HIV prevention enters a new era

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Practice Alert

HIV prevention enters a new era

J Fam Pract. 2004 July;53(7):563-565

By

Doug Campos-Outcalt, MD, MPA

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References

1. Centers for Disease Control and Prevention (CDC). National Center for HIV, STD, and TB Prevention. Advancing HIV prevention: the science behind the new initiative. Available at: www.cdc.gov/hiv/partners/ahp_science.htm.

2. Hays RB, Paul J, Ekstrand M, Kegeles SM, et al. Actual versus perceived HIV status, sexual behaviors and predictors of unprotected sex among young gay and bisexual men who identify as HIV-negative, HIV-positive and untested. AIDS 1997;11:1495-1502.

3. CDC. Primary and secondary syphilis among men who have sex with men – New York City, 2001. MMWR Morb Mortal Wkly Rep 2002;51:853-856.

4. CDC. Resurgent bacterial sexually transmitted disease among men who have sex with men—King County, Washington, 1997–1999. MMWR Morb Mortal Wkly Rep 1999;48:773-777.

5. Institute of Medicine No Time to Lose: Getting More from HIV Prevention. Committee on HIV Prevention Strategies in the United States, Division of Health Promotion and Disease Prevention. Washington, DC: National Academies Press; 2001.

6. CDC. Cases of HIV infection and AIDS in the United States, 2002. HIV/AIDS Surveillance Report 2002;14:1-58.Available at: www.cdc.gov/hiv/stats/hasr1402.htm.

7. Kamb ML, Fishbein M, Douglas JM, et al. efficacy of risk reduction counseling to prevent human immunodeficiency virus and sexually transmitted diseases: A randomized controlled trial. JAMA 1998;280:1161-1167.

8. Wenger NS, Kussling FS, Beck K, Shapiro MF. Sexual behavior of individuals infected with the human immunodeficiency virus: The need for intervention. Arch Int Med 1994;154:1849-1854.

9. Kilmarx PH, Hamers FF, Peterman TA. Living with HIV. Experiences and perspectives of HIV-infected sexually transmitted disease clinic patients after posttest counseling. Sex Transm Dis 1998;25:28-37.

10. Higgins DL, Galavotti C, O’Reilly KE, et al. Evidence for the effects of HIV antibody counseling and testing on risk behaviors. JAMA 1991;266:2419-2429

11. Weinhardt LS, Carey MP, Johnson BT, Bickham NL. Effects of HIV counseling and testing on sexual risk behavior: a meta-analytic review of published research, 1985–1997. Am J Public Health 1999;89:1397-1405.

12. Kamb ML, Fishbein M, Douglas JM, et al. Efficacy of risk-reduction counseling to prevent human immunodeficiency virus and sexually transmitted diseases. JAMA 1998;280:1161-1167.

13. Walensky RP, Losina E, Steger-Craven KA, Freedberg KA. Identifying undiagnosed human immunodeficiency virus: the yield of routine, voluntary inpatient testing. Arch Intern Med 2002;162:887-892.

14. CDC. Revised recommendations for HIV screening of pregnant women. MMWR Recomm Rep 2001;50(RR-19):59-86.

15. CDC. Notice to readers: Approval of a new rapid test for HIV antibody. MMWR Morn Mortal Wkly Rep 2002;51:1051-1052.

The Centers for Disease Control and Prevention (CDC) estimates 40,000 new HIV infections occur annually in the US, and this may be increasing. Close to 1 million people in this country are living with HIV, and an estimated one quarter of them do not know they are infected.¹ Thus, the infection often is detected late; 40% of those infected find out about it <1 year before AIDS develops. The result of delayed detection, or failed detection, is a large group of infected persons who unknowingly expose others to the disease for a prolonged period.²

Alarming trends

Recent epidemiologic trends indicate our preventive efforts are inadequate. Risky behavior is increasing among certain subpopulations of men who have sex with men.^3,4 In the US, 300 babies a year are born with HIV infection, despite effective interventions to prevent mother-to-baby transmission, largely because infection in the mother is not detected during pregnancy.¹ Needle exchange for IV drug users, a proven effective intervention, remains underused because of political objections.⁵

While the HIV epidemic in the US remains driven by infections in men who have sex with men and those who use illicit intravenous drugs, the number of heterosexually transmitted infections has increased each year and was estimated at 9183 new infections in 2002; 3234 among men and 5949 among women. In addition, the disease has become a major cause of health disparity in this country. Comparative AIDS rates per 100,000 in 2002 were 5.9 for whites, 8.5 for American Indians/Native Americans, 19.2 for Hispanics and 58.7 for African Americans.⁶

Effective treatments warrant more effective detection

On the other hand, the use of highly active anti-retroviral therapy has been very successful in altering the course of the disease in those infected, lowering death rates dramatically. The result has been an increasing number of people living with HIV/AIDS. While treatment lowers viral loads and presumably makes one less infectious, the overall community effect of an increasing number of infected persons still able to transmit the virus to others could be negative unless education is effective in reducing behavior that places others at risk.

Change is needed

All of these trends have created a need to reexamine HIV prevention efforts. The main HIV prevention interventions used in the US for 2 decades have included screening donated blood; screening pregnant women and administering antiretroviral agents to HIV-positive mothers during pregnancy and to their newborns; needle exchange programs (in a few locations); community-wide and risk-group specific education; and confidential or anonymous HIV counseling and testing programs.

Counseling and testing programs have used extensive pretest and posttest counseling sessions in an attempt to keep those who are HIV negative from contracting the disease. However, studies have shown that counseling and testing do not significantly alter sexual behavior among those who are HIV negative; they are effective for those who are HIV positive.^7-11 Counseling of those who are HIV negative can be more effective if patient centered methods are used.¹²

CDC’S new initiative

The CDC has recently reviewed its HIV prevention efforts and initiated a new campaign called Advancing HIV Prevention (AHP). This initiative has 4 components:

Make HIV testing a routine part of medical care whenever and wherever patients go for care.
Use new models for diagnosing HIV infections outside traditional medical settings.
Prevent new infections by working with people diagnosed with HIV and their partners.
Decrease mother-to-child HIV transmission.

Potential benefits of increased testing include earlier detection and entry of infected persons into treatment, earlier notification and testing of contacts, shorter periods during which infected persons unknowingly transmit the infection to others, and reduced stigma of testing as it becomes routine. However, this strategy will be effective only if those who are HIV positive can receive medical care and social support and be convinced to avoid exposing others. Fortunately, the evidence is good that intensive counseling and case management can achieve these goals.^8-11 Another potential benefit is earlier notification of contacts, either by the patient or the public health department, depending on local public health practice.

Testing during pregnancy is well accepted and widely used but is still not universally implemented. Voluntary testing is more acceptable if implemented as a routine test with a choice to opt out—ie, informing women that the HIV test is being offered as part of routine testing and that they have the option of refusing it. Selective testing based on perceived risk misses cases and contributes to stigmatization of those tested.¹³ The CDC recommends that women who refuse testing should be counseled on the potential benefits of HIV testing to them and to their babies; and that providers should recommend the test while, preserving the mother’s right to refuse should she decide the test is not in her best interest.¹⁴