Preventing HIV Transmission / Prevention with Positives

Background

Helping patients to reduce the risk of transmitting HIV to others is an important aspect of medical care for HIV-infected individuals. Most people with HIV infection want to prevent others from being infected with HIV, but they may practice sexual or injection drug behaviors that put others at risk of infection. Most HIV-infected patients also want to protect themselves from acquiring sexually transmitted diseases (STDs) or bloodborne infections. This chapter offers recommendations for discussing HIV transmission and prevention with HIV-infected patients, with the goal of reducing HIV transmission. This aspect of care is often referred to as "prevention with positives" (PWP).

Although antiretroviral therapy (ART) substantially reduces the risk of transmitting HIV infection, it is not fully effective. Additionally, only a minority of persons living with HIV infection in the United States is taking ART and a smaller proportion has maximal suppression of the HIV viral load. Thus, behavioral and other risk-reduction interventions remain important aspects of HIV prevention.

Taking responsibility for preventing HIV transmission is an important concern for most people with HIV, as well as for their health care providers. Multiple studies have shown that one third to three fourths of HIV medical providers do not ask their patients about sexual behavior or drug use. However, many HIV-infected individuals report that they want to discuss prevention with their health care providers. Each patient visit presents an opportunity to provide effective prevention interventions, even in busy clinical settings.

It is clear that information alone, especially on subjects such as sexual activity and drug use, cannot be expected to change patients' behavior. However, health care providers can help patients understand the transmission risk of certain types of behavior and help patients establish personal prevention strategies (sometimes based on a harm-reduction approach) for themselves and their partners. Some patients may have difficulty adhering to their safer sex goals. In these cases, referrals to mental health clinicians or other professional resources such as prevention case management may be helpful.

Patient-education needs are variable and must be customized. Providers must assess the individual patient's current level of knowledge as part of developing a prevention plan. All the information that a patient needs cannot be covered during a single visit. A patient's prevention strategy should be reinforced and refined at each visit with the clinician. Clinicians also should ask patients questions to determine life changes (e.g., a new relationship, a breakup, or loss of a job) that may affect the patient's sexual or substance use practices. If the patient can read well, printed material can be given to reinforce education in key areas, but it cannot replace a direct conversation with the clinician.

National Prevention Intervention Efforts

The U.S. Centers for Disease Control and Prevention (CDC) has developed a prevention approach called High-Impact Prevention that focuses on populations at greatest risk of acquiring or transmitting HIV, using proven, scalable, and cost-effective interventions. Proven interventions include:

• HIV testing and linkage to care
• ART
• Prevention programs for people living with HIV and their partners
• Prevention programs for people at high risk of HIV infection
• Access to condoms and sterile syringes
• Screening and treatment for sexually transmitted diseases (STDs)
• Substance abuse treatment

The CDC has identified a number of prevention interventions aimed at persons with HIV infection that meet criteria for efficacy and scientific rigor. These are conducted on individual, group, or community levels, and a number of them may be implemented in the treatment setting. A summary of these interventions can be accessed online at the CDC website. Training and educational materials for effective intervention models can be found on the CDC-supported Diffusion of Effective Behavioral Interventions (DEBI) website.

The U.S. Preventive Services Task Force (USPSTF) has recommended high-intensity behavioral counseling to prevent STDs (including HIV) in persons at risk of these infections; these approaches also are being used in persons with HIV infection to reduce their risk of transmitting HIV. Effective high-intensity behavioral counseling typically comprises multiple sessions with either groups or individuals. Examples of these are included amongst the models presented on the CDC and DEBI websites.

