A Guide to Primary Care of People with HIV/AIDS
Chapter 4: Prevention of HIV in the Clinical Care Setting
Chapter 4:
Prevention of HIV in the Clinical Care Setting
RATIONALE FOR HIV PREVENTION IN PRIMARY CARE
INTERVENTIONS FOR HIV PREVENTION
KEY POINTS
SUGGESTED RESOURCES
REFERENCES
RATIONALE FOR HIV
PREVENTION IN
PRIMARY CARE
Why is HIV prevention important in the
HIV clinical care setting?
Why rob banks?…
Because that is where the money is!
There is growing awareness that the majority of people
living with HIV are having sex and that active substance
abuse, often with needle-sharing behavior, remains
common in the setting of HIV infection (see Chapter 13:
Management of Substance Abuse). The HIV clinical care
setting provides an opportunity to work with patients
to reduce their risk of transmitting HIV to others.
Studies are under way to measure the effectiveness of
comprehensive clinical care in preventing the spread of
HIV. Until those results are available, one should assume
that interventions to reduce HIV concentrations in the
body through antiretroviral therapy (ART) combined
with behavioral counseling to reduce high-risk sexual
behaviors and, when indicated, drug abuse treatment
are important approaches to decreasing the incidence
of HIV infection.
Do most primary care providers incorporate
HIV prevention into their care?
Experienced providers, and even HIV specialists, often
do not conduct screening and assessment of behavioral
risk or offer prevention counseling for their HIV-infected
patients. The degree to which these are neglected is
startling. Nationwide, approximately a third of HIV-
infected patients report that their providers have never
counseled them about HIV prevention; in some settings
as many as three quarters of HIV medical care providers
do not ask about sexual behavior and as many as half do
not ask about drug use (Marks et al, 2002; Natter et al,
U.S. Department of Health and Human Services, Health Resources and Services Administration, HIV/AIDS Bureau
Michael P. Johnson, MD, MPH
4
2002). Results of an unpublished study suggest that HIV
specialists are less likely than primary care physicians to
engage clients in discussions about sexual and drug-using
behaviors. Barriers of time, training, and comfort level
contribute to this missed opportunity for HIV prevention.
What factors are associated with high-risk
behaviors of people living with HIV?
People living with HIV often practice high-risk sexual
and drug-using behaviors in association with poor
adherence to clinical care in general and to ART
regimens in particular (Wilson et al, 2002). This is of
particular concern given the risk of viral resistance with
poor medication adherence, which may subsequently
result in transmission of resistant viral strains to others.
Also, both adherence to HIV prevention practices and
adherence to medication regimens appear to be related
to mental health problems, which are common among
people with HIV (Kalichman et al, 2002). In particular,
depression and anxiety disorders are common and
should be assessed in patients who report continued
high-risk sexual and drug-using behaviors. Any of
these conditions should alert the provider to probe
for problems in the other conditions or behaviors;
addressing underlying issues can lead to improvements
in several important behaviors.
What behavioral inter ventions work
to prevent people living with HIV from
transmitting HIV?
The earliest behavioral interventions provided factual
information and generated fear of AIDS to motivate
people to reduce high-risk behavior. Most experts now
agree that these interventions do not effectively reduce
high-risk behaviors of persons at greatest risk for
acquiring HIV, and that generating fear of AIDS most
likely increases stigmatization of people living with
HIV infection.
21
 A Guide to Primary Care of People with HIV/AIDS
Chapter 4: Prevention of HIV in the Clinical Care Setting
A number of counseling interventions have been
found to be more effective than providing knowledge
alone. Among these effective approaches are brief,
provider-delivered counseling messages, which can
be delivered within the context of a clinical encounter
(Kamb et al, 1998; CDC, 2001). Several theoretical
behavioral models have been used to guide counseling
interventions. Some common elements of these theory-
based counseling approaches include:
• Establishing dialogue and rapport with the client
and providing ongoing services in an understanding
4 and nonjudgmental manner, often with the support
of trained peers to supplement the provider-based
counseling
• Understanding and addressing client needs, situations,
and pressures for sexual and drug-using behavior (eg,
mental health needs), with emphasis on issues that
might be perceived by the client as more pressing
than HIV prevention (eg, food, housing, employment),
and external barriers to the adoption of safer
behaviors (eg, domestic violence)
• Addressing the client’s high-risk behavior in a
step-wise manner, understanding the readiness
and motivation for a change in each specific high-
risk behavior, and building the client skills for
implementing such changes
These elements are the basis for the assessment and
counseling recommendations discussed below, which
can be implemented in the clinical setting, along with
planning and mobilization of supportive services.
What is the role of drug abuse treatment in
preventing HIV transmission?
Sharing of drug-injection paraphernalia is directly
related to HIV transmission through the transmission
of infected blood. Drug and/or alcohol abuse indirectly
lead to HIV transmission through the exchange of sex
for drugs and enhanced sexual risktaking under the
