A Guide to Primary Care of People with HIV/AIDS - Canadian Public ...

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A Guide to Primary Care of People with HIV/AIDS Chapter 4: Prevention of HIV in the Clinical Care Setting 4 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 abuse is addressed in Chapter 13. Table 4-2. Screening for Sexually Transmitted Diseases STD Syphilis Gonorrhea Chlamydia Trichomonas Herpes simplex virus Recommended test Non-treponemal serologic test (RPR, VDRL) Nucleic acid amplification test (first-catch urine or urethral [male]/ cervical [female] specimen) or culture (urethral [male]/cervical [female] specimen) Nucleic acid amplification test (first-catch urine or urethral [male]/ cervical [female] specimen) Wet mount or culture (vaginal secretion) Type-specific HSV-2 antibody testing What behavioral assessment and counseling interventions 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. 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 additional HIV-infected persons through HIV counseling 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 drugequipment-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. 24 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 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 sexual activity Abstinence (safest behavior) Correct condom use (latex or polyurethane condoms, used with water-based, not oil-based, lubricants, used from start to finish of any sexual penetration) Other means of reducing risk 4 Effect of drug use on sexual decisionmaking Potential increase in sexual risk behavior following drug and/or alcohol use Risk of HIV transmission when sharing drug-injection equipment Highest risk for HIV transmission 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 transmission risk Greatest risk of HIV transmission when viral load is elevated (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 Motivation for HIV prevention Suggested content 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 behaviors Identification of barriers, such as mental health needs, substance 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 and/or referral to overcome barriers to adopting safer behaviors Identification of history of past efforts to address the issue impeding the adoption of safer behavior 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
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