Table of Contents
| Abstract |
| Working with HIV-positive people to tell their sex and drug-injecting partners they have HIV is the first step in prevention with positives. Step 2 is encouraging positive people to consider starting antiretroviral therapy, with an eye toward reaching and maintaining an undetectable viral load. Clinician experience in the United States suggests that results of HPTN 052 have opened another avenue to discussing starting antiretroviral therapy. Because most sexually transmitted infections (STIs) remain asymptomatic, appropriate screening for STIs is essential to limiting HIV transmission risk from positive people. Despite data confirming low HIV transmission risk in people with an undetectable viral load, providers should continue to stress condom use. Circumcision lowers the risk of HIV transmission from positive heterosexual men. But the CDC and other groups urge caution in considering circumcision for gay men because of limited evidence in this population and because the risks of circumcision remain largely unexplored in them. Serosorting limits HIV transmission in gay men who do not use condoms but cannot be recommended as a primary prevention strategy. Clinicians should remember that most HIV transmissions from injection drug users come during sex, not needle sharing. Plentiful evidence shows that behavioral interventions can help HIV-positive people refrain from transmission-risk behavior. Some of these interventions involve little or no provider time and can be completed by patients using hand-held devices in the waiting room. The CDC plans to stress these time-saving strategies in its 2012 prevention-with-positives guidelines. |
Reasons why clinicians fail to engage HIV-positive patients on transmission risk almost outnumber reasons why clinic-based prevention strategies work. The first article in this issue ponders both lists of reasons. This article probes clinic-based strategies for bridling transmission from positives -- with a focus on strategies that take little provider time and won't break the clinic budget.
First Step in Positive Prevention: Telling Partners
Before providers can lift a finger -- or prescription pad -- to prevent HIV-positive people from transmitting their virus, they've got to know who's positive. That's why the CDC and others are pushing hard to test as many people as possible, regardless of perceived HIV risk. Once a person gets diagnosed and referred to care, the provider must address another urgent priority -- making sure the new patient's partners know.
For an array of reasons easy to imagine, people with HIV often avoid telling sex partners they're infected. One study of 675 HIV-positive men who have sex with men (MSM) in six US cities found that 30% told no sex partners they had HIV in the past 90 days.¹ Another study discussed below recorded a 7% notification rate.²
HIV providers must remember that most states and some local governments have laws regulating HIV disclosure to partners; many states also regulate disclosure by clinicians to third parties at high risk of getting infected by already positive patients.³ Some health departments give HIV-positive people a set time to notify partners. If the partners don't show up for counseling and testing by the end of that "contract period," the health department gives them the news.³
CDC guidelines advise providers to ask all positive people at their first visit whether they've told sex and needle-sharing partners they have HIV.³ And keep asking at follow-up visits, the CDC says, because many patients will have found new partners in the interim. (The CDC is releasing revised and greatly expanded guidance on prevention with positives in 2012. See the interview with the CDC's Kathleen Irwin in this issue.)
A 1992 trial that randomized newly diagnosed people to physician- or self-notification of partners found that physicians successfully notified 78 of 157 sex or needle-sharing partners (50%), while patients themselves notified only 10 of 153 partners (7%).² Among notified partners, 23% had HIV.
Second Step to Positive Prevention: Undetectable Viral Load
Long before HPTN 052 offered sumptuous proof that triple antiretroviral therapy slashes the risk of HIV transmission in HIV-discordant couples, plentiful evidence forged a fast link between lower viral loads and slimmer chances of transmission. That principle became clear well before the dawn of triple therapy, when US and French investigators found that zidovudine taken by pregnant women and newborns sliced the risk of mother-to-child transmission 67.5% (95% confidence interval [CI] 18.4 to 32.5, P = 0.00006).⁴
In ensuing decades, one trial after another showed that one drug is better than none, two are better than one, and three are best in cutting chances of vertical HIV transmission, clearly because each stronger regimen lowers viral load more. Testing three triple regimens in 730 women, the Mma Bana study in Botswana found that more than 90% of women across the three groups had a viral load below 400 copies/mL at delivery and through follow-up.⁵ Six months after delivery, the HIV transmission rate in this breast-feeding population was 1.1% -- equivalent to rates in formula-feeding Western populations.
The same principle applies to sexual or parenteral transmission of HIV. In the seminal study of 415 HIV-discordant Ugandan couples before antiretroviral therapy became available, none of 51 people with a viral load below 1500 copies/mL infected their partner.⁶ In a study of 253 antiretroviral-naive HIV-discordant monogamous Ugandan couples, the researchers divided HIV-positive partners into four equal groups reflecting their HIV load: under 3090 copies/mL, 3090 to 14,450 copies/mL, 14,450 to 75,850 copies/mL, and over 75,850 copies/mL.⁷ Compared with people in the lowest viral load quartile, those in the next higher quartile had a 3.31 times higher risk of transmitting HIV, those in the quartile above that had a 6.39 times higher risk, and those in the highest quartile had a 7.06 times higher risk. (Figure 1).