influence of these substances. Drug abuse treatment is
an important intervention in the setting of HIV clinical
care (see Chapter 13) and should be considered as
an important and effective means of HIV prevention
among persons with HIV who abuse drugs and/or
alcohol.
What is known about the role of antiretroviral of nonoccupational HIV transmission if therapy is
therapy in preventing HIV transmission?
Effective ART leads to a decline in plasma viral
load, which reduces the risk of maternal-infant HIV
transmission. The risk of sexual transmission of HIV
is strongly correlated with plasma HIV levels (Quinn,
2000) (see Figure 4-1). There is also a strong correlation
between changes in plasma viral load and the HIV
22 U.S. Department of Health and Human Services, Health Resources and Services Administration, HIV/AIDS Bureau
viral load in genital secretions (Ball et al, 1999);
however, HIV can be present in genital secretions
when plasma HIV is suppressed below the level of
detection. While it is highly likely that effective ART
leads to a significant reduction in HIV infectivity, from
a behavioral standpoint an increase in high-risk sexual
behavior because of a sense of lower risk to others
has been observed in persons being treated with ART
(Dukers, 2001; Scheer, 2001). For this reason, HIV
prevention counseling remains important for those on
effective ART, and it is particularly important when viral
loads rise, eg, due to interruption of therapy and/or
emergence of viral resistance.
Figure 4-1. Associations of HIV Plasma Viral
Load and Sexual Transmission of HIV
25
per 100 person-years
Transmission Rate
20
15
10
5
0
>50,000 10,000-49,999 3,500-9,999 400-3,499 <400
HIV-1 RNA (copies/ml)
Source: Quinn TC, Wawer MJ, Sewankambo N, et al. Viral load and
heterosexual transmission of human immunodeficiency
virus type 1. N Engl J Med. 2000;342:921-929. Copyright
2000 Massachusetts Medical Society. All rights reserved.
Reprinted with permission.
What is the role of nonoccupational
postexposure prophylaxis (nPEP) in the
prevention of HIV infection?
Nonoccupational postexposure prophylaxis (nPEP)
refers to the use of ART to prevent HIV after a
significant sexual exposure to HIV (eg, after sexual
assault or condom breakage during intercourse
between a discordant couple). A complete review
of postexposure prophylaxis (PEP) can be found in
Chapter 11: Postexposure Prophylaxis. In summary, a
28-day course of ART may be considered for prevention
initiated within 72 hours after a significant exposure
from a person with known or suspected HIV infection.
This approach will be addressed in upcoming US Public
Health Service (PHS) guidelines for nPEP (watch the
AIDSInfo website listed in Suggested Resources for
these guidelines).
 A Guide to Primary Care of People with HIV/AIDS
Chapter 4: Prevention of HIV in the Clinical Care Setting
INTERVENTIONS FOR HIV
PREVENTION
What can the provider do to enhance Closed-ended Risk-screening Questions
prevention practice in the clinical setting?
Primary care interventions to assess and reduce the
risk that HIV-infected persons will transmit the virus to
others can be conducted at the level of 1) medical care,
2) other care (eg, case management, social services),
and 3) clinic structure. Ideally, interventions at all 3
levels are combined to maximize the opportunities
for HIV prevention, and each clinic will structure its
interventions differently according to its configuration
and resources. The following recommendations are
directed primarily to the medical provider, although
there are often other clinic staff members who support
and reinforce these risk assessment and counseling
interventions. Training can enhance the skills and
motivation for providers to integrate these activities
into their routine practice (see Suggested Resources and
Chapter 18: Keeping Up-to-Date: Sources of Information
for the Provider).
How can the provider identif y a patient’s risk
behaviors? For each of your partners, do you know if
A brief history should be taken at each regularly
scheduled clinic visit to identify knowledge of HIV
transmission, sexual and drug-using behavior, and
symptoms of an STD (eg, urethral or vaginal burning
or discharge, dysuria, genital or anal ulcers, inter-
menstrual bleeding, or lower abdominal pain in
women). History-taking methods include written,
audio, and computerized questionnaires and face-to-
face interviews, using either structured or open-ended
questions (see examples in Table 4-1). Studies suggest
that patients may provide more honest and detailed
responses to questionnaires not administered face-to-
face. Also, physicians trained in discussing sensitive
sexual and drug-using issues are likely to perform
better than those who are not. Providers should give
positive reinforcement to patients when the screening
questions indicate no high-risk sexual and drug-using
behaviors. Conversely, indications of high-risk behavior
should trigger a medical/laboratory evaluation for
STDs, behavioral risk assessment and counseling
interventions, and referral and contact notification,
as indicated. For more detailed discussion, see the
section on Risk Assessment and Counseling in Chapter
2: Approach to the Patient as well as the screening
questions for drug abuse in Chapter 13: Management of
Substance Abuse.
U.S. Department of Health and Human Services, Health Resources and Services Administration, HIV/AIDS Bureau
Table 4-1. Examples of Open- and
Open-ended questions
What do you know about HIV transmission?
What, if anything, are you doing that could
result in transmitting HIV to another person?
Tell me about any sexual activity since your last
clinic visit. 4
What do you know about the HIV status of each
sex partner?