Techniques for Brief, Effective Interventions by Providers

A number of strategies have been shown to be more effective than providing information alone. Effective and brief provider-initiated interventions include the following elements:

• Establish rapport and provide services in an understanding, nonjudgmental manner. Patient educators, nurses, peer counselors, social workers, and mental health providers may be effective in discussing prevention strategies with patients.
• Conduct a quick, detailed behavioral risk assessment:
  • See the key areas of risk assessment and intervention listed in Table 1, below.
  • Assess where the patient's risk behavior lies along the risk continuum (described in chapter Smoking Cessation).
  • Correct misinformation and answer questions.
  • Assess the patient's readiness for behavior change (see "Stages of Change model," below).
  • Screen for and treat STDs: a positive STD test can be a biologic marker of behavioral risk, and STDs may facilitate HIV transmission (see chapter Initial and Interim Laboratory and Other Tests).
  • Supply medications, condoms, and lubricant as needed.
• Assess the patient's readiness for change and approach any high-risk behavior in a step-wise manner, recognizing when the patient is ready for next steps. Such interventions may be carried out for 5-10 minutes per visit over a series of visits. The "Stages of Change" model and appropriate strategies include the following:
  • Precontemplation: The patient is not ready to change; reassess at subsequent visits.
  • Contemplation: The patient is considering a change in the future; discuss and help the patient to identify concrete next steps, such as a date for initiating change.
  • Preparation: The patient is ready to change soon; discuss a concrete action plan and connect the patient with appropriate resources as needed.
  • Action: The patient is actively engaged in changing behavior; continue to discuss and address challenges; offer encouragement.
  • Maintenance: The patient has made behavioral changes; continue to discuss and address challenges, offer encouragement and congratulations.
  • (Relapse): The patient has relapsed to previous risky behaviors; recognize the triggers and difficulties the patient had with maintenance and offer support and encouragement to try again when the patient is ready.
• Customize messages, as each individual patient's needs are variable.
• Understand that patients often have competing priorities and pressures involving mental health needs, relationships, finances, housing, employment, and other issues that may result in risky sexual and drug-use behaviors.

Summary of Prevention with Positives: Key Areas of Intervention

More detailed discussions of topics follow this table.

Sexual Transmission and Prevention of HIV

Begin the education process by learning what the patient and his or her immediate family members (if the family is aware of the patient's HIV status) believe about HIV transmission. Also be sure the patient understands how the virus is not transmitted (e.g., via sharing plates and eating utensils or using the same bathrooms) to allay any unnecessary fear.

Advise the patient not to share toothbrushes, razors, douche equipment, or sex toys to avoid transmitting HIV via blood or sexual secretions. This also will help prevent the transmission of other bloodborne or sexually transmitted infections, including hepatitis C, from coinfected patients. The patient should not donate blood, plasma, tissue, organs, or semen because these can transmit HIV to the recipient.

There is no reason why a person with HIV cannot have an active, fulfilling, and intimate sex life. However, the patient must be counseled properly about the risk of transmission. This discussion between the provider and patient should be client centered. This means that the provider should let the patient guide the discussion, starting from the patient's current point of knowledge and practice, always addressing any presenting concerns the patient may have prior to proceeding with a discussion about sexual transmission and risk. The provider should ask open-end questions, in a nonjudgmental manner, to elicit information about the patient's relationships, sexual behaviors, and current means of reducing transmission risk.

It is important to recognize that not every patient seeks the complete elimination of risk (e.g., via abstinence) but rather a reduction in risk, chosen after the options are discussed with the provider. The clinician may help the patient select and practice behaviors that are likely to be less risky. There are many methods for reducing risk, including the following:

• Disclosing HIV status
• Reducing the number of sex partners
• Maintaining maximal suppression of HIV through ART
• Using condoms, particularly for anal or vaginal intercourse (insertive or receptive)
• Having sex only with other HIV-infected partners (serosorting)
• Avoiding drug use in conjunction with sex
• Using adequate lubrication to avoid trauma to genital or rectal mucosa

If the patient requires more extensive counseling to support behavioral changes, the provider should refer the patient to support groups or prevention case management to meet those needs. Certainly, if the patient is dealing with a dual or triple diagnosis (including substance abuse or mental illness), a referral to address those needs is indicated.

Partner Notification

A good way to begin a discussion about HIV prevention and transmission is with an inquiry about any previous experiences disclosing to partners. The provider then can ask whether the patient currently has a need to disclose to one or more partners and whether he or she is ready and motivated to share information about HIV status. The provider should prompt patients to consider several questions about disclosure, including how they might approach the discussion, how their partners might react, what information they might offer their partners, whether partners are likely to keep their status confidential, and whether they have any concerns about personal safety (e.g., owing to fear of a violent reaction). If patients fear violence or retaliation or are not ready to share their status but want their partners to know, the provider may offer assistance with partner notification, for example through the local health department, in a confidential manner. As an alternative, patients may want the provider to talk with their partners, and that option can be offered as well. See the U.S. Department of Veterans Affairs HIV website for a patient-oriented discussion of partner notification.

