HIV Infection Prevention
The Centers for Disease Control and Prevention (CDC) estimates that approximately 1.2 million persons are living with HIV in the United States.* The number of HIV infected U.S. residents is expected to increase over time due in part to the following:
- Impact of economic crisis: The current economic crisis has severely impacted state and local governments and community-based organizations, with $170 million in cuts to state HIV/AIDS prevention and care programs in fiscal year 2009 alone. These cuts mean that essential HIV prevention services will reach fewer of those at risk of HIV infection. In addition, waiting lists for the federal AIDS Drug Assistance Program (ADAP), which provides HIV treatment to low-income individuals, are at record highs.
- Increasing HIV prevalence: It is anticipated that the number of people living with HIV will continue to increase over time, due to the remarkable benefits of life prolonging HIV treatments. As more people live with HIV, opportunities for transmission increase, as does the need for prevention services and medical care.
- Complacency: Despite the severe impact of HIV in the United States, studies show that many Americans — even those at greatest risk of infection — have grown complacent about HIV. This is a major concern since lack of awareness about HIV can contribute to increased risk behaviors, and reduce community and governmental mobilization.
On July 13. 2010 the U.S. initiated a national plan to significantly reduce new HIV infections by 2015. "The United States will become a place where new HIV infections are rare and when they do occur, every person, regardless of age, gender, race/ethnicity, sexual orientation, gender identity or socioeconomic circumstance, will have unfettered access to high quality, life-extending care, free from stigma and discrimination." The National HIV/AIDS Strategy has set forth the following goals and action plan:
Reducing New HIV infections
• By 2015, lower the annual number of new infections by 25%.
• Reduce the HIV transmission rate, by 30%.
• By 2015, increase the percentage of people living with HIV who know their serostatus from79% to 90%
|Reducing New HIV Infections
• Intensify HIV prevention efforts in the communities where HIV is most heavily concentrated
• Expand targeted efforts to prevent HIV infection using a combination of effective, evidence-based approaches
• Educate all Americans about HIV epidemic and the value of early testing, diagnosis and treatment.
Increasing Access to Care and Improving Health Outcomes for People Living with HIV
• By 2015, increase the proportion of newly diagnosed
patients linked to clinical care within three months of their HIV diagnosis from 65% to 85%.
• By 2015, increase the proportion of Ryan White HIV/AIDS Program clients who are in continuous care (at least 2 visits for routine HIV medical care in 12 months at least 3 months apart) from 73% to 80%.
• By 2015, increase the number of Ryan White clients with permanent housing from 82% to 86%
|Increasing Access to Care and Improving Health Outcomes for People Living with HIV
• Establish a seamless system to immediately link people to continuous and coordinated quality care when they learn they are infected with HIV
• Take deliberate steps to increase the number and diversity
of available providers of clinical care and related services for
people living with HIV
• Support people living with HIV with co-occurring health conditions and those who have challenges meeting their basic needs, such as housing
|Reducing HIV-Related Health Disparities
• Improve access to prevention and care services for all Americans.
• By 2015, increase the proportion of HIV diagnosed gay and bisexual men with undetectable viral load by 20%.
• By 2015, increase the proportion of HIV diagnosed Blacks with undetectable viral load by 20%.
• By 2015, increase the proportion of HIV diagnosed Latinos with undetectable viral load by 20%.
|Reducing HIV-Related Disparities and Health Inequities
• Reduce HIV-related mortality in communities at high risk for HIV infection
• Adopt community-level approaches to reduce HIV infection in high-risk communities
• Reduce stigma and discrimination against people living with HIV
||Achieving a More Coordinated National Response to the HIV Epidemic
• Increase the coordination of HIV programs across the Federal government and between Federal agencies and state, territorial, tribal, and local governments
• Develop improved mechanisms to monitor and report on progress toward achieving national goals
HIV Testing + HIV Medical Treatment+ Prevention Counseling = Fewer HIV infections, better health and longer life.
