtained for the period before knowledge of a first positive HIV test result; however, study participants may have continued this behavior after they tested positive for HIV. This assumption is consistent with the findings of other investigators that trading sex for money or drugs is difficult to change, despite a person's knowledge of HIV infection.Substance use, especially use of crack cocaine, is highly prevalent in this community and, along with poverty and economic needs ("survival sex"), it may be driving much of the ongoing HIV risk behaviorparticularly among womenthrough the exchange of sex for money or drugs.
Our study found that UPS after notification of a positive HIV test result was more commonly reported by patients who received HAART than by those who did not receive HAART. The use of HAART may contribute to a misconception that risk of HIV transmission is eliminated, especially if the HIV-1 plasma load is low. Although clinical studies indicate that HIV transmission rates are positively associated with plasma virus load, there is no threshold below which transmission never occurs. Furthermore, identification of drug-resistant strains of HIV in newly infected patients who have never received antiretroviral therapy (primary drug resistance) have been increasingly described in communities where antiretroviral therapy is commonly prescribed. Although the lack of adherence to HAART may generate drug resistance, it is ongoing risk behavior that leads to transmission of primary drug-resistant HIV strains. Alternatively, because data about protected sex were not collected, it is possible that persons receiving HAART who benefit from animproved health status may generally engage in increased sexual activity, both protected and unprotected, that may not be related to their perception of transmission risk.
The association between use of HAART and report of UPS after learning that HIV test results were positive showed that there was a strong interaction with a history of trade of sex for money or drugs. Subjects who both used HAART and had a history of trade of sex for money or drugs had an AOR of 11 for UPS after learning of HIV-positive serostatus, compared with those who had neither characteristic.Although persons who engage in trade of sex for money or drugs may want to decrease their risk of transmission of HIV with use of HAART, the lack of condom use among these persons illustrates a potential misunderstanding of the current prevention messages that advocate continued condom use even if HAART is being administered. Alternatively, the same factors that drive continued commercial sextrade, such as maintaining a drug habit, may lead some patients to sell their HAART and other HIV-related medications to other individuals or to pharmacies.
Genital ulcer diseases, such as herpes simplex and syphilis, and nonulcerative STDs, such as gonorrhea and chlamydia, can increase HIV viral shedding in the genital tract and have been associated with an increased risk of HIV transmission. We found that approximately one-fourth of patients, including nearly one-third of the women, reported diagnosis of an STD after they had learned that they were HIV infected. Diagnosis and treatment of STDs in HIV-infected patients should play a critical role in strategies to reduce transmission of HIV.
The prevalence of risk behavior for HIV transmission was higher among patients who knew their HIV positive test result longer. This may be the result of a cumulative effect related to increased opportunity, with time, for risky behavior and/or a waning of motivation for risk-behavior modification ("prevention fatigue") over time that leads to recidivism of unsafe sex practices. However, our study did not assess the frequency and/or recentness of risk-reduction counseling.
It was encouraging that reporting of IDU and needle and paraphernalia sharing was much lower for individuals after they had learned of their positive HIV test result than before. Data on enrollment of patients in methadone maintenance, needle exchange, and other substance abuse treatment programs were not collected as part of the study, but participation in such programs, along with risk-reduction counseling by health care providers, may have had an impact on these findings.
A limitation of the study is our inability to distinguish behavior, such as UPS or needle sharing, that is likely to cause HIV transmission (to a partner who is HIV uninfected) from behavior that is likely to have no impact on transmission (to a partner who the patient knew was also HIV infected). Also, this study relied on self-reported risk behavior, which may underestimate actual risk behavior. STD data were based on participant's reports of STD diagnoses by health care providers. An STD that did not prompt a patient to see a health care providermay not have been reported, and STDs that may be relatively asymptomatic, such as gonorrhea and chlamydia, may be underdiagnosed, especially among women. Some STDs mentioned in the questionnaire, such as herpes simplex virus, are chronic and may relapse over time; therefore, a newly diagnosed STD may not always represent a newly acquired STD. Lastly, because of its cross-sectional design that reviewed past behaviors, our study was not able to examine the exact temporal relationship between knowledge of HIV serostatus, onset ofparticular risk behaviors after notification of test result, onset of HAART use, or exact timing of patient knowledge of changes in virus load, factors that might influence ongoing risk behavior. Recall of risk behaviors by study subjects may be affected by the time elapsed since they first learned of a positive HIV test result. A prospective study is needed to address more fully these important issues.