Antiretrovirial Therapy

ART that results in maximal HIV suppression is an important means of HIV prevention. In serodiscordant heterosexual couples, ART has been shown to reduce the risk of sexual transmission of HIV by 96%. Similar randomized controlled study data for MSM, injection drug users, and other HIV risk groups do not exist, but multiple other lines of evidence suggest that effective ART sharply reduces risk of HIV transmission. Thus, ART should be offered to all HIV-infected persons, both to benefit their own health and to reduce risk of HIV transmission to others. Current DHHS guidelines recommend ART for persons who are at risk of transmitting HIV to sex partners.

Discuss the importance of ART both as a health benefit for the individual patient and as a means of protecting partners who may be at risk of HIV infection. Offer ART as indicated and support adherence in order to optimize the effectiveness of ART as both treatment and prevention.

Note that ART does not eliminate HIV transmission risk. In some individuals, there can be substantial discrepancies between HIV RNA levels in the serum and the sexual fluids. There have been case reports of HIV transmission from HIV-infected individuals who had maximal virologic suppression on ART.

Helping Patients Reduce the Risk of Sexual Transmission

Standard Condom Use

Make sure that the patient understands how HIV is transmitted and which types of sexual acts are more and less risky than others. For vaginal or anal sex, correct use of latex or polyurethane condoms reduces the risk of HIV transmission considerably. Patients should be encouraged to use condoms as much as possible. For HIV-infected individuals, condom use is effective in reducing the risk of contracting another illness (such as hepatitis C or another STD) and the (apparently low) risk of becoming reinfected with another strain of HIV. It should be noted that condoms are less effective in reducing the transmission of organisms such as human papillomavirus (HPV) and HSV, which may result from viral shedding from skin. In the event of allergy to latex or other difficulty with latex condoms, polyurethane male or female condoms may be substituted. "Natural skin or "lambskin" condoms are not recommended for HIV prevention.

Of course, condoms must be used correctly to be highly effective in preventing HIV transmission. Be sure that the patient knows exactly how to use a condom. Table 2 provides instructions for condom use.

Advise patients to avoid using nonoxynol-9 (N-9) spermicides. Data suggest that N-9 may increase risk of HIV transmission during vaginal intercourse and can damage the rectal lining. N-9 never should be used for anal intercourse.

For patients who complain about lack of sensitivity with condom use, the following techniques may help:

• Apply a drop of lubricant inside the condom (not more, because it increases the risk that the condom will come off).
• Use polyurethane condoms instead of latex because they conduct heat and may feel more natural.
• Use insertive (female) condoms, which are not as restrictive to the penis.
• Use specially designed condoms that do not restrict the top of the penis (e.g., Inspiral, Xtra Pleasure).

For patients who are unable or unwilling to use condoms, the following suggestions may help reduce HIV transmission risk:

• Use plenty of lubricant to reduce friction and microtrauma, which create portals of entry for the virus.
• Avoid spermicides that damage the vaginal or anorectal linings.
• Avoid douching products.
• Avoid recreational drugs, especially methamphetamine, that impair the ability to maintain "safer" sexual behaviors.
• Avoid the use of drugs such as nitrates (poppers) that enhance blood flow to the genitals.

Insertive (Female) Condom Use

The insertive "female" condom may be used for vaginal or anal intercourse. It is a thin polyurethane pouch with a flexible ring at the opening, and another unattached flexible ring that sits inside the pouch to keep it in position in the vagina (for use in the anus, the inner ring must be removed and discarded). The female condom may be an option for women whose male partners will not use male condoms or for couples who do not like standard condoms. Female condoms are more expensive than male condoms, but may be procured at a lower cost at some health departments or Planned Parenthood clinics. They generally are less well known to patients and may be unacceptable to some women whose culture or religion prohibits or discourages touching one's own genitals. Note that the female condom cannot be used at the same time as a male condom.

