Eight Strategies to Trim Transmission Risk in People With HIV

Getting HIV-Positive People to Don Condoms

Condoms are lots easier to make than antiretrovirals, lots cheaper, and lots easier to get to people with HIV. Yet this low-tech latex sheath stops HIV transmission dead if used properly. No one has figured out how much condoms have stunted the epidemic's growth, but they certainly had a hand in Uganda's dramatic drop in HIV prevalence from 18% in 1992 to 6% in 2002.¹⁹ And a recent study from India suggests that a pilot prevention program stressing condom use and other measures may have averted over 100,000 new HIV cases in 5 years.²⁰

In a systematic review of five studies, WHO researchers figured that consistent condom use by MSM cuts HIV transmission risk 64% and STI acquisition risk 42%.²¹ WHO guidelines for HIV prevention and treatment in MSM strongly recommend condoms for MSM and transgender people, noting that "water- and silicone-based lubricant use is key for the correct functioning of condoms during anal sex."²¹

The first figure in 2003 CDC prevention guidelines suggest how to tailor messages on condom use for HIV-positive people.³ The opening question might be, "How often do you use condoms when you have sex?" If the person says never or sometimes, the next question could be, "What do you plan to do about using condoms in the future?" And if the person has no plan, an appropriate follow-up may be, "Do you know that you could catch an STI that way, and it could make your HIV infection worse?"

CDC authorities urge physicians to supply condoms to HIV-positive patients,³ and HRSA guidelines say physicians should hand out condoms and lubricant.¹⁸ HRSA details condom-use pointers providers can give patients, as well as suggestions for people who complain about lack of sensitivity with condoms (Table 3).

Circumcision Works ... for Some

Three randomized trials established that medical male circumcision cuts the risk of HIV acquisition in heterosexual African men.^22-24 WHO now endorses circumcision for heterosexual men in countries with high HIV prevalence,²⁵ and some African countries gave circumcision a prominent place in their HIV prevention agenda. But WHO does not recommend circumcision for gay or bisexual men and, in fact, advises against it: "Not offering adult male circumcision to prevent HIV and STI acquisition is suggested over offering it to MSM and transgender people."²¹ Although WHO aims these guidelines at MSM in low- and middle-income countries, the agency recommends making this document available to men in high-income countries as well.

What makes WHO take this negative stance? WHO cited a Cochrane Database systematic review decocting 20 studies of male circumcision for HIV prevention in MSM.²⁶ Three studies of 1792 men determined that circumcision did not protect MSM who primarily practiced receptive anal intercourse (odds ratio [OR] 1.20, 95% confidence interval [CI] 0.63 to 2.29). Seven studies of 3465 men who mostly practiced insertive anal sex yielded evidence that foreskin removal did lower their HIV acquisition risk almost 75% (OR 0.27, 95% CI 0.17 and 0.44).²⁶

The Cochrane review found no evidence that circumcision protects gays or bisexuals from syphilis, herpes simplex virus 1, or herpes simplex virus 2.²⁶ Cochrane rated overall evidence quality low in these studies and stressed that no studies analyzed adverse effects of circumcision.

Surveying all these findings, WHO guideline writers decided "it is not clear if the benefits outweigh the risks [for MSM] at this point in time, as male circumcision, like any other operation, carries some risks."²¹ On top of that, WHO cautioned, "there are significant concerns regarding its acceptability and implementation among MSM in different cultural settings."²¹ WHO, Cochrane, and the CDC²⁷ all agree that findings to date do not support circumcision as an HIV prevention strategy for gay or bisexual men and that further research should address the potential role of circumcision among MSM who take the insertive role during anal intercourse.

Caution makes sense when weighing the potential role of circumcision in preventing HIV among gay men, regardless of whether they prefer being insertive "tops" or receptive "bottoms." A retrospective CDC study of 4889 North American and European MSM enrolled in the VAXGen HIV vaccine trial underlines that point.²⁸ An analysis that controlled for demographics and risk behaviors determined that being uncircumcised did not raise the risk of picking up HIV even a tiny bit (adjusted hazards ratio [AHR] 0.97, CI 0.56 to 1.68). In study visits during which men reported unprotected insertive anal sex with a positive partner, HIV infection was reported in 3.16% of visits by circumcised men and 3.93% of visits by uncircumcised men (relative risk [RR] 0.80, CI 0.46 to 1.39).

Should uncircumcised HIV-negative heterosexual men in the United States and countries with similar HIV epidemics be encouraged to get circumcised to lower their HIV risk? In April 2007, after release of results from the three randomized African trials,^22-24 the CDC held a 2-day powwow on circumcision to prevent HIV infection in the United States and summed up with this advice for heterosexuals:

"Sufficient evidence exists to propose that heterosexually active males be informed about the significant but partial efficacy of male circumcision in reducing risk for HIV acquisition and be provided with affordable access to voluntary, high-quality surgical and risk-reduction counseling services."²⁷

Whether uncircumcised HIV-positive heterosexuals should be urged to get circumcised to curb chances of transmitting HIV to sex partners is another question entirely. Mathematical modeling suggests that male circumcision trims the risk of male-to-female HIV transmission more than first predicted.²⁹ Basing their analysis on HIV transmission rates in four randomized trials and in observational studies of already circumcised men in stable partnerships, these investigators calculated that male circumcision eases the risk of male-to-female HIV transmission by 46%.