Effective HIV Prevention Strategies:
- Prevention Counseling works; yet only 45% of people with HIV receiving medical care also received prevention counseling in the previous 12 months.* Prevention counseling should be offered and encouraged in all health-care facilities that serve patients at high risk (e.g., STD clinics), because these facilities routinely elicit information about the behaviors that place persons at high risk for HIV. Prevention counseling need not be explicitly linked to HIV testing. However, some patients might be more likely to think about HIV and consider their risk-related behavior when undergoing an HIV test. HIV testing presents an excellent opportunity to provide or arrange for prevention counseling to assist with behavior changes that can reduce risk for acquiring HIV infection.
- Prevention programs for people living with HIV. Individual and small-group interventions delivered by health care providers, peers, and others have been shown to significantly reduce risk behaviors among people who have been diagnosed with HIV to help ensure they do not transmit the virus to others.*
- Prevention programs for people at risk of HIV infection. Individual, small-group, and community interventions for people who are at risk of HIV infection significantly reduce risk behavior in diverse populations, including men who have sex with men,* heterosexual women and men, drug users, and youth.*
- Partner services. Partner services reduce the spread of HIV by facilitating the confidential identification and notification of partners who may have been unknowingly exposed to HIV, providing them with HIV testing, and linking them to medical care, prevention programs, and other services.*
- HIV Testing - About 240,000 people in the U.S. do not know they are infected with HIV. The CDC recommends HIV screening for patients aged 13–64 years in all health-care settings*. Testing is a critical component of prevention efforts because when people learn they are infected, they can take steps to protect their own health and prevent HIV transmission to others.
- Screening and treatment for other sexually transmitted infections.*
- STDs appear to increase susceptibility to HIV infection by two mechanisms. Genital ulcers (e.g., syphilis, herpes, or chancroid) result in breaks in the genital tract lining or skin. These breaks create a portal of entry for HIV. Additionally, inflammation resulting from genital ulcers or non-ulcerative STDs (e.g., chlamydia, gonorrhea, and trichomoniasis) increase the concentration of cells in genital secretions that can serve as targets for HIV (e.g., CD4+ cells).
- STDs also appear to increase the risk of an HIV-infected person transmitting the virus to his or her sex partners. HIV-infected individuals who are also infected with other STDs are particularly likely to shed HIV in their genital secretions. For example, men who are infected with both gonorrhea and HIV are more than twice as likely to have HIV in their genital secretions than are those who are infected only with HIV. Moreover, the median concentration of HIV in semen is as much as 10 times higher in men who are infected with both gonorrhea and HIV than in men infected only with HIV. The higher the concentration of HIV in semen or genital fluids, the more likely it is that HIV will be transmitted to a sex partner.
- Herpes can make people more susceptible to HIV infection, and it can make HIV-infected individuals more infectious. It is critical that all individuals, especially those with herpes, know whether they are infected with HIV and, if uninfected with HIV, take measures to protect themselves from infection with HIV.
- Early detection and treatment of curable STDs should become a major, explicit component of comprehensive HIV prevention programs at national, state, and local levels.
- Antiretroviral therapy. Treating people living with HIV early in their infection dramatically reduces the risk of transmitting the virus to others, underscoring the importance of HIV testing and access to medical care and treatment. A recent clinical trial showed that treating people living with HIV early on reduces the risk of transmitting the virus to others by 96 percent.* Treatment is also essential for reducing the risk of transmission from HIV-infected pregnant women to their infants.* Only 28% of all people who know they are HIV infected, get regular medical care, take ART and have the HIV virus under control.*
- Pre-exposure Prophylaxis with oral antiretroviral medications has been demonstrated to reduce the risk of transmission among men who have sex with men. A randomized controlled trial performed by Grant; Lama; Anderson; et al. compared a combination emtricitabine and tenofovir to placebo. Treatment provided a 44% reduction in HIV transmission over the 1.2 year study.
