What Do HIV Doctors Tell Their Patients About Prevention?

Dr. Sax is director of the HIV Program and Division of Infectious Diseases at Brigham and Women's Hospital in Boston.

The most important thing they can do is avoid getting syphilis or hepatitis C. Those two infections can be really nasty. And even though virologic suppression for HIV leads to a nearly uninfectible situation -- people don't get superinfected if they're on treatment already and they're suppressed; that just doesn't happen. And people don't transmit if they're on HIV therapy and suppressed. But they can definitely still catch hepatitis C and syphilis. And I've seen it happen numerous times, and it is not pleasant. You've got to be careful.

I say, "If you're in a monogamous relationship, where your partner is HIV positive and suppressed, and it's a monogamous relationship, then you guys make your decision. You're not going to get HIV, right? But if you're not sure it's a monogamous relationship, either for you or for him, then you've got to be careful, in these times."

Dr. Fitzpatrick is a professorial lecturer for the George Washington University School of Pubic Health, and an adjunct faculty member in the Howard University College of Medicine.

I tell them all to consider disclosing their HIV status to at least one person. Although I think consistent condom use is unrealistic for many people, I tell them about condoms anyway and for those who are not suppressed and in relationships or who remain sexually-active, I talk to them about PrEP [pre-exposure prophylaxis] and ask them to invite their partners in for a consultation.

Dr. Wohl is an associate professor of medicine at the University of North Carolina School of Medicine and the co-director of HIV services at the North Carolina Department of Corrections.

[One of my patients asked], "I just want to know if I have sex with somebody and I'm undetectable -- because I am, and I take my pills every day -- what's my chance of spreading the virus to them?"

I tell people basically the truth. I say that, "Studies show that the chance of you infecting someone, given all the things we just talked about -- and you don't have gonorrhea at the same time -- that your chances are infinitesimally small: ones in tens and tens and tens of thousands. I'd be lying to you if I said that there was a high likelihood you were going to infect someone." So I try to be honest with them.

But I say, "But if you're having sex with other people and you have an inflammatory STD, all bets are off. If you never take you medicine the way you should, all bets are off."

[In terms of PrEP,] I said to him, "If you're talking about one partner and you guys are going to have unprotected sex, a discussion could be had with her about whether or not she wants to -- in addition to what I just said, that all the protection you get from your HIV medicine, want to have her treated with [PrEP]."

Dr. Lee is an assistant clinical professor of medicine at the University of Kansas and the founder and director of Southwest Boulevard Family Health Care.

Most of my patients who are infected with HIV really do not want to transmit this lifelong disease to others. Our clinic provides male condoms at the front desk and we offer pre-exposure prophylaxis for partners of our patients. We also encourage those with HIV to tell their friends about PrEP and we offer a PrEP clinic time weekly for those who are not our patients.

Dr. Mayer is a professor of medicine and community health at Brown University and an attending infectious disease physician at Miriam Hospital.

The important thing is training health care providers because there's so much stigma around sex, particularly gay sex, and people are not necessarily comfortable talking to their providers about their sex lives. So I think the first thing is that clinicians have to realize that talking to patients about sex is as important as taking a blood pressure. It's a vital sign that's very much a part of human behavior. So that's one piece.

Then it's trying to figure out smarter ways to get standard information -- just because somebody's a man who has sex with men doesn't mean that he needs PrEP. But clearly, if they're not volunteering their behavior to their providers then those individuals aren't going to even be offered PrEP.

Conversely, if people talk to their provider about their sex lives, PrEP is not necessarily the most important thing. It may be screening for syphilis, gonorrhea, chlamydia, dealing with the fact that a person's depressed because a relationship's over. It's thinking about these things in a larger context. I think HIV and other STD prevention will be more successful if we embed it more in primary health care.

Dr. Katsivas is an associate physician at the Owen Clinic at the University of California, San Diego.

I see mostly HIV positive [patients]. But they might have HIV-negative partners, or friends, or husbands or wives. So I promote the use of condoms, and I promote PrEP -- both. I promote those together. I think they should be together. Studies were done with these two components of prevention together and I think that's how they should be promoted.

On the other hand, people when they hear that pre-exposure prophylaxis has a very high degree of protection, then they want to get rid of the condom. It's all something that I would discuss.

Dr. Tebas is an associate professor of medicine at the University of Pennsylvania School of Medicine and principal investigator in the AIDS Clinical Trials Unit (ACTU) at the University of Pennsylvania.

We talk always about using condoms. And we talk about the importance of safe sex, and the importance of disclosure to partners, and not engaging in high-risk behavior. Our success is variable. I see a lot of sexually transmitted diseases in patients with HIV. But you try to insist on being very focused on the message for these patients, and making sure that everybody listens to it.

I also have a lot of emphasis on hepatitis C. There is an ongoing hepatitis C epidemic that affects HIV-infected individuals. And they have to be particularly careful because of the immune suppression -- in spite of successful antiretroviral therapy -- it makes them vulnerable for hepatitis C. And they have to be aware that there is a sexually transmitted risk that affects this particular population. They have to be very careful.

Dr. Gulick is a professor of medicine and chief of the Division of Infectious Diseases at Weill Medical College of Cornell University, and an attending physician at the New York Presbyterian Hospital in New York City.

The good news is that we have lots of choices. Condoms are still an important part of things. If we know that they're in a relationship, a serodiscordant relationship, where one's positive and one's negative, we know that putting the positive partner on treatment is a great way to prevent infection in the negative partner -- assuming that they're not having sex outside the relationship. But we know people do.

So then that brings up the subject of PrEP, which is now FDA approved and recommended by the CDC for people that are at increased risk, which would be pretty much all sexually active MSM, men who have sex with men. And it would be heterosexual, both men and women, in certain communities. And then anyone who's had a recent sexually transmitted infection, is part of a discordant couple, or is having sex in a community where there's a high incidence of HIV should seriously think about PrEP.

Dr. Masur is a clinical professor of medicine at George Washington University and chief of the Critical Care Medicine Department at the NIH Clinical Center.

I think we all know how HIV is transmitted. We know about sexual behavior. We know about needle sharing. Yet, what is disappointing is that if you look at diseases of social behavior, we have done a terrible job over the last 40 years at changing behavior. We have cheap therapies for syphilis and gonorrhea. We have therapies for chlamydia. Yet we are very ineffective, especially in our large urban areas, at reducing those diseases. And for those diseases, a short course of drugs, sometimes one dose, is curative.

So for prevention, I wish that we had a better message for patients that would resonate for them. Again, we have to keep emphasizing to them personal responsibility. We have to emphasize to be sure that they have the knowledge because I think sometimes we overestimate what patients understand.

But, again, I'm looking forward to better understanding how we can change social behavior. And I'm distressed, as I suspect all of us are, at how little progress we've made in that area in the last several decades.

Dr. Saag is a physician and HIV researcher at the University of Alabama at Birmingham.

Treatment is prevention. You take your medicine, get your virus undetectable, you don't have to sweat it, as long as you're not sharing needles or blood. I think the likelihood of transmitting through sexual activity approaches zero. I can't swear it's zero, but I think it's damn close. So, just take your medicine for yourself, and for anybody else you might be with.