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HIV Prevention in Clinical Practice

HIV infection is the ultimate preventable disease. Quite early in the epidemic, it was known that HIV was transmitted through sexual intercourse or injection of infected blood or from an infected mother to her fetus. Such knowledge constitutes an important armament against this lethal virus, but, sadly, it is not sufficient to protect people from HIV. Many personal, social, and medical problems in the world could be averted if individuals and societies were able to put this knowledge into action.

HIV is simultaneously a virus and a phenomenon. When it is viewed only as a virus, it is hard to see why HIV prevention is a problem at all. People normally want to avoid harming themselves and others. When viewed as a phenomenon, however, HIV points to the many personal and societal causes of disease transmission. It points to the difficulties people have in making their intentions match their behavior. It points to the inequalities in dyadic relationships, which help to spread HIV. It points to societies' reluctance to prepare young people to manage their intimate relations, to admit to sexual diversity, to responsibly manage complex health and social problems such as drug abuse, and to provide access to health care. It points to the world's failure to care about improving living conditions in poor countries.

Physicians are in a unique position to stop the spread of HIV. Patients want to hear about AIDS from their doctors. Most adults believe that physicians are useful and credible sources of information about AIDS. Despite this, a nationwide survey of patients revealed that only 15% had discussed AIDS with their physicians in the previous five years, although 94% had seen a physician during that time. Moreover, nearly three quarters of the discussions that took place were at the patients' urging.¹ Physicians can and must do more to stop the spread of HIV.

AIDS is Here to Stay

The past 18 years of the AIDS epidemic have taught us that HIV disease is here to stay. Even if HIV vaccines pass the rigors of clinical trials and become available for general use, they are unlikely to be 100% effective, provide sterilizing immunity, or reach 100% of the world's people, especially in the regions that need them the most. The disheartening news about the slow pace of developments in the search for a cure and a vaccine has prompted greater awareness that behavioral and social change and selected biomedical interventions (e.g., better case finding and treatment of sexually transmitted diseases, improved barrier methods, virucides) will be the primary tools of HIV prevention for the foreseeable future.^2,3

The rate of new HIV infections is increasing rapidly in the U.S. among young persons, ethnic minorities, and the urban poor. Male-to-male sex and injection drug use remain the most prominent transmission modes in this country.⁴ Heterosexual transmission is also on the rise in the U.S. (it has always been the major route of transmission in the developing world). These five chilling facts about the epidemiology of HIV transmission in the U.S. emphasize the need for better screening by clinicians

• AIDS is the leading cause of death among Americans aged 25 to 44 years.
  
• Half of new infections are in persons younger than 25 years and one fourth in persons younger than 22 years.
  
• Heterosexual transmission of HIV, especially from men to women, is increasing.
  
• HIV disease disproportionately affects the urban poor, especially members of ethnic minority groups.
  
• HIV remains a potent presence among the groups first affected by it: gay and bisexual men and injection drug users (IDUs).⁵
  

What Can Physicians Do?

Primary care physicians are crucial in the fight to stop new HIV infections. First, physicians should screen all patients for HIV risk. Half of all deaths occurring in the U.S. each year have behavioral causes -- accidents, tobacco, diet, lack of exercise, and unprotected sex. Clinicians have incorporated preventive counseling for the first four of these behaviors into their daily medical practice. For example, the overwhelming majority of primary care physicians "usually" or "always" ask their adult patients about cigarette smoking (94%) and alcohol use (84%). But physicians are more reticent when it comes to asking about unprotected sex and other HIV risk behaviors. In one study only 49% asked about the use of illicit drugs, 31% about condom use, 27% about sexual orientation, and 22% about the number of sexual partners.⁶ To guide physicians in the difficult task of helping patients change their behavior, Table 1 lists seven principles for HIV prevention in medical practice.

Screening for HIV risk need not be laborious or intensive. One-on-one AIDS prevention education is not necessary for every patient, since HIV risks are not spread evenly among the population. Instead, primary care physicians should focus on discovering which patients are at high risk and concentrate prevention efforts on them. A simple set of screening questions, such as those shown in Table 2, can identify most people in need of intensive HIV prevention efforts.⁷

HIV antibody testing should be encouraged for anyone who might be at risk for HIV infection and also for women who are pregnant or contemplating pregnancy. Individuals can receive testing anonymously or confidentially, along with professional pre- and post-test counseling.

Counseling for Safer Practices is Key

HIV prevention requires that the physician talk about sexuality and drugs in a nonjudgmental way, and this can be difficult. Individuals should be advised to reduce the number of their sexual partners and to use condoms (male or female) with sexual partners. HIV is most easily transmitted via needle sharing or unprotected vaginal or anal intercourse. Debates have raged recently about the safety of oral sex. The risk of transmission from oral sex is far less than that from anal or vaginal sex, but it is not zero. People should be taught that HIV transmission can and does take place through oral sex, especially when vaginal secretions or semen are taken into the mouth. Condoms are advised.

A pregnant HIV-infected woman should be advised about the latest recommendations for using antiretrovirals to prevent transmission to the fetus. The risk of passing the infection can be cut by over 60% with the appropriate treatment before, during, and after delivery.