- In July of 2012, the U.S. Food and Drug Administration approved Truvada (emtricitabine/tenofovir disoproxil fumarate), the first drug approved to reduce the risk of HIV infection in uninfected individuals who are at high risk of HIV infection and who may engage in sexual activity with HIV-infected partners.
- Truvada, taken daily, is to be used for pre-exposure prophylaxis (PrEP) in combination with safer sex practices to reduce the risk of sexually-acquired HIV infection in adults at high risk.
- Truvada for PrEP must only be used by individuals who are confirmed to be HIV-negative prior to prescribing the drug and at least every three months during use. The drug is contraindicated for PrEP in individuals with unknown or positive HIV status.
- The most common side effects reported with Truvada included diarrhea, nausea, abdominal pain, headache, and weight loss. Serious adverse events in general, as well as those specifically related to kidney or bone toxicity, were uncommon.
- the FDA has required Gilead to collect viral isolates from patients who contract HIV while taking Truvada for PrEP to test for the presence of treatment resistance. The FDA also asked Gilead to collect data on pregnancy outcomes for women who become pregnant while taking the drug. Additionally, they required Gilead to conduct a trial that evaluates the relationship between treatment adherence, adverse events, patients’ risk for seroconversion, and the rate of treatment-resistant virus among seroconverters.
Tenofovir 1% vaginal gel formulation has not been found to reduce the risk of HIV acquisition in women.
- Access to condoms. People need tools that enable them to reduce the risk of HIV transmission.
- Condom (Male): Public health distribution of male condoms in bath houses during the 1980s provided spectacular evidence that combining barrier protection and behavioral change could effectively decrease HIV transmission.* The CDC states that, "latex condoms, when used consistently and correctly, are highly effective in preventing the sexual transmission of HIV".* UNAIDS, the Joint United Nations Programme on HIV/AIDS states that consistent and proper male latex condom use can reduce the risk of HIV transmission to around 1 in 5000 sexual acts. "The male latex condom is the single, most efficient, available technology to reduce the sexual transmission of HIV and other sexually transmitted infections".* To achieve the maximum protective effect, condoms must be used both consistently and correctly. Condom education is an important component of HIV prevention programs:
- Expired condoms or those exposed to heat or cold, i.e., condoms stored in a wallet for prolonged periods are prone to failure.
- Condoms pre-packaged with Nonoxynol-9 are no longer recommended.
- Do not open the packaging with sharp objects including teeth.
- Foreskin of the uncircumcised penis must be retracted before applying the condom.
- Prepare the condom by unrolling about half an inch to ascertain the interior from the exterior side
- Pinch and hold the condom at the tip to create a reservoir, place the condom on the glans of the erect penis and roll the condom down the shaft to the base, avoid trapping air.
- The condom must be applied to an erect and dry penis or the condom can slide off during intercourse
- Apply lubricant generously to the entire exterior condom surface, lubricant protects the receptive membranes from abrasion and tearing.
- Remove the condom while the penis is still erect, grasp the condom tip and remove retaining the semen.
- Dispose of the condom safely; clean and dry the penis and apply a new condom before entering any orifice.
- Condom (Female): is a barrier contraceptive device consisting of a thin closed ended flexible sheath fitted with two soft plastic rings. The ring at the closed end is folded and used as a vagina insertion device. The open ended ring remain outside of the vagina and helps protect the vulva and male genitally from fluid exchange during intercourse. The condom is prelubricated and intended for one time use. The intact condom is impermeable to sperm and STDs including HIV. The female condom can be inserted in anticipation of intercourse and remain in place after ejaculation allowing more sexual spontaneity.