Our findings demonstrate that individuals who know that they are HIV infected may be an important source for transmission of HIV and STDs in an urban setting. This study highlights that trade of sex for money or drugs is an important factor associated with transmission risk behavior in HIV-seropositive persons, especially women. Periodic risk assessment and screening for STDs should be a routine part of HIV primary care, and, when STDs are identified, there should be a discussion with the patient about sexual practices. Patients should be cautioned that the use of antiretroviral therapy is not a guarantee against virus transmission. Resources should be mobilized for routine screening for STDs, for behavioral modification to reinforce safe sex practices, and for improved access to drug dependency programs.
Recommendations for Incorporating Human Immunodeficiency Virus (HIV)Prevention into the Medical Care of Persons Living with HIV
Kenneth H. Mayer, Section Editor
Centers for Disease Control and Prevention, Health Resources and Services Administration, National Institutes of Health, HIV Medicine Association of the Infectious Diseases Society of America, and the HIV Prevention in Clinical Care Working Group
The estimated number of annual new human immunodeficiency virus (HIV) infections in the United States has remained at 40,000 for >10 years. Reducing the rate of transmission will require new strategies, including emphasis on prevention of transmission by HIV-infected persons.
Medical care providers can affect HIV transmission by screening HIV-infectedpatients for risk behaviors, communicating prevention messages, discussing sexual and drug-use behaviors, reinforcing changes to safer behavior, referring patients for services such as substance abuse treatment, facilitating partner counseling and referral, and identifying and treating other sexually transmitted diseases.
The Centers for Disease Control and Prevention (CDC), the Health Resources and Services Administration (HRSA), the National Institutes of Health (NIH), and the HIV Medicine Association (HIVMA) of the Infectious Diseases Society of America (IDSA) have recently collaborated to develop evidence-based recommendations for incorporating HIV prevention into the medical care of persons living with HIV. This article summarizes key aspects of the recommendations.
The estimated number of annual new HIV infections in the United States has remained at 40,000 for over 10 years. Reducing the rate of HIV transmission will require new strategies, including increased emphasis on preventing transmission by persons living with HIV. Clinicians providing medical care to HIV-infected persons can play a key role in helping their patients reduce risk behaviors and maintain safer sexual and drug-using practices and can do so with a feasible level of effort, even in constrained practice settings. The Centers for Disease Control and Prevention (CDC), the Health Resources and Services Administration (HRSA), the National Institutes of Health (NIH), and the HIV Medicine Association (HIVMA) of the Infectious Diseases Society of America (IDSA) have recently collaborated to develop recommendations for incorporating HIV prevention into the medical care of persons living with HIV. The recommendations were developed using an evidence-based approach. The strength of each recommendation is indicated on a scale of A (strongest recommendation for) to E (recommendation against); the quality of available evidence supporting the recommendation is indicated on a scale of I (strongest evidence for) to III (weakest evidence for), and the outcome for which the recommendation is rated is provided. The recommendations are categorized into 3 major components: (1) screening for HIV transmission risk behaviors and sexually transmitted diseases (STDs); (2) providing, and referring for, behavioral risk-reduction interventions and related services; and (3) facilitating notification, counseling, and testing of infected persons' partners. This article summarizes key aspects of the recommendations for readers of this journal.
RISK SCREENING
Risk screening, a brief assessment of behavioral and clinical factors associated with transmission of HIV and other STDs, can be used to identify patients who should receive more in-depth risk assessment, HIV risk-reduction counseling, other risk-reduction interventions, or referral for other services (e.g., substance abuse treatment). Screening methods include asking patients about behaviors associated with transmission of HIV and other STDs, eliciting patient reports of symptoms of other STDs, and laboratory testing for other STDs.
Behavioral risk screening should address both sex-related and injection drugrelated behaviors. Screening can be done with brief, self-administered, written questionnaires; computer-, audio-, and video-assisted questionnaires; structured face-to-face interviews; and personalized discussions. Screening questions can be either open-ended or closed (directed). Open-ended questions avoid simple "yes" or "no" responses and encourage patients to discuss personal risks and the circumstances in which risks occur. Clinicians who receive training are more likely to perform effective behavioral risk screening. Screening for behavioral risks can be done by ancillary staff before the patient is seen by the clinician or by the clinician during the medical encounter. Provider reminder systems (e.g., computerized reminders) increase the likelihood that recommended screening is done regularly.