Tell me about condom use during any sexual
activity.
Tell me about any drug use or needle sharing
since your last clinic visit.
Closed-ended questions
Do you know the facts about how HIV is and is
not transmitted?
Have you had sex (vaginal, anal, or oral) with
any partner since your last clinic visit?
he/she has HIV infection, doesn’t have HIV
infection, or are you not sure?
Did you use a condom every time, from start to
finish of each sexual encounter?
Have you shared drug injection equipment
(including needle, syringe, cotton, cooker,
water) with anyone?
Note: Symptoms of STDs (eg, urethral or vaginal
burning or discharge, dysuria, genital or
anal ulcers, inter-menstrual bleeding or
lower abdominal pain among women)
are asked in a closed-ended format,
regardless of behavioral question format.
What medical and laboratory screening should
be done?
Symptoms or signs of an STD or known exposure to
STDs should prompt immediate physical and laboratory
examinations. However, because STDs are often present
without symptoms, every patient should be screened
for laboratory evidence of syphilis, trichomonads
(women only), gonorrhea, and chlyamdia at the initial
visit and at least annually (see Table 4-2). Some experts
also recommend type-specific testing for herpes
simplex virus type 2 because of its association with
a higher risk of HIV transmission and possible need
23
 A Guide to Primary Care of People with HIV/AIDS
Chapter 4: Prevention of HIV in the Clinical Care Setting
for enhanced counseling. More frequent screening
for STDs is appropriate with evidence or suspicion of
high-risk sexual behavior (eg, sex with a new partner,
sexual activity without consistent and correct condom
use); however, there are no data to guide the precise
frequency. More frequent screening might also be
appropriate in asymptomatic men who have sex with
men (MSM) and younger women because of a higher
STD prevalence among these demographic groups.
The local prevalence of these infections might guide
frequency of screening. Laboratory screening for drug
4 abuse is addressed in Chapter 13.
Table 4-2. Screening for Sexually
Transmitted Diseases
STD Recommended test
Syphilis Non-treponemal serologic test
(RPR, VDRL)
Gonorrhea Nucleic acid amplification test
(first-catch urine or urethral [male]/
cervical [female] specimen) or
culture (urethral [male]/cervical
[female] specimen)
Chlamydia Nucleic acid amplification test
(first-catch urine or urethral [male]/
cervical [female] specimen)
Trichomonas Wet mount or culture
(vaginal secretion)
Herpes simplex virus Type-specific HSV-2
antibody testing
What behavioral assessment and counseling additional HIV-infected persons through HIV counseling
inter ventions should the provider implement?
Specific suggestions for assessment and counseling
are presented in Table 4-3 and in Chapter 2. Each
clinic must decide which aspects of HIV prevention
assessment and counseling are best done by the
primary provider, by other clinical providers with whom
the patient interacts, or some combination of both.
Brief interventions by physicians have been found to
be effective with other conditions, including smoking
cessation, improving dietary behavior, and reduction of
alcohol consumption. Thus, while data are limited on
the topic of HIV prevention, physicians should provide
such counseling until studies suggest alternate and
improved approaches.
24 U.S. Department of Health and Human Services, Health Resources and Services Administration, HIV/AIDS Bureau
How can clinic staff other than the primary
medical provider enhance HIV prevention
practice?
In most medium-sized and larger clinics, staff
members other than the primary medical provider
are responsible for referral, contact notification, and
quality improvement, which can all be used to enhance
prevention practice, as discussed below. In addition,
specific structural interventions (eg, arranging client
flow to ensure interaction with clinic staff who conduct
prevention counseling, use of video, written handouts
or other educational media, and distribution of
condoms) can strengthen the role of other clinic staff in
prevention activities.
What role does referral to community
resources play in HIV prevention?
Some complex patient issues and conditions fall
beyond the scope of a primary care clinic and must
be addressed before risky behavior can be reduced or
eliminated. These include drug abuse, mental health
issues, domestic violence, and assistance with needs
such as housing, food, and employment. Each clinic
should have established relationships with community
resources to address these issues, and staff members
should have thorough knowledge of the available
services as well as mechanisms in place to ensure that
patients can access the services. Finally, followup should
be done to be certain that the referrals are utilized
and are effective for each patient. It is unlikely that
persons at highest risk for transmitting HIV to others
can effectively reduce such behavior without access to a
comprehensive array of services and supports.
What are key elements of contact notification?
Contact notification is an effective way to identify
and testing, bring them into care, and provide support
to help them avoid transmitting HIV to others. Health
departments traditionally conduct contact notification;
in some States providers are required by law to report
to the health department known sexual or drug-
equipment-sharing contacts of persons infected with
HIV. The standard method is to inform the patient’s
contacts that they have been placed at risk and need
HIV testing without identifying the source.
 A Guide to Primary Care of People with HIV/AIDS
Chapter 4: Prevention of HIV in the Clinical Care Setting