Be sure the patient knows how to use the insertive condom before she or he needs it; after teaching, encourage practice when alone at home and unhurried. Women who have used the diaphragm, cervical cap, or contraceptive sponge may find it easy to use the female condom. Illustrated directions are included in each box of insertive condoms. Instructions on the use of insertive condoms are provided in Table 3.

Oral Sex

Although there is evidence that some people have become infected through receptive oral sex, the risk of HIV transmission via oral sex, in general, is much lower than the risk of transmission by vaginal or anal sex. Thus, most public health and prevention specialists focus their attention on riskier sexual and drug-use behaviors. However, because HIV transmission can occur with oral sex, clinicians should address this issue with patients and help them make informed decisions about risk reduction. Sores or lesions in or around the mouth or on the genitals may increase the risk of HIV transmission, as may a concurrent STD. Patients (and their partners) should avoid oral-genital contact if they have these conditions. Similarly, patients and partners can further reduce risk by not brushing or flossing teeth before oral sex. Individuals who wish to further reduce the risk of HIV transmission during oral sex may use barriers such as condoms, dental dams, and flexible plastic kitchen wrap.

Individuals who smoke crack cocaine often develop open burns, cracked lips, or damaged mucous membranes inside the mouth and thus may be at elevated risk of HIV transmission via oral sex. HIV-infected crack users should be counseled about the risk of transmitting HIV to uninfected partners through those portals of entry during oral sex and should receive risk-reduction counseling. In addition, they (or their partners) may benefit from techniques such as insulating the end of the crack pipe to reduce burns while smoking (e.g., with a rubber band or spark plug cap) and avoiding the brittle or sharp-edged copper scrubbing pads used as screens in the crack pipe.

Influence of Substance Use on Sexual Behavior

Alcohol and drug use can contribute significantly to the risk of sexual transmission of HIV, because of behavioral disinhibition. While intoxicated, substance users may, for example, forgo condom use, practice riskier sexual behaviors, have multiple partners, or use erectile dysfunction agents to sustain sexual activity. Addressing substance use issues is an important aspect of PWP. Patients should be assessed for HIV transmission risks associated with alcohol and injection or noninjection drug use, including crystal methamphetamine, in the context of their sexual behaviors (for injection drug use, see below). As always, it is important to approach the patient in a nonjudgmental manner. If alcohol or other drugs are posing barriers to practicing safer behaviors, the provider should counsel the patient to reduce or avoid substance use before engaging in sex, or refer the patient to prevention case management for more specialized risk reduction. Often, the provider can help the patient identify methods for reducing HIV transmission risk, including means that do not require abstaining from alcohol and drug use.

Injection Drug Use and Prevention of HIV

Clinicians should discuss substance use, including steroid use, and reinforce the patient's understanding of the adverse effects that these drugs can have on the body and the immune system. Assess whether referral for treatment is appropriate, and be knowledgeable about referral resources and mechanisms. If the patient is using injection drugs, emphasize the fact that HIV is readily transmitted by sharing needles and other injection equipment and that reusing or sharing needles and syringes can cause additional infections (e.g., endocarditis, hepatitis C). Assess the patient's readiness to change his or her drug injection practices, and refer to drug treatment programs as appropriate. Refer to an addiction counselor for motivational interviewing or other interventions, if available. After completion of substance abuse treatment, relapse prevention programs and ongoing support will be needed. If the patient continues to use needles, discuss safer needle-use practices (Table 1) and refer to a needle-exchange program, if one is available, so that syringes and needles are not reused. A partial listing of needle exchange sites may be found on the North American Syringe Exchange Network website, although many states either do not have facilities or are prohibited from listing them. Local harm-reduction activists may be aware of specific programs for obtaining clean needles and syringes. Patient-education flyers on safer injection practices, safer stimulant use, overdose prevention, and other topics are available on the Midwest AIDS Education and Training Center website.

Noninjection Drug Use and Prevention of HIV Transmission

Exposure to HIV through contaminated blood may occur with the use of noninjection drugs; for example, by sharing cocaine straws or sniffers through which cocaine is inhaled. These straws easily can penetrate fragile nasal mucosa and become contaminated with blood from one user before being used by another individual, who may then experience mucous membrane exposure or even a cut or break in the mucous membrane from the bloody object. Straws or sniffers should not be shared.

