CLINICAL CARE-BASED PREVENTION

Some guidance on how to integrate HIV prevention into clinical care is available from the U.S. Preventive Services Task Force Guide to Clinical Preventive Services (U.S. Preventive Services Task Force, 1996), which provides a careful review of scientific evidence and indicates which preventive services are most effective. First, the guide recommends that all adolescents and adult patients should be advised about risk factors for HIV and other sexually transmitted diseases (STDs), and counseled about effective measures to reduce the risk of infection. Clinicians are further recommended to assess risk factors for HIV infection by obtaining a careful sexual and drug use history for all patients, and to periodically screen for infection among all persons at increased HIV risk. Providers who care for injection drug users (IDUs) are recommended to advise them about measures to reduce their risk of infection and to refer them to appropriate drug treatment facilities. These basic HIV prevention recommendations become even more critical for clinicians that provide care to patients known to be HIV-infected.

The Committee believes that, in all clinical care settings serving HIV-infected persons and those at high risk of infection, the standard of care should include the taking of sexual and drug-using histories to help determine each patient’s risk and the appropriate level of HIV prevention intervention. If an HIV-infected individual is found to have another STD, this in itself should trigger the delivery of some type of HIV prevention counseling, as STD infection is a marker for risky sexual behavior. This is particularly important because studies have shown that STDs in an HIV-infected individual may facilitate HIV transmission by increasing the concentration of the virus in genital secretions (Moss and Kreiss, 1990; Cohen et al., 1997).

Even HIV-infected persons receiving antiretroviral therapy can still spread infection. Some studies have shown that antiretroviral therapy can reduce a person’s viral load, which has been associated with a decrease in infectiousness of the person’s blood or genital secretions (Musicco et al., 1994; Royce et al., 1997; Ragni et al., 1998). These findings suggest the potential use of antiretroviral therapy in HIV prevention. However, a recent study shows that treated individuals may continue to shed HIV even after 6 months of therapy, and thus may continue to pose at least some risk for transmitting the virus to sex partners (Barroso et al., 2000). In addition, recent statistics showing a rise in HIV infections among San Francisco’s gay male population (San Francisco Department of Public Health et al., 20001), a community that has high levels of access to antiretroviral therapy, heightens the need to focus prevention interventions on HIV-infected persons and to develop multifaceted approaches to



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