Table 4-3. Suggested Counseling Content for Behavioral Risk Reduction

Factual topics about

HIV transmission Suggested content

Relative risk of HIV transmission during sex Most to least risky activities: receptive anal > receptive vaginal > insertive anal >
insertive vaginal > receptive oral > insertive oral

Preventing HIV transmission during Abstinence (safest behavior)

sexual activity Correct condom use (latex or polyurethane condoms, used with water-based,
not oil-based, lubricants, used from start to finish of any sexual penetration) 4
Other means of reducing risk

Effect of drug use on sexual decisionmaking Potential increase in sexual risk behavior following drug and/or alcohol use

Risk of HIV transmission when Highest risk for HIV transmission

sharing drug-injection equipment Risk of other disease transmission for either user
Entire works (drug paraphernalia), not only needles, need to be clean

Impact of viral load level on HIV Greatest risk of HIV transmission when viral load is elevated
transmission risk (eg, when antiretroviral therapy is stopped or is ineffective)
HIV transmission still possible during effective antiretroviral therapy (eg, there
can be HIV in genital secretions even when plasma viral load is undetectable)

Components of assessment
and counseling Suggested content

Motivation for HIV prevention Risk to self: acquiring non-HIV infectious agent and acquiring
drug-resistant HIV strain
Risk to others: transmitting HIV

Readiness and capacity for HIV prevention Patient’s belief about his/her desire, intent, and sense of capacity
to adopt behaviors that prevent HIV transmission

Barriers to adopting safer sexual and drug-using Identification of barriers, such as mental health needs, substance
behaviors abuse, domestic violence, and other social and economic pressures that might
impede the adoption of behaviors to prevent the transmission of HIV

Willingness to accept in-depth counseling Identification of history of past efforts to address the issue impeding
and/or referral to overcome barriers to the adoption of safer behavior
adopting safer behaviors Encouragement and offering of assistance for more
in-depth support through referral

Development of an HIV prevention plan Creation of a plan mutually agreeable to patient and provider,
written for both the medical record and the client

Discussion of reproductive intentions Assessment of need for in-depth counseling with HIV-experienced
obstetrician to address risks and benefits of conception

U.S. Department of Health and Human Services, Health Resources and Services Administration, HIV/AIDS Bureau 25
 A Guide to Primary Care of People with HIV/AIDS
Chapter 4: Prevention of HIV in the Clinical Care Setting