The presence of new STDs often suggests recent or ongoing sexual behaviors that may result in HIV transmission. Also, substantial evidence suggests that many STDs enhance risk for HIV transmission or acquisition; therefore, early detection and treatment of bacterial STDs may reduce risk for HIV transmission. Clinicians should routinely ask patients about STD symptoms; the presence of such symptoms should always prompt diagnostic testing and, when appropriate, treatment. However, clinical symptoms are not sensitive for identifying many infections, because most STDs are asymptomatic; therefore, laboratory screening (i.e., testing on the basis of risk estimation, regardless of clinical indications for testing) of HIV-infected persons is a cornerstone of identifying persons at risk for transmitting HIV and other STDs to others.
Women of childbearing age should be questioned during routine visits about the possibility of pregnancy. Women who suspect pregnancy or have missed their menses should be tested for pregnancy. Early pregnancy diagnosis would benefit even women not receiving antiretroviral treatment, because they could be offered treatment to decrease risk for perinatal HIV transmission.
BEHAVIORAL INTERVENTIONS
Behavioral interventions are strategies designed to change the knowledge, attitudes, behaviors, or practices of individuals to reduce their personal health risks or their risk of transmitting HIV to others. Behavioral change can be facilitated by environmental cues in the clinic or office, messages delivered to patients by clinicians or other qualified staff on-site, or referral to other persons or organizations providing prevention services.
Clinic or office environments can be structured to support prevention. All patients should receive printed information about HIV transmission risks and preventing transmission of HIV to others. Information can be conveyed throughout the clinic; for example, posters and other visual cues containing prevention messages can be displayed in examination rooms and waiting rooms. These materials usually can be obtained through health department HIV/AIDS and STD programs or from the National Prevention Information Network (NPIN) (telephone: 1-800-458-5231; Web site: http://www.cdcnpin.org).
All HIV-infected patients can benefit from brief prevention messages emphasizing the need for safer behaviors to protect their own health and that of their sex or needle-sharing partners. Such messages include discussion of the patient's responsibility for appropriate disclosure of HIV serostatus to sex and needle-sharing partners. These messages can be delivered by clinicians, nurses, social workers, case managers, or health educators. Many patients have inadequate information about factors influencing HIV transmission and methods for preventing transmission. They should understand that the most effective methods for preventing HIV transmission remain those that protect noninfected persons against exposure to HIV. For sexual transmission, the only certain means for HIV-infected persons to prevent transmission to noninfected persons are sexual abstinence or sex only with a partner known to be already infected with HIV. However, restricting sex to partners of the same serostatus does not protect against transmission of other STDs or the possibility of HIV superinfection unless condoms of latex, polyurethane, or other synthetic materials are consistently and correctly used. For injection-related transmission, the only certain means for HIV-infected persons to prevent transmission to noninfected persons are abstaining from injection drug use or refraining from sharing injection equipment (e.g., syringes, needles, cookers, cottons, and water).
Some sexual behaviors have a lower average per-act risk for transmission than others, and replacing a higher risk behavior with a relatively lower risk behavior may reduce the likelihood that HIV transmission will occur. However, risk for HIV transmission is affected by numerous biological and behavioral factors, and estimates of the absolute per-episode risk for transmission associated with different activities may be misleading when applied to a specific patient or situation. High viral load is an important risk factor for HIV transmission. By lowering viral load, antiretroviral therapy may reduce risk for HIV transmission. However, since HIV can be detected in the semen, rectal secretions, female genital secretions, and pharynx of HIV-infected patients with undetectable plasma viral loads, all patients receiving therapy, even those with undetectable plasma HIV levels, should understand that they may still be able to transmit HIV. Few data are available on efficacy of postexposure prophylaxis for nonoccupational exposure; thus, the potential availability of postexposure prophylaxis should not be used to justify risky behavior.
Interventions tailored to individual patients' risks can be delivered to patients at highest risk for transmitting HIV infection and for acquiring new STDs. This includes patients whose risk screening indicates current behaviors that may lead to transmission, who have a current or recent STD, or who mention issues of concern in discussions with the clinician. Any positive results of screening for behavioral risks or STDs should be addressed in more detail with the patient so a more thorough risk assessment can be done and an appropriate risk-reduction plan discussed and agreed upon. At a minimum, an appropriate referral should be made and the patient should be informed of risks involved in continuing the behavior. HIV-infected persons who remain sexually active should understand that the only certain means for preventing transmission to noninfected persons is to restrict sex to HIV-infected partners. For mutually consensual sex with persons of unknown or discordant serostatus, consistent and correct use of condoms made of latex, polyurethane, or other synthetic materials can significantly reduce risk for HIV transmission. HIV-infected patients who continue injection drug use should understand the risks of sharing needles and be provided information regarding substance abuse treatment and access to clean needles.