Knowledge alone is rarely sufficient to motivate behavior change. People who persist in high-risk behavior do so for a variety of reasons. It is important that the physician attempt to understand why risky behaviors are continuing, in order to provide the best advice. It is the rare individual who deliberately infects others. The easiest way to discover why someone is engaging in unsafe practices is to ask the person about the circumstances surrounding the most recent risky act. The major reasons will most likely be intoxication, unavailability of condoms or clean needles, or lack of power in the relationship. Referral to agencies for help with these problems can go a long way in helping people overcome barriers to safety.

HIV-infected Individuals Need Targeted and Tailored Interventions

HIV prevention efforts have not targeted potentially infected individuals, who should be encouraged to undergo antibody testing and, if found to be infected, to assume personal responsibility not to spread HIV further. This state of affairs has its origins, at least in part, in a desire to minimize discrimination against and stigmatization of infected individuals. While 90% of gay Australian men know their antibody status, in the U.S. only 65% of gay men, 50% of intravenous drug users, and 30% of heterosexuals with multiple partners know their antibody status. Physicians should encourage antibody testing for anyone potentially exposed to HIV. Since infectivity in the primary infection period, before HIV antibodies develop, is estimated to be 50- to 2,000-fold greater than in the subsequent asymptomatic period, encouraging people to be tested as soon as possible after exposures could be especially effective in reducing the spread of new HIV infection.

Treating HIV infection is another important way to reduce transmission, since effective drug regimens can reduce levels of virus circulating in blood, vaginal secretions, or semen.

Physicians Should Advocate for Sound Prevention Practices in the Community

HIV prevention is one of the success stories of the decade. Although we still have 40,000 new infections in the U.S. every year, successful prevention strategies have been put in place. The goal is not to demand perfection but rather to move individuals to safer, if not completely safe, practices. Good prevention strategies explode the three major myths of HIV prevention: that condoms don't work, that early sex education increases promiscuity, and that providing clean syringes and needles to injection drug users increases drug use in the community. All three propositions are absolutely false.^3,8 A compendium of well-established and validated HIV prevention strategies and guidelines is available on the web at HIV InSite, at http://hivinsite.ucsf.edu/prevention.

We could cut the number of new infections in the U.S. in half tomorrow if proven prevention strategies were implemented without reservation. Compelling evidence has come from cities where the HIV prevalence among IDUs has remained very low (less than 5%), including Glasgow, Scotland; Lund, Sweden; Sydney, Australia; Toronto, Canada; and Tacoma, Washington, USA.⁹ These cities began HIV prevention programs early, made clean syringes available, and developed outreach programs for out-of-treatment IDUs. In other cities that did not implement strategies such as these, HIV prevalence among IDUs has reached 20% or more.

Australia and New Zealand provide good examples of sound HIV prevention policies and practices. Australia retarded the spread of HIV among IDUs and heterosexuals and decreased the spread of new infection transmitted through homosexual contact by aggressive and effective prevention efforts. In Australia the number of newly diagnosed infections occurring in homosexually active men decreased from a peak of 2,284 in 1987 to 772 in 1994. A marked decline in unsafe sexual practices among homosexually active men has also been documented. In both Australia and New Zealand, the potential epidemic among idus has been halted; there has been no increase in HIV and AIDS rates in the past five years among this risk group.

We could do the same in the United States. Physicians should work individually and through their medical societies to do what is right to prevent the spread of this terrible disease.

— Thomas J. Coates, PhD

Dr. Coates is Professor of Medicine and Epidemiology at the University of California, San Francisco (UCSF), and Director of the UCSF AIDS Research Institute and Center for AIDS Prevention Studies.

Published in Journal Watch HIV/AIDS Clinical Care January 1, 1999

Citation(s):

1. Gerbert B et al. Are patients talking to physicians about AIDS? Am J Public Health 1990 80 467-468.

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2. Stryker J et al. HIV prevention: Looking back, looking ahead. JAMA 1995 273 1143-1148.

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3. Coates TJ et al. HIV prevention in developed countries. Lancet 1996 348 1143-1148.

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4. Holmberg SD. The estimated prevalence and incidence of HIV in 96 large US metropolitan areas. Am J Public Health 1996 86 642-654.

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5. Centers for Disease Control and Prevention. First 500,000 cases -- United States, 1995. MMWR Morb Mortal Wkly Rep 1995 44 849-853.

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6. Centers for Disease Control and Prevention. HIV prevention practices of primary care physicians -- United States, 1992. MMWR Morb Mortal Wkly Rep 1994 42 988-992.

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7. Hearst N. AIDS risk assessment in primary care. J Am Board Fam Pract 1994 7 44-48.

8. Francis D and Chin J. The prevention of acquired immunodeficiency syndrome in the United States. JAMA 1987 257 1357-1366.

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9. Des Jarlais DC et al. Maintaining low HIV seroprevalence in populations of injecting drug users. JAMA 1995 274 1226-1231.

• Medline abstract (Free)