An important goal of initiating anti-retroviral therapy (ART) in HIV-infected individuals is to prevent transmission of the virus. And, indeed, there is good evidence that appropriate management reduces viral transmission, in part by reducing viral load in patients to, ideally, undetectable levels. In one international trial, heterosexual patients with CD4 counts of 350-550 cells/mm3 randomized to ART exhibited a relative reduction of 95% in the number of transmitted infections compared to the control group. The results were so impressive that the trial was halted early.1
But ART is just one component of a comprehensive approach required to reduce HIV transmission. Secondary approaches, which include behavioral, social, and educational efforts, are just as, if not more, important. The name for these approaches? Prevention with Positives (PwP).
The New York State Department of Health AIDS Institute highlights Prevention with Positives in its HIV Clinical Guidelines Program. Its key recommendations can grouped into three categories:
Education and counseling
♦ Provide information about the definition of “risky sexual activities,” and about sharing needles and safe sex practices.
♦ Refer patients to community-based programs where they can obtain clean needles/syringes and condoms, as well as to substance abuse management programs.
♦ Provide educational brochures, posters, and videos available in waiting areas and for distribution to patients.
♦ Identify HIV-infected women who want to become pregnant, then provide the appropriate counseling, prenatal care and ART to prevent mother-to-baby transmission
♦ Identify serodiscordant partners and recommend ART even if their CD4 is greater than 500 cells/mm3
♦ ART adherence
♦ Safe sexual practices; this can include providing free condoms in HIV clinics/offices.
♦ Substance abuse rehabilitation
♦ Partner testing, including onsite or easily accessible HIV testing for uninfected partners
♦ Prophylactic ART for uninfected partners who may been exposed to the virus
♦ Opportunities to ensure patients remain under medical care, which has been shown to reduce risky behaviors.2, 3
An underlying theme to all these approaches is communication. Yet many studies find that up to 75% of HIV clinicians do not ask their patients about sexual behavior or drug use, even though patients say they’d like to talk to their healthcare providers about preventing virus transmission.4 The best communication approaches combine motivational interviewing with open-ended, nonjudgmental questions. Here's some suggested language:4
♦ What do you know about HIV transmission?
♦ What, if anything, are you doing that could result in transmitting HIV to another person?
♦ Tell me about any sexual activity/needle sharing/drug or alcohol use since your last clinic visit.
♦ What do you know about the HIV status of each sex partner?
♦ Tell me about condom use during any sexual activity.
♦ What has made it more difficult for you to use condoms during this sexual encounter or with this partner?
♦ Do your sex practices differ with HIV-infected versus HIV-uninfected partners ("sexual positioning")?
Before you can proceed to implementing evidence-based approaches to reduce the risk of viral transmission, a critical part of caring for HIV patients is building a partnership so they trust you and feel comfortable talking with you about the risky behavior that may promote it.
1. Cohen MS, Chen YQ, McCauley M, et al. Prevention of HIV-1 infection with early antiretroviral therapy. N Engl J Med. 2011;365(6):493-505.
2. Metsch LR, Pereyra M, Messinger S, et al. HIV transmission risk behaviors among HIV-infected persons who are successfully linked to care. Clin Infect Dis. 2008;47(4):577-584.
3. Latkin CA, Forman-Hoffman VL, D'Souza G, et al. Associations between medical service use and HIV risk among HIV-positive drug users in Baltimore, MD. AIDS Care. 2004;16(7):901-908.
4. Preventing HIV Transmission/Prevention with Positives; Available at: http://aidsetc.org/aidsetc?page=cg-303_prevention_with_positives. January 2011.