Though HIV incidence data from HIV-discordant heterosexual African couples may not apply precisely to gay and straight couples in the United States and similar countries, this research certainly offers keen insights into how viral load may affect transmission. A canny modeling study relied on data prospectively collected from 3381 HIV-discordant African couples from 2004 to 2008, including 108 with genetically linked HIV transmissions.⁸ The model predicted that every 0.74 log (about 5.5-fold) lower viral load cut heterosexual transmission risk 50%, regardless of starting viral load in the population and other HIV-related population traits.
Meta-analysis of 11 studies involving 5021 heterosexual couples counted 461 HIV transmissions, only 5 of them from an antiretroviral-treated partner.⁹ No one with a viral load below 400 copies/mL passed HIV to a partner. These couples lived in three African countries, Brazil, India, Spain, Thailand, and the United States.
Population-based modeling studies show that, as communities start using robust antiretroviral combinations, "community viral load" drops, followed by HIV incidence (the new infection rate).¹⁰⁻¹² For example, British Columbia's centrally controlled antiretroviral program allowed researchers to figure that individual use of triple therapy soared 547% from 1996 to 2009, reaching only 837 people in 1996 and 5413 in 2009 (P = 0.002).¹¹ Over the same period, the number of new HIV diagnoses dwindled 52%, from 702 to 338 per year (P = 0.001). On an annual basis, the number of people on combination therapy correlated inversely -- and tightly -- with the number testing positive (-0.89, P < 0.0001).
With all these findings pointing (insistently) in the same direction, no one could be surprised that antiretroviral therapy stymied sexual HIV transmission in HPTN 052.¹³ But the magnitude of that effect was stunning. The trial enrolled 1763 HIV-discordant couples in nine countries, 97% of them heterosexual and 94% of them married. Everyone had a CD4 count between 350 and 550 cells/mm³, and no one had taken antiretrovirals. The investigators randomized HIV-positive partners in these couples to start antiretroviral therapy immediately or to wait till their CD4 count dropped to 250 cells/mm³ or they had an AIDS disease.
The Data and Safety Monitoring Board pulled the plug on HPTN 052 early when results through February 2011 showed that 28 couples had a genetically confirmed HIV transmission, only 1 of them in the early-antiretroviral group. Starting antiretrovirals immediately chopped the HIV transmission risk by 96%. Because the 1 genetically linked transmission in the early-antiretroviral group probably occurred before treatment made the positive partner's viral load undetectable, HPTN 052 confirmed earlier nonrandomized studies that found no sexual HIV transmissions from people with an undetectable viral load.
"Drinking the Kool-Aid" on Treatment as Prevention
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.
Risk Screening and STI Testing for Positive Prevention
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
Screen people for high-risk behavior at each visit.
Ask patients about sexually transmitted infection (STI)-related symptoms at each visit.
Give a general message about risk reduction at each visit.
Tailor messages for patients who report high-risk behavior.
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).
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
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).
| Table 3. HRSA Condom Use Advice for HIV-Positive People |
General Advice
Advice for People Who Complain About Lack of Sensitivity With Condoms
|
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.
Behavioral Interventions Can Trim Transmission Risk
One might assume that getting people on antiretrovirals, getting their viral load under 50, and screening for and treating other STIs will prevent HIV transmission so effectively that providers needn't bother with costly, time-consuming, hit-or-miss behavioral interventions.
But some new behavioral tactics are inexpensive, require little or no provider time, and proved effective in randomized trials.
So ignoring this option may deprive some HIV-positive people of an approach that fits their needs best. For example, behavioral interventions may be a good bet for healthy people who want to put off antiretroviral therapy, those on treatment who can't reach an undetectable viral load, people with continuing high-risk behavior despite regular counseling, patients who like to take charge of their own health, and people inclined to try group programs or who have an amicable provider relationship that makes one-on-one interventions a natural fit.
In 2006 CDC investigators ran a meta-analysis of interventions designed to quell risk behaviors in HIV-positive people to see what worked and what predicted success.³⁹ They considered only studies that used randomization or assignment with minimal bias, relied on statistical analysis, and assessed behavioral or biologic outcomes at least 3 months after the intervention. Together the interventions cut the risk of unprotected sex almost 40% (OR 0.57, 95% CI 0.40 to 0.82) and clipped STI incidence 80% (OR 0.20, 95% CI 0.05 to 0.73). Among the traits of successful programs were delivery by providers or counselors, delivery in settings where HIV-positive people receive routine services or medical care, and a design based on behavioral theory. (See the interview with the CDC's Nicole Crepaz in this issue for details of this meta-analysis.)