Prevention messages can be reinforced by subsequent longer or more intensive interventions in clinic or office environments by nurses, social workers, or health educators, if feasible. Many patients have underlying issues that impede adoption of safer behaviors, and achieving behavioral change is often dependent on addressing such issues. Clinicians will usually not have time or resources to fully address these issues, many of which can best be addressed through referrals for services such as intensive HIV prevention interventions (e.g., multisession risk-reduction counseling), medical services (e.g., family planning and contraceptive counseling, substance abuse treatment), mental health services (e.g., treatment for sexual compulsivity), and social services (e.g., housing, protection from domestic violence). Patients who have difficulty initiating or sustaining behaviors that reduce or prevent HIV transmission may benefit from prevention case management (PCM). PCM provides intensive, client-centered risk assessment; prevention counseling; and assistance accessing other services to address issues that affect patients' health and ability to change risk-taking behavior.
For IDUs, ceasing injection drug use is the only reliable way to eliminate risk for injection-associated HIV transmission; however, many IDUs are unable to sustain abstinence without substance abuse treatment. Early entry and maintenance in substance abuse treatment programs and sustained abstinence from injecting are important for reducing risk for HIV transmission from infected IDUs. Some IDUs are not able or willing to stop injecting drugs; for these persons, once-only use of sterile syringes can significantly reduce risk for injection-related HIV transmission. Information on access to sterile syringes and safe syringe disposal may be obtained through health departments or HIV/AIDS prevention programs.
Referrals that match the patient's self-identified priorities are more likely to be successful than those that do not. Discussion with the patient can identify factors that may make it difficult for the patient to complete the referral (e.g., lack of transportation). Patients need specific information to successfully access referral services and may need assistance (e.g., scheduling appointments) to complete referrals. When a clinician does not have the capacity to make all appropriate referrals, or when needs are complex, a case manager can help make referrals and coordinate care. Referral guides and other information usually can be obtained from health department HIV/AIDS prevention and care programs.
Clinicians can prepare to deliver HIV prevention messages and behavioral interventions by developing strategies for incorporating risk-reduction interventions into patients' clinic visits, obtaining training, becoming familiar with interventions that have demonstrated effectiveness and becoming familiar with community resources. Training on risk screening and prevention can be obtained at CDC-funded STD/HIV Prevention Training Centers (http://depts.washington.edu/nnptc) and HRSA-funded AIDS Education and Training Centers (http://www.aids-ed.org). Additional information related to behavioral interventions is available through many health department HIV/AIDS programs. A complete listing of state AIDS directors is available from the National Alliance of State and Territorial AIDS Directors (NASTAD) (http://www.nastad.org). Examples of case scenarios for prevention counseling are provided in tables.
PARTNER COUNSELING AND REFERRAL SERVICES, INCLUDING PARTNER NOTIFICATION
Many HIV-infected persons are not aware of their infection; thus, they cannot benefit from early medical care and do not know they may be transmitting HIV to others. Reaching such persons as early after infection as possible is important for their health and for reducing HIV transmission. Partner counseling and referral services (PCRS), including partner notification, are intended to address these problems by (1) providing services to HIV-infected persons and their sex and needle-sharing partners so the partners can take steps to avoid becoming infected or infecting others, and (2) helping infected partners gain earlier access to medical care and other services.
A key element of PCRS involves informing current and past partners that they have been exposed to HIV and advising them to have HIV counseling and testing. PCRS is confidential and voluntary. Partners can be reached and informed of their exposure by the infected person, clinicians in the private sector, or health department staff. Notification by the health department appears to be substantially more effective than notification by the infected person. Also, one observational study suggested health department specialists were more successful than physicians in interviewing patients and locating partners. Health departments have staff who are trained to do partner notification and skilled at providing this free, confidential service. These specialists can work closely with public and private sector clinicians who treat persons with HIV and other STDs. Most states and some cities or localities have laws and regulations related to informing partners they have been exposed to HIV. Clinicians should know and comply with such requirements. Additional information related to PCRS is available through health department HIV/AIDS programs.
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