Tattoo, Piercing, and Acupuncture Equipment

Patients should be aware of the risk of contamination of tattoo equipment, inks, and piercing equipment, and they should avoid situations wherein they might either transmit HIV or pick up other bloodborne pathogens. Acupuncturists generally use sterile needles, but clients should verify that before using their services.

Perinatal HIV Transmission

HIV-infected women can have healthy pregnancies, with good health outcomes for both mother and baby. For this to occur, women must know their HIV status as early as possible, preferably before becoming pregnant, and must receive effective ART. Although intervention to reduce the risk of perinatal infection is most effective if begun early in pregnancy, or preferably before pregnancy, it may be beneficial at any point in the pregnancy, even as late as during labor. For further information, see chapter Reducing Perinatal HIV Transmission.

Preexposure Prophylaxis (PrEP)

Preexposure prophylaxis (PrEP) refers to the use of oral or topical ARVs before HIV exposure with the goal of preventing HIV infection. Recent studies have evaluated PrEP strategies using oral tenofovir + emtricitabine (Truvada), oral tenofovir, and vaginal tenofovir to prevent sexual acquisition of HIV in high-risk women and men who have sex with men (MSM). Several have shown efficacy (ranging from about 40% to 75%) in reducing infection risk, but two others have not demonstrated protective benefit. The effectiveness of PrEP appears to be strongly related to the study participants' adherence to the PrEP medication, but other factors that explain the divergent findings of these studies have yet to be elucidated. It should be noted that, in these PrEP studies, the ARV prophylaxis was given in conjunction with other risk-reduction interventions, including counseling, condom provision, and STD testing and treatment. Further studies of the efficacy and safety of various types of PrEP in different populations are under way. The CDC has issued interim guidelines on the use of oral tenofovir-emtricitabine as PrEP in MSM (see "References," below); until more data are available, alternative approaches to PrEP should not be undertaken.

Postexposure Prophylaxis for Nonoccupational HIV Exposure

Postexposure prophylaxis (PEP) may be considered for certain sexual exposures, sexual assaults, and other nonoccupational exposures to HIV. As with occupational PEP, a risk assessment must be completed and ART, if indicated, must be started as soon after exposure as possible. The risks and toxicities of antiretroviral drugs must be weighed against potential benefits, and the client's informed consent must be obtained. For further information, see chapter Nonoccupational Postexposure Prophylaxis.

References

• Centers for Disease Control and Prevention. 2009 Compendium of Evidence-Based HIV Prevention Interventions. Atlanta: Center for Disease Control and Prevention; 2009.
• Centers for Disease Control and Prevention. High-Impact HIV Prevention: CDC's Approach to Reducing HIV Infections in the United States. Atlanta: U.S. Centers for Disease Control and Prevention; August 2011.
• Centers for Disease Control and Prevention. Interim Guidance: Preexposure Prophylaxis for the Prevention of HIV Infection in Men Who Have Sex with Men. MMWR Recomm Rep. 2011 Jan 28;60(RR-3):65-69.
• Centers for Disease Control and Prevention. Sexually Transmitted Diseases Treatment Guidelines, 2010. MMWR 2010 Dec 17; 59 (No. RR-12):1-110.
• Cohen MS, Chen YQ, McCauley M, et al.; HPTN 052 Study Team. Prevention of HIV-1 infection with early antiretroviral therapy. N Engl J Med. 2011 Aug 11;365(6):493-505.
• Richardson JL, Milam J, McCutchan A, et al. Effect of brief safer-sex counseling by medical providers to HIV-1 seropositive patients: a multi-clinic assessment. AIDS. 2004 May 21;18(8):1179-86.
• U.S. Department of Health and Human Services, Health Resources and Services Administration. A Guide to Primary Care for People with HIV/AIDS, 2004 Edition. Washington: U.S. Department of Health and Human Services; 2004.
• U.S. Department of Health and Human Services. Guidelines for the Use of Antiretroviral Agents in HIV-1-Infected Adults and Adolescents. March 27, 2012.
• U.S. Department of Veterans Affairs. Prevention for Positives. In: Primary Care of Veterans with HIV. April 2009.