How can HIV prevention be made a part of

routine clinic practice?
HIV prevention, often neglected as a component of
HIV clinical care, is more likely to be a part of routine
clinic practice if it is part of the clinical continuous
quality improvement activities (see Chapter 17: Quality
Improvement). While the most effective indicators for
prevention practice in the clinical setting are not known,
considerations include medical record documentation
of risk assessment history, prevention counseling,
medical/laboratory examination for STDs, establishment
4 of a prevention plan, and completion of referrals. There
should be regular assessment of whether such tasks
are completed and regular feedback to staff members
regarding the success rates of completing these
interventions. Finally, training interventions should
be guided by data from these quality improvement
activities (see Chapter 18).
KEY POINTS
The HIV clinical care setting offers
an ongoing opportunity to work
with patients to reduce their risk of
transmitting HIV to others.
Common elements of behavioral
interventions to reduce HIV risktaking
include establishing rapport with the
patient, addressing immediate patient
needs (eg, mental health problems,
substance abuse, housing), and working
in small steps to build motivation and
skills for change.
SUGGESTED RESOURCES
Institute of Medicine/Committee on
HIV Prevention Strategies in the United
States. No time to lose: getting more
from HIV prevention. Ruiz MS, Gable
AR, Kaplan EH, Stoto MA, Fineberg HV,
Trussell J, eds. Washington DC: National
Academy Press. 2001.
Centers for Disease Control and Prevention.
Advancing HIV prevention: New strategies
for a changing epidemic – U.S. 2003.
MMWR. 2003;52:329-332. Available at
http://www.cdc.gov/hiv/pubs/mmwr.htm.
Centers for Disease Control and
Prevention. Incorporating HIV prevention
into the medical care of persons living
with HIV. MMWR. 52(RR12):1-24. July 18,
2003. Available at: http://www.cdc.gov/hiv/
pubs/guidelines.htm#prevention.
WEBSITES
AIDSInfo: http://www.AIDSInfo.nih.gov
Accessed 11/03.
HIVInsite: http://www.hivinsite.org?InSite?p
age=Prevention Accessed 11/03.

A brief history of patient risk behaviors STD/HIV Prevention Training Centers

and HIV prevention counseling should be (PTCs): http://depts.washington.edu/nnptc
parts of each patient visit.
Accessed 10/03.
Besides HIV prevention counseling, the
following are important components of
HIV prevention in the clinical setting:
contact notification, drug abuse treatment,
screening for STDs, decreasing the
patient’s viral load through ART, and nPEP.
Structural interventions for HIV
prevention include making available
educational materials and condoms,
establishing strong referral relationships
with social service and substance abuse
services, and incorporating prevention
indicators into quality improvement
activities.

26 U.S. Department of Health and Human Services, Health Resources and Services Administration, HIV/AIDS Bureau
 A Guide to Primary Care of People with HIV/AIDS
Chapter 4: Prevention of HIV in the Clinical Care Setting
REFERENCES
Ball JK, Curran R, Irving WL, Dearden
AA. HIV-1 in semen: determination of
proviral and viral titres compared to blood,
and quantification of semen leukocyte
populations. J Med Virol. 1999;59:356-363.
Centers for Disease Control and Prevention.
Revised guidelines for HIV counseling,
testing and referral. MMWR. 2001;50
(RR-19):1-57.
Dukers NH, Goudsmit J, de Wit JB, Prins
M, Weverling GJ, Coutinho RA. Sexual
risk behavior relates to the virological
and immunological improvements during
highly active antiretroviral therapy in HIV-1
infection. AIDS. 2001;15:369-378.
Kalichman SC, Rompa D, Luke W, Austin
J. HIV transmission risk behaviors among
HIV positive persons in serodiscordant
relationships. Int J STD/AIDS. 2002;13:677-
682.
Kamb ML, Fishbein M, Douglas JM, et al.
Efficacy of risk-reduction counseling to
prevent human immunodeficiency virus and
sexually transmitted diseases; a randomized,
controlled trial. Project RESPECT Study
Group. JAMA. 1998;280:1161-1167.
U.S. Department of Health and Human Services, Health Resources and Services Administration, HIV/AIDS Bureau
Marks G, Richardson JL, Crepaz N, et al. Are
HIV care providers talking with patients
about safer sex and disclosure?: A multi-
clinic assessment. AIDS. 2002;16:1953-1957.
Natter J, Fiano T, Gamble B, Wood RW.
Integrating HIV prevention and care services:
the Seattle “Collaboration Project.” J Public
Health Manag Pract. 2002 Nov;8:15-23.
4
Quinn TC, Wawer MJ, Sewankambo N, et al.
Viral load and heterosexual transmission of
human immunodeficiency virus type 1. N
Engl J Med. 2000;342:921-929.
Scheer S, Chu PL, Klausner JD, Katz MH,
Schwarcz SK. Effect of highly active
antiretroviral therapy on diagnoses of
sexually transmitted diseases in people with
AIDS. Lancet. 2001;357:432-435.
Wilson TE, Barron Y, Cohen M, et al. The
Women’s Interagency HIV Study. Adherence
to antiretroviral therapy and its association
with sexual behavior in a national sample
of women with human immunodeficiency
virus. Clin Infect Dis. 2002;34:529-534.
27