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How to Integrate Prevention into Clinical Practice

New recommendations provide useful information on how to incorporate HIV and STD prevention into the everyday clinical care of HIV-infected individuals: a key strategy of the CDC's revised prevention plan.

For the first twenty years of the epidemic, HIV prevention efforts focused almost exclusively on encouraging safer sexual and drug-use practices among at-risk HIV-seronegative populations. However, the epidemic in the U.S. has changed significantly. Fueled by the success of antiretroviral therapy, HIV-infected people are living longer, healthier lives, allowing them to pursue normal life activities, including sex. A variety of recent data indicate that there has been an upsurge in high-risk sexual and drug-using behaviors in certain populations, including people who know that they are HIV-infected, are in care, and are receiving antiretroviral therapy. Among men who have sex with men, the increase in high-risk sexual behavior has been accompanied by an increase in rectal gonorrhea and early syphilis rates and recent evidence suggests that HIV incidence might also be on the rise. More limited data are available in other at-risk populations, several studies have documented increasing incidences of antiretroviral resistance among newly infected treatment-naive individuals, the result of continuing risk behaviors, and HIV transmission from seropositive individuals who are in care and receiving treatment.

Thus, the new strategy for HIV prevention recently unveiled by the CDC (see MMWR 2003 April 18 and ACC Research Notes June 2003) focuses HIV prevention efforts in seropositive individuals and includes programs specifically designed to (a) increase the number of HIV-infected people who are aware of their serostatus and are in care and (b) to reduce risk behavior among HIV-diagnosed individuals and their partners. An important component of the latter strategy is the incorporation of HIV prevention counseling into the routine medical care of HIV-infected individuals. These recommendations, endorsed by the CDC, Health Resources and Services Administration, NIH, and the IDSA, are designed to aid clinicians in this new role we are being asked to perform by reviewing the rationale for integrating prevention counseling into HIV clinical practice and by ranking various prevention strategies based on the strength of the available scientific evidence.

There are compelling clinical and public health reasons for incorporating sexual and drug-use risk-reduction programs among HIV-infected individuals into clinical practice: First, recent evidence suggests that high-risk sexual behavior remains prevalent among HIV-infected individuals, with as many as a third of such individuals aware of their serostatus, but continuing to practice unprotected anal or vaginal intercourse. Second, a high prevalence of other sexually transmitted diseases (STDs) has been documented among HIV-infected individuals. Third, high-risk behavior in already-infected individuals puts these patients at risk for re-exposure to HIV and "superinfection" with a second, potentially drug-resistant, virus. Superinfection, regardless of resistance profile, has been associated with poor clinical outcome in case studies. Finally, high-risk behavior among HIV-infected individuals who are in care and on antiretroviral treatment increases the incidence of drug resistance. These recommendations identify 3 key activities for clinicians:

• Risk screening: Regularly screen for HIV and STD transmission risk behaviors and regularly screen for new STDs through laboratory testing.
  
• Behavioral interventions: Provide general and tailored risk-reduction messages to support and enhance prevention to patients on site and, when indicated, refer patients for additional risk-reduction services and other services that help to reduce HIV transmission risk (e.g., substance abuse treatment).
  
• Notification, counseling, and referral of partners: Ensure that patients are provided with the necessary support for disclosure of serostatus and that their partners receive the necessary referrals.
  

For seropositive individuals, the clinic or physician may present the only opportunity that they will have to receive information about prevention of HIV transmission. Because behavior change often occurs in incremental steps, these recommendations suggest that providers conduct brief behavioral interventions at each clinic visit. The hope is that, over time, such interventions may result in adoption and maintenance of safer sex, safer drug-use practices, or both. The trusting relationship that develops between many patients and their clinicians and the repeated encounters that characterize HIV care provides a special opportunity to integrate prevention into the clinical care setting. Although it remains unknown which intervention strategies are optimal, the recommendations do model useful approaches through sample questions and a series of case vignettes. The recommendations stipulate that all new patients should be provided with printed information about what constitutes HIV-risk behavior, how to prevent transmitting HIV to others, and how to prevent acquisition of new STDs. In addition, free condoms should be readily accessible in the clinic. Finally, prevention messages and strategies should become part of the long-term patient treatment plan.

The overall prevention message we should give our HIV-infected patients is clear: They must practice safe sex and other risk-reduction measures to protect themselves and others from new infections. The recommendations touch on medication adherence only briefly, but it can be argued this issue is closely linked with prevention. Medication adherence reduces the overall risk for transmission and especially the risk for transmission of resistant virus: It is good for the health of the patient and that of the public. Moreover, adherence, like prevention, is a matter on which the HIV clinician struggles to counsel patients on an ongoing basis. Finally, additional work is needed to define optimal strategies for delivering adherence and risk-reduction counseling in the HIV clinic. Meanwhile, these recommendations should aid clinicians in meeting this new, critical mandate. The CDC is sponsoring a webcast to discuss these recommendations on November 15, 2003; information is available at: http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5232a7.htm.

— Carlos del Rio, MD, and Gerald H. Friedland, MD

Dr. del Rio is an Associate Editor of ACC. Dr. Friedland is Consulting Editor of ACC.

Published in AIDS Clinical Care October 1, 2003

Citation(s):

Incorporating HIV Prevention into the Medical Care of Persons Living with HIV. Recommendations of CDC, the Health Resources and Services Administration, the National Institutes of Health, and the HIV Medicine Association of the Infectious Diseases Society of America. MMWR Rec Rep 2003 Jul 18; 52 (RR-12):1-24.

HIV Prevention strategic plan through 2005. CDC 2000 (http://www.cdc.gov/nchstp/od/hiv_plan/default.htm).

DiClemente RJ et al. Prevention interventions for HIV positive individuals. Sex Transm Infect 2002 Dec; 78:393-5.

• Original article (Subscription may be required)
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Auerbach J et al. The place of prevention in HIV clinical care: A roundtable discussion. AIDS Clin Care 2002 Jun; 14:49-58.

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Scheer S et al. Effect of highly active antiretroviral therapy on diagnoses of sexually transmitted diseases in people with AIDS. Lancet 2001 Feb; 357:432-435.

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Schreibman T and Friedland G. Human immunodeficiency virus infection prevention: Strategies for clinicians. Clin Infect Dis 2003 May 1; 36:1171-6.

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