But it is probably naive to imagine that many uncircumcised HIV-positive men -- straight or gay -- can be persuaded to shed their foreskin to protect sex partners. A confidential survey of 653 MSM recruited in London gyms found that only 10% of 464 uncircumcised men said they would sign up for a study of circumcision to prevent HIV infection.³⁰ Only one third of uncircumcised men thought circumcision has benefits, compared with two thirds of circumcised men. Similar proportions of these men (39% uncircumcised and 37% circumcised) reported unprotected anal sex in the past 3 months. One quarter of uncircumcised men had HIV infection.

On the other hand, about half of HIV-negative MSM in a 2006 US study claimed they would get circumcised if research showed the operation would trim their HIV risk.³¹ Researchers interviewed 780 men at gay pride events, all of them presumed to be HIV-negative and 133 of them (17%) uncircumcised. The gay pride events took place in Birmingham, Alabama, Anchorage, Alaska, Raleigh-Durham, North Carolina, Springdale, Utah, Charlotte, North Carolina, Chicago, and St. Louis.

Seventy-one of 133 uncircumcised men (53%) claimed they would consider circumcision, pending favorable research results. Black men, men who did not inject drugs, and men who believed circumcision would lower their risk of penile cancer were more likely to consider circumcision. The research summarized above suggests those men are still waiting to see if circumcision will help keep them free of HIV. But physicians who care for HIV-negative gay men should be aware some may consider circumcision.

Does Serosorting Sort Out HIV Risk?

HIV clinicians heaved grateful sighs in the middle of the last decade when they learned that gay men had devised their own strategy to limit HIV transmission and that it seemed to work.^32,33 Serosorting -- having sex only with men of the same HIV status -- appeared to explain why STI incidence rose from 1998 through 2004 in San Francisco MSM while HIV incidence peaked in 1999 then leveled off.³³ But even these early reports noted that HIV incidence remained high and cautioned that "a strategy of risk reduction by HIV serosorting can be severely limited by imperfect knowledge of one's own and one's partners' serostatus."³³

Analyzing data from 3 studies in developed countries, WHO figured that HIV-negative men who relied on serosorting rather than consistent condom use had a 79% higher risk of HIV acquisition (RR 1.79, 95% CI 1.2 to 2.65) and a 61% higher risk of getting a new STI (RR 1.61, 95% CI 1.43 to 1.81).²¹ Compared with no condom use, however, serosorting cut chances of HIV infection 53% (RR 0.47, 95% CI 0.26 to 0.84) and whittled STI risk by 14% (RR 0.86, 95% CI 0.78 to 0.93).

WHO concluded that "serosorting may be a potential harm reduction strategy for [MSM] who choose not to use condoms, but it should not be promoted as an alternative strategy for HIV prevention. Consistent condom use is a more effective method to prevent HIV infection."²¹ These experts advise frequent HIV and STI screening for MSM who rely solely on serosorting to shield themselves from sexually transmitted intruders.

CDC positive-prevention guidelines stress that condom-free serosorting does not protect men from picking up new STIs or another HIV.³ Although the clinical hazards of superinfection with a second HIV remain open to question, a few case reports suggest a second HIV may be much nastier than the first,^34-36 and a superinfecting HIV could bear resistance mutations.

HIV providers should be aware that HIV-negative serosorters may believe they have a lower risk of getting infected, may indulge in unprotected sex as a result, and may get tested for HIV less than once yearly, as the CDC recommends.³⁷

Advice on Working With IDUs and Other Drug Abusers

Although injection drug users (IDUs) accounted for only 10% of new HIV infections in the United States in recent years, that rate did not budge from 2006 through 2009, the most recent years for CDC calculations.³⁸ That plateau implies that IDUs continue to infect their partners at a steady pace.

There's no secret about how to cut HIV transmissions in drug injectors -- get them to quit shooting up by referring them to opioid-substitution programs.³ And if that doesn't work, urge them to use clean injection equipment and never to reuse or share that equipment.³ Providers should not neglect counseling IDUs about sexual transmission of HIV, which accounts for more transmissions in this group than equipment sharing.

The CDC's 2003 positive-prevention guidelines suggest a thoughtful approach to asking IDUs about their needle-sharing habits and encouraging them to stop completely if they haven't already (Figure 2 in CDC guidelines³). An HIV provider might get the ball rolling by asking, "How often do you borrow or share a needle or works?" If the patient answers sometimes or always, the provider could ask, "What do you plan to do about sharing needles in the future?" If the person has no plans, possible follow-up questions may be "Have you heard that HIV can survive in the cotton and rinse water?" or "Can you tell me something about sharing needles?" If the person does have a plan, the clinician might ask, "How do you think your friends will deal with you when you don't share needles or works?"

The CDC stresses that giving up injecting "is the only reliable way to eliminate the risk of injection-associated HIV transmission."³ These guidelines cite more than a dozen studies showing that substance abuse treatment -- particularly opioid substitution -- can reduce risky injection habits, risky sex, and HIV incidence. For IDUs who can't or won't quit shooting, the CDC favors "once-only use of sterile syringes" because "it is difficult to reliably disinfect syringes" and because studies show disinfecting is not as safe as using a new sterile syringe.

The Midwest AIDS Training + Education Center offers a useful patient-level flier on avoiding needle sharing and keeping needles clean at www.uic.edu/depts/matec/Drug/Safer.htm (accessed November 5, 2011). Providers can download the flier and print it on two pages.

As research summarized in the first article in this issue shows, noninjection drug use also inflates the risk of HIV transmission. HIV providers should talk to patients about drug use and should refer those who need help getting a handle on their habit.