In the United States, although high-risk behavior has declined remarkably in some groups, especially gay males; recent data is showing a resurgence of infection. This resurgence is certainly multi-factorial, due in part to wavering political and public support. Large-scale campaigns, such as the "safer sex" educational efforts, condom promotion, and needle-exchange programs, have had variable and inconsistent results in modifying behaviors over time. Further, physicians’ (or clinicians’) potential to influence patients’ attitudes and behaviors have, unfortunately, gone largely unrealized. In contrast to cigarette smoking, for which we play a recognized role in public health prevention efforts, counseling and advice about HIV prevention is offered in fewer than one percent of patient visits to their primary care physician. Finally, new therapies, which prolong and preserve life for many of those infected, may also decrease the fear of contracting HIV. Unfortunately, they do not work for everyone, are difficult to take, and are associated with significant potential toxicities and long-term complications.
Since a cure or vaccine is unlikely in the near future, efforts to curtail the HIV epidemic must focus on HIV prevention as a primary goal. Physicians and other healthcare providers must play a significant role in counseling and other preventive efforts. It is important for physicians to recognize that HIV prevention does not require extensive counseling skills and psychological interventions. I view prevention as part of routine health education, assessing risk and providing information, which will help to modify high-risk behaviors.
Who is at Risk?
In the United States alone, more than one million Americans are believed to be infected with the HIV virus and there are 40 to 80,000 new infections each year. Once considered largely an urban disease of gay men and intravenous (IV) drug users, as the HIV epidemic has grown, the groups at-risk have changed. Women, adolescents/young adults, and racial minorities are the fastest growing populations being infected with HIV.
Where they used to represent only a handful of cases, adolescent and young-adult women now account for more than 20 percent of AIDS cases nationwide, and the most rapidly increasing way in which people are becoming infected with HIV is heterosexual sex. While traditionally concentrated in urban centers, HIV cases have gradually shifted more to suburban locations.
So, to answer my own question, "Who is at risk?" In a word—EVERYONE! I assume all my patients—adolescent and adult—to be at-risk for HIV. Therefore, I ask everyone specific questions about sexual and other high-risk behaviors, and tailor my education and counseling accordingly. In my opinion, assuming anyone to be not at-risk of HIV is a dangerous and misguided practice.
HIV Prevention and Sexual Behavior
In order to offer effective counseling and education about HIV, a physician must first feel comfortable taking a sensitive and comprehensive sexual history. This involves being comfortable discussing sexuality, respecting individual differences, using "real-world" language that patients understand, and asking pointed questions about specific behaviors—not just, "Are you sexually active?"
Abstinence
With each patient, I discuss a range of sexual options in relation to HIV transmission and risk—including abstinence. All people (particularly adolescents) should be supported in their decision to abstain from sexual activity. Yet, I remain aware that many young people are choosing to have sex. In my experience, an HIV prevention strategy based on abstinence alone is a misguided and unrealistic option. Therefore, I address all patients with nonjudgmental messages, which emphasize taking personal responsibility for protection against HIV. Specifically, while safer sex guidelines have historically emphasized limiting your number of sexual partners and avoiding partners who may be at-risk of HIV, I believe more important messages are:
- protect yourself with consistent, appropriate latex condom or dental dam use
- limit yourself to lower risk sexual activities
For people who are allergic to latex, I advise using polyurethane condoms. I provide everyone with specific instructions about correct condom use such as using adequate lubrication with a water-based lubricant. Improper usage can make condoms break and lead to unnecessary HIV exposure, not to mention pregnancy risk.
HIV basics
When it comes time for specific HIV education, I always make sure to cover the basics - i.e., that HIV is transmitted sexually by exposure of the mucous membranes of the penis, mouth, vagina, and rectum to infected semen, pre-ejaculate (pre-cum), vaginal secretions, or blood. I explain that sexual transmission of HIV is unpredictable. In other words, one person may be infected from a single sexual encounter, yet another may have multiple encounters and never become infected. Furthermore, while patients frequently ask me to assign some numeric risk to specific sexual behaviors (5 percent, 10 percent risk, etc.), I explain that these risks are difficult, if not impossible, to quantify. I prefer to describe sexual risk as occurring along a continuum from low-to-high risk behaviors.
Low- and high-risk activities
Mutual masturbation, fondling, and kissing are exceedingly low-risk activities. Unprotected (without a condom) anal and vaginal intercourse are clearly the highest risk sexual activities. I try to dispel common misperceptions such as—men cannot contract HIV from vaginal intercourse or insertive ("top") anal intercourse. This clearly is not true. Perhaps the biggest gray area in patients’ minds regarding sexual transmission of HIV is oral sex. Seroconversion, or HIV transmission resulting from oral sex has been documented and new information is showing that oral sex may be more risky than previously thought. Therefore, while in the past there has been some debate concerning the degree of risk associated with oral sex, it is becoming increasingly important that appropriate use of a latex condom or dental dam during oral sex is encouraged.
HIV Prevention and Drug Use
One-third of all cases of HIV are believed to be related to injection drug use. This statistic does not include the large numbers of individuals who contract HIV through high-risk sexual activity while under the influence of drugs (injection or noninjection) or alcohol. For patients who use drugs, my goals are to encourage:
- abstinence from drug use altogether
- referral to drug treatment programs
- use of clean needles and avoidance of sharing needles
- should the patient become infected with HIV, prevention of unsafe sex or other practices that place others at risk
Unfortunately, these goals are not always attainable. Patients frequently are unwilling or unable to change their behavior, accept treatment, or access appropriate substance use services. Frequently faced with this scenario, my strategy for HIV prevention conforms more closely to a harm reduction model. This model accepts that drug use exists and occurs, but attempts to minimize the adverse consequences of that behavior.