The Cochrane group analyzed 44 studies of behavioral interventions involving 18,585 MSM with or without HIV.⁴⁰ These studies, published or presented from 1988 through 2007, included 26 small-group interventions, 21 individual-level interventions, and 11 community-level interventions. Overall, these programs cut the risk of unprotected sex or partner numbers by 15% to 27%, depending upon study type. The Cochrane experts concluded that "HIV prevention for this population can work and should be supported."⁴⁰
Besides conducting the just-cited meta-analysis,³⁹ the CDC's Prevention Research Synthesis (PRS) team reviews and vets mountains of evidence on HIV prevention interventions and distills it all on Web pages devoted to "promising-evidence interventions" that can rein in sex- or drug-related risk behaviors, curb rates of new HIV and other STIs, or bolster HIV-protective behaviors.⁴¹ The 28 programs identified to date meet PRS efficacy criteria and are judged scientifically sound.
Four of these interventions target HIV-positive people: Options/Opciones Project, Partnership for Health, Together Learning Choices (TLC), and Women Involved in Life Learning With Other Women (WiLLOW). Options/Opciones and Partnership for Health are one-on-one interventions delivered by the HIV provider. TLC is a small-group intervention aimed at teens and young adults, and WiLLOW is a small-group program for HIV-positive women. Table 4 describes these four programs and provides links for further information.
Innovative interventions discussed by Stephen Morin in the interview in this issue let patients screen themselves for transmission risk behaviors on laptops or handheld devices while waiting for their appointment. If the patient signals some risk on these self-administered surveys, a red flag waves in the clinic's electronic medical records, alerting the provider before the patient visit and allowing the provider to take appropriate action. The table between the two interviews in this issue describes four patient self-administered programs.
Not content with merely parsing and rating HIV risk-reduction programs, the CDC collaborates with Danya International to train providers, health departments, and community groups in science-based HIV-prevention interventions.⁴² A comprehensive Web site offers complete explanations of programs and a city-by-city calendar of free courses: go to the Diffusion of Effective Behavioral Interventions (DEBI) site at www.effectiveinterventions.org/en/home.aspx. The top of the home page offers a link to a 20-minute online DEBI overview.
Reviewing findings from trials done largely in high-income countries, WHO recommends behavioral interventions for HIV prevention in MSM, including individual interventions, community-level interventions, targeted Internet-based information, social marketing strategies, and sex venue-based outreach.²¹
WHO analyzed studies of two Internet-based strategies, one that aimed to temper risk behavior in US MSM with HIV (21%) or without HIV⁴³ and one in Peru to increase HIV testing in seronegative MSM.⁴⁴ Among men who practiced unprotected anal intercourse when the US study began, after 3 months those randomized to the Internet program reported a marginally lower number of men with whom they had risky sex than did men in the control arm (risk reduction 15.6%, 95% CI 0.704 to 1.013, P = 0.068 in an adjusted analysis).⁴³
WHO observed that "Internet-based HIV prevention interventions make it easier for MSM with Internet access to obtain relevant HIV prevention messages in an anonymous fashion, at a convenient time and in private."²¹ Prevention instruction and counseling via the Internet may be particularly appropriate for rural residents, who have to travel far to their HIV clinic or behavioral intervention sites, or for people uncomfortable with group interventions. One study of 475 rural US MSM found that one such program reduced anal sex and increased condom use.⁴⁵ But so far the CDC lists no Internet-based prevention programs for HIV-positive people.
Clinicians who don't know how their patients use digital media should start learning. How many providers who care for gay men know that many of them favor a smart-phone app, GRINDR, that melds social networking with GPS to help men find friends -- and sex partners -- fast? A study of 375 young gay men who use GRINDR in Los Angles found that 153 men (43%) reported unprotected receptive anal intercourse in the past month, 163 (47%) reported unprotected insertive anal intercourse, and 181 (48%) had sex under the influence of alcohol or drugs.⁴⁶ More than half of these men, 56%, found a sex partner via GRINDR. And when using GRINDR, fewer HIV-positive than negative men asked their potential partner's HIV status, a finding suggesting some of these positive men don't bother serosorting.
Limited clinic time and other strictures may sometimes frustrate clinicians who set their mind on one of the 3- to 10-minute positive-prevention exchanges recommended by the CDC (Table 4, Options/Opciones Project and Partnership for Health). But interventions self-administered by patients (summarized between the two interviews in this issue) take little or no provider time. And it takes about 5 seconds to ask office staff to copy the Prevention Pointers sheet that follows this article in RITA! and about 4 seconds to pull it out of a drawer and hand it to an HIV-positive patient at every visit.
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