Long before HPTN 052 confirmed that antiretrovirals taper HIV transmission rates, the CDC cautioned that undetectable virus in plasma does not necessarily mean virus-free semen, rectal secretions, or genital or pharyngeal fluids.3,14,15 And an unreadable load in plasma depends on steady adherence and staying free of other sexually transmitted infections. Even certain vaccinations can hike viral load. On top of that, some studies show that doing well on antiretroviral therapy can make people reckless in bed. So even universal treatment of diagnosed people will not tamp down their transmission risk completely.
But it's a big step in that direction. Of the 18 top HIV physicians who responded to RITA!'s survey on positive prevention (see box), 16 listed reining in HIV with antiretrovirals as a prime strategy, and 7 of those 16 cited HPTN 052.13
"The single most important thing clinicians can do to prevent transmission is to treat their HIV-positive patients with antiretroviral therapy, our most effective form of prevention," wrote Joel Gallant (Johns Hopkins University). "That doesn't mean that other forms of prevention don't matter anymore," he added. "It's still important to talk about behavior change and condom use, for example. But if every HIV-positive person had an undetectable viral load, the epidemic would be over."
David Wohl (University of North Carolina) seconded that opinion, noting that HIV incidence in HPTN 052 "was pretty low in the control group not treated with antiretrovirals." That means the "prevention measures in the control [arm] -- pretty standard stuff -- seemed to have an effect. That said, I have really drunk the Kool-Aid when it comes to use of antiretrovirals to prevent transmission."
Others believe HPTN 052 opens an avenue to discussing positive prevention with their patients. "I've been pleasantly surprised how the 'treatment-as-prevention' message from 052 has facilitated discussion about prevention in clinical practice, and how motivating prevention can be for people considering starting therapy," said Paul Sax (Harvard Medical School).
Steven Deeks (University of California, San Francisco) agreed, noting that "in my recent experience, this public health aspect of treatment has been a great motivator for some individuals to seek care and begin therapy, so I am optimistic transmission rates will decline."
Some HIV-positive people who may not want to start treatment for their own health "will opt for treatment to prevent transmission," Ian Frank (University of Pennsylvania) is finding. As a corollary to this emerging attitude, Frank suggested, treatment as prevention "can be particularly motivational for people in discordant couple relationships" and for another patient subset -- HIV-positive people looking for a partner but assuming no HIV-negative person would consider a relationship. Now, Frank noted, a positive person with well-controlled infection can tell a potential partner, "I have a low risk for transmission of my infection because my viral load is undetectable," and that "can change someone's outlook" on finding a partner.
Besides treating people to make their viral load too low to tote, what else should HIV providers do to help patients avoid dispatching their virus to others? HIV Medicine Association (HIVMA) primary care guidelines prescribe four essentials:16
Do providers have to keep hammering on prevention at every visit? The CDC thinks so. "Clinicians should recognize that [HIV transmission] risk is not static," the 2003 guidelines state.3 "Patients' lives and circumstances change, and a patient's risk of transmitting HIV may change from one medical encounter to another."
The HIVMA guidelines, freely available online, 16 boast an ample section on risk screening in people with HIV, including a list of questions most clinicians should feel comfortable asking (Table 3 in Reference 16). HIVMA guidelines also feature pointers on carrying out the four steps listed above.
CDC positive-prevention advice spells out recommendations on screening for transmission risk and STIs (Table 1).3 The CDC stresses that most STIs are asymptomatic, so these risky infections remain masked unless lab tests uncover them. CDC and HIVMA guidelines outline asymptomatic STI screening advice by (1) initial versus subsequent patient visit, (2) gender, and (3) risk (Table 2).
|Table 1. CDC Advice on Screening HIV-Positive People for Transmission Risk and STIs|
Screen HIV-positive adults for HIV transmission risk behaviors in a straightforward, nonjudgmental manner. Screening should be done at the initial visit and subsequent routine visits, at least once a year.
Any indication of risky behavior should prompt a more thorough assessment of HIV transmission risks.
Ask HIV-positive adults about STI symptoms at the first and every following routine visit.
Regardless of reported sexual behavior or other epidemiologic risk information, such signs or symptoms should always prompt diagnostic testing and, when appropriate, treatment.
At the first visit screen all HIV-positive adults for laboratory evidence of syphilis and all HIV-positive women for trichomoniasis.
Screen for cervical chlamydial infection at the first visit in all sexually active women under 25 years and other women at increased risk, even if asymptomatic.
At the first visit consider screening all HIV-positive adults for gonorrhea and chlamydial infection.
Because of the cost of screening and the variability of gonorrhea and chlamydia prevalence, decisions about routine screening for these infections should be based on epidemiologic factors. [But see results of the large British self-screening study discussed in the text.17]
Repeat STI screening at least annually if the patient is sexually active or if earlier screening revealed STIs.
STI screening should be done more frequently (for example, every 3 to 6 months) for asymptomatic people at higher risk.
At the first and each subsequent routine visit, question HIV-positive women of childbearing age to identify possible current pregnancy, interest in future pregnancy, or sexual activity without reliable contraception.
Ask women whether they suspect pregnancy or have missed their menses and, if so, test them for pregnancy.
STI, sexually transmitted infection.
Source: Centers for Disease Control and Prevention. 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. 2003;52(No. RR-12).3
|Table 2. CDC and HIVMA Guidelines for Screening to Detect Asymptomatic STIs|
|All Patients||Women||Patients Reporting Receptive Anal Sex||Patients Reporting Receptive Oral Sex|
|All Sexually Active Patients||Asymptomatic Persons at Higher Risk|
||More frequent periodic screening (e.g., every 3 to 6 months) if any of the following factors are present:
NAAT, nucleic acid amplification test; RPR, rapid plasma reagin; STI, sexually transmitted infection; VDRL, venereal disease research laboratory test for syphilis.
Sources: Centers for Disease Control and Prevention. 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. 2003;52(No. RR-12).3 Aberg JA, Kaplan JE, Libman H, et al. Primary care guidelines for the management of persons infected with human immunodeficiency virus: 2009 update by the HIV Medicine Association of the Infectious Diseases Society of America. Clin Infect Dis. 2009;49:651-681.16
Patients can even test themselves for gonorrhea and chlamydia in an HIV clinic, according to results of a large London study.17 In this nurse-led self-screening program, HIV-positive men and women are invited to collect specimens by self-swabbing. Diagrams on rectal, pharyngeal, and vaginal self-swabbing are posted in clinic rest rooms. Staff screens samples with nucleic acid amplification tests.
The 976 screens completed over 8 months in people without STI symptoms disclosed 143 infections (14.6%), at rates of 17.4% in MSM, 2.1% in heterosexual men, and 1.5% in women.17 Six people with a self-detected STI had a transient spike in HIV load. Among 78 people taking antiretrovirals at STI diagnosis, 72 had a viral load below 40 copies/mL and 6 had a load between 40 and 70 copies/mL. The researchers recommend STI screening for MSM every 4 months and annual testing for heterosexuals. They suggest this approach "may address some of the barriers to screening in this population."
The Health Resources and Services Administration (HRSA) 2011 Guide for HIV/AIDS Clinical Care includes a useful table (on pages 134 and 135) suggesting questions to ask and assessments for (1) sexual practices, (2) partner notification, (3) STI screening, and (4) drug and alcohol use.18
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