HIV basics regarding drug use
The first step is education. For patients who actively use IV drugs, I once again cover the basics—i.e., that HIV is transmitted through drug use when blood or other bodily fluids from an infected individual is transferred to an individual who is not yet HIV infected. Patients are informed that sharing needles and syringes is the most common way IV drug users become infected. I urge all of my IV drug-using patients to avoid these practices. I advise all patients who inject drugs to use sterile needles for each injection. Users who continue to share needles are given detailed instructions as to how to best disinfect their apparatus ("works").
HIV is most effectively killed by first flushing the drug apparatus with clean water. It must then be soaked or rinsed in full-strength bleach for at least one minute, followed by another thorough clean water rinse. In some areas, such as Massachusetts, clinicians can refer IV drug users to needle-exchange programs. Here, patients can exchange used (nonsterile) drug apparatus for clean (sterile) supplies. Several studies have shown that needle-exchange programs reduce HIV transmission among injection drug users and are a useful addition to any comprehensive HIV prevention effort. Critics, however, fear these programs deter IV drug users from seeking treatment and may, in fact, endorse drug use. No evidence supports these claims. With overwhelming support from the scientific community, debate over needle exchange appears to have more to do with politics, than sound public health practice.
HIV Prevention and Pregnancy
No single HIV-prevention effort has been as successful as efforts with pregnant women. Mother-to-infant transmission of HIV accounts for more than 90 percent of pediatric AIDS cases. In this country, approximately 7,000 infants are born to HIV-infected women each year, but the overwhelming majority of these babies are not HIV infected. In developing countries the numbers are much, much higher. During pregnancy, labor, or delivery, HIV can be transmitted from mother to infant in as many as one-third of cases if no antiretroviral therapy is used. In recent years, drug therapies designed to fight HIV (antiretroviral agents) have been shown to be effective at reducing this rate of transmission. One particular drug, AZT (zidovudine), when given to both a pregnant woman and her newborn infant, can reduce HIV transmission rates to as low as eight percent. Other HIV drug therapies may also be effective but have not yet been adequately studied.
Armed with a tremendous opportunity to reduce HIV transmission, I make sure to offer HIV testing and counseling to all women of childbearing age. For women who are infected with HIV, I provide education about contraception, the risks of mother-to-infant HIV transmission, and the use of antiretroviral drugs to help reduce this risk. It is also important that HIV-infected women, especially those with HIV-negative partners, be counseled regarding safer sex and, if they want to become pregnant, about alternatives to unprotected intercourse. Of course, the final decision regarding antiretroviral therapy is up to each woman individually.
In the United States, where drugs such as AZT are readily available, prevention efforts in pregnant women have been quite successful in decreasing the number of HIV-infected newborns. However, certain under-served populations of women—such as the poor and racial/ethnic minorities—need to be increasingly targeted by this prevention effort. The situation is far worse in developing countries, where a lack of resources limits the availability of antiretroviral drugs and a lack of public health infrastructure limits widespread access to HIV testing, health education, and medical care.
HIV Prevention After Exposure
Until recently, people had little reason to seek medical attention after exposure to HIV, e.g., when a condom broke or after a needle-stick exposure. A study of healthcare workers found that treatment with AZT shortly after a needle stick (post-exposure) reduced the odds of subsequent HIV infection by almost 80 percent. Post-exposure prophylaxis (or PEP, as it is commonly called) involves taking antiretroviral medications shortly after exposure to HIV. If PEP is effective for healthcare workers exposed to HIV by needle stick, it seems logical to consider it for people exposed to HIV through sexual contact—a much more common source of HIV transmission.
The theory behind PEP as an HIV prevention strategy is that antiretroviral therapy given shortly after exposure may help prevent infection by either blocking the multiplication of HIV and/or boosting one’s immune system to get rid of the virus.
As of yet, there is no direct evidence supporting PEP following sexual exposure and there are currently no national guidelines or protocols for PEP in this circumstance. Despite this, based largely on theory and from our experience with healthcare workers, many physicians and healthcare centers across the country (including ours) offer PEP following sexual exposure to HIV.
Most people (and many clinicians) have never heard of PEP. Increasing public awareness is essential if it is to become part of a comprehensive HIV prevention strategy. Find out if and where PEP is offered in your area. Patients need to understand that PEP is not a first line strategy to prevent HIV. Condom use, safer sexual practices, and avoidance of other high-risk activities remain the "gold standards" of HIV prevention strategies. However, in cases where our primary prevention methods have failed, PEP can be used to try to reduce one’s risk of acquiring HIV. The extent to which PEP reduces HIV risk following sexual exposure is still largely unknown.
Keeping in mind that there are no universally accepted guidelines, I recommend PEP to any patient who has had unprotected anal or vaginal intercourse, or oral sex with ejaculation with a person known to be HIV-infected or at high risk for HIV, such as an IV drug user. PEP needs to be started within three days (72 hours) of exposure. PEP is most appropriate for people exposed through isolated sexual encounters and who seem willing to practice safer behaviors in the future, but there are no hard and fast guidelines for when to use PEP under these circumstances.
Conclusion
With no cure or vaccine on the horizon, our efforts to overcome the HIV epidemic must remain focused upon prevention. Whether it is sexual activity, drug use, or other behavior that puts one at risk of contracting HIV, people need to be given the education and skills to protect themselves. |
Comment by Julie Davids