- Male Circumcision: The CDC reports that "Male circumcision has been found to significantly reduce the circumcised male's chance of contracting HIV and other sexually transmitted infections from an infected female. However, male circumcision confers only partial protection and should be considered as only one of several other prevention measures". "Biologically, there are several possible reasons why circumcised men are less likely to contract HIV: (1) the foreskin is moist and helps the virus survive and reproduce. When the foreskin is removed, this moist environment is eliminated as well; (2) the foreskin is not keratinized and thus may have greater susceptibility to tears during intercourse, providing a portal of entry for pathogens, including HIV;4 and (3) the foreskin has a high concentration of target cells to which the virus can attach and cause infection".*
- Needle exchange/safe
needle programs: Needle
exchange programs (NEPs) are not without controversy. NEP proponents argue that in the proper environment, IV Drug Users (IDUs) will choose sterile syringes and needles over contaminated injection apparatus, thereby reducing their risk of contracting or transmitting HIV and other blood borne disease. Zero drug tolerance proponents argue that clean needle programs should not be used to reduce the transmission of HIV and blood borne disease because they promote immoral and illegal behavior.
Recently, the 1988 restriction on federal funding for NEPs was lifted when the U.S. Surgeon General determined that NEPs are a form of treatment. Given appropriate leadership and resources, creation of NEPS in urban American HIV hot spots should duplicate the success experienced in cities like Vancouver, BC. Unfortunately many states, including Florida,
continue to restrict access to syringes by enforcing drug paraphernalia
laws, and regulating the purchase and sale of syringes in pharmacies.
- "In localities where sterile syringe distribution is illegal, IDUs are more likely to obtain syringes from unsafe sources and to engage in injecting risk behaviors. Legalizing and rapidly implementing sterile syringe distribution programs are critical for reducing parenterally transmitted HIV, HBV, and HCV among IDUs."*
- "Engaging drug abusers in drug treatment, needle exchange, and related programs is pivotal to primary prevention of HIV".*
- "needle-exchange programs have been widely demonstrated to be effective in reducing substance use-related risk behaviors (such as needle sharing) without increasing overall prevalence of substance use in either adults or youth".*
- "The lower the fraction of needles in circulation that are contaminated, the lower the risk of new HIV infections."*
- "There is no credible evidence to date that drug use is increased among participants as a result of programs that provide legal access to sterile equipment."*
Combining well managed needle-exchange programs, condom distribution and safe practice counseling offers a real opportunity to reduce HIV transmission. Where NEPs are thwarted, education
efforts must to be made to IDUs not to share needles, cotton, syringe,
or cookers - all of which may be contaminated with blood. People need to be encouraged
to use new needles and syringes or to sanitize their injection sets with full strength bleach and rinse thoroughly
with water before each use.
Substance abuse programs:
The United States has approximately 1.5 million injection drug users and many
additional people who use other drugs, such as cocaine, crack, or alcohol. However,
there are only about one-half million drug treatment slots available. Therefore,
meeting the needs of HIV positive people who suffer from substance abuse presents
a particular challenge.
is said to be the only 100% effective method of preventing sexually transmitted HIV infection.
Abstinence is an act of self-denial which implies capacity to consent to an act and the psychological, physical and economic independence to refuse to partake. Unfortunately, abstinence is not an option equally available to all persons:
have shown that up to 60% of young people who vow to remain abstinent do not
actually do so.
- Childtrends.org estimates that in 2002, in the U.S., 13% of females and 5% of males are the victim of statutory rape during their first sexual experience.*
- The U.S. Dept. of Justice reports that approximately 1.5 million women and 834,700 men are raped and/or physically assaulted by an intimate partner annually in the United States.
- "Hustling" or sex work is a common means of surviving on the streets and paying for drugs among homeless youth.*
Universal precautions are mandated by OSHA for health care workers, as
a way to prevent occupational exposure to blood borne pathogens, e.g. HIV, Hepatitis A, B, C,
Staph, Strep, Syphillis, TB, etc.
needle exchange is not available, injection drug users need to be taught
to sanitize their with full-strength bleach and rinse with water before