HIV Prevention and Transmission
Despite substantial advances in the treatment of human immunodeficiency virusHIV AIDS infection, the estimated number of annual new HIV infections in the United States has remained at 40,000 for over 10 years. HIV prevention in this country has largely focused on persons who are not HIV infected, to help them avoid becoming infected. However, further reduction of HIV transmission will require new strategies, including increased emphasis on preventing transmission by HIV-infected persons. HIV-infected persons who are aware of their HIV infection tend to reduce behaviors that might transmit HIV to others. Nonetheless, recent reports suggest that such behavioral changes often are not maintained and that a substantial number of HIV-infected persons continue to engage in behaviors that place others at risk for HIV infection.
Reverting to risky behavior can be as important in the transmission of HIV as the orignal failure to adopt safer sex practices. Unprotected anal sex appears to be occurring more frequently in some urban centers, particularly among young men who have sex with men (MSM). Viral and bacterial STDs in HIV infected patients receiving care has been noticed more frequently, indicating ongoing risky behaviors. Further, despite declining syphilis prevalence in the general U.S. population, sustained outbreaks of syphilis among MSM, many of whom are HIV infected, continue to occur in some areas; rates of gonorrhea and chlamydial infection have also risen for this population. Increased STD rates amoung MSM show increased potential for HIV transmission, both these rates suggest ongoing risky sexual behavior, and because STDs increases HIV’s infectivity and susceptibility. Studies suggest that optimism about the effectiveness of highly active antiretroviral therapy (HAART) for HIV may be contributing to relaxed attitudes toward safer sex practices and increased sexual risk-taking by some HIV-infected persons.
Injection drug use also continues to play a key role in the HIV epidemic; at least 28% of AIDS cases among adults and adolescents with known HIV risk category reported to CDC in 2000 were associated with injection drug use. In some large drug-using communities, HIV seroincidence and seroprevalence among injection drug users (IDUs) have declined in recent years. The decline has been a result of several things, including a increased use of sterile needles, lower rates of needle sharing, shifts from injection to noninjection methods of using drugs, and the cessation of drug use. Injection drug use amoung heroin users has helped to increase HIV infection substantially in some areas, serving as a reminder that avoiding all high risk behavior is important.
Doctors and Clinicians caring for HIV-infected persons can help play a key role in help their patients reduce their risk factors. Caregivers can make a big difference to affect patients’ risk factors for transmission of HIV to other people by performing brief tests for HIV transmission risk factors; communicating safe practices; talking about sexual and drug use behavior and positively reinfocing changes to safer behavior. These measures may also decrease patients’ risks of acquiring other STDs and bloodborne infections (e.g., hepatitis). Managed care plans can play an important role in HIV prevention by incorporating these recommendations into their practice guidelines, educating their providers and enrollees, and providing condoms and educational materials. In the context of care, prevention services might be delivered in clinic or office environments or through referral to community-based programs. Some clinicians have expressed concern that reimbursement is often not provided for prevention services and note that improving reimbursement for such services might enhance the adoption and implementation of these guidelines.