Despite substantial advances in the treatment of human immunodeficiency virusHIV AIDS infection, the estimated number of annual new HIV infections in the United States has remained at 40,000 for over 10 years. HIV prevention has mostly focused on persons who are not infected, in order to help them avoid becoming infected. However, further reduction of HIV transmission will require new strategies, including increased emphasis on preventing transmission by HIV-infected persons. HIV-infected persons who are aware of their HIV infection tend to reduce behaviors that might transmit HIV to others. Nonetheless, recent reports suggest that such behavioral changes often are not maintained and that a substantial number of HIV-infected persons continue to engage in behaviors that place others at risk for HIV infection.
Reversion to risky sexual behavior might be as important in HIV transmission as failure to adopt safer sexual behavior immediately after receiving a diagnosis of HIV. Unprotected anal sex appears to be occurring more frequently in some urban centers, particularly among young men who have sex with men (MSM). Bacterial and viral sexually transmitted diseases (STDs) in HIV-infected men and women receiving outpatient care have been increasingly noted, indicating ongoing risky behaviors and opportunities for HIV transmission. Further, despite declining syphilis prevalence in the general U.S. population, sustained outbreaks of syphilis among MSM, many of whom are HIV infected, continue to occur in some areas; rates of gonorrhea and chlamydial infection have also risen for this population. Increased STD rates amoung MSM show increased potential for HIV transmission, both these rates suggest ongoing risky sexual behavior, and because STDs increases HIV's infectivity and susceptibility. Studies suggest that optimism about the effectiveness of highly active antiretroviral therapy (HAART) for HIV may be contributing to relaxed attitudes toward safer sex practices and increased sexual risk-taking by some HIV-infected persons.
Drug use still continues to play a big role in the HIV pandemic; 28% of HIV/AIDS cases in adults and adolescents with known HIV risk category report to the CDC in 2000 were associated with needle drug use. In some large drug-using communities, HIV seroincidence and seroprevalence among injection drug users (IDUs) have declined in recent years. The decline has been a result of several things, including a increased use of sterile needles, lower rates of needle sharing, shifts from injection to noninjection methods of using drugs, and the cessation of drug use. However, injection-drug use among young adult heroin users has increased substantially in some areas a reminder that, as with sexual behaviors, changes to less risky behaviors may be difficult to sustain.
Clinicians providing medical care to HIV-infected persons can play a key role in helping their patients reduce risk behaviors and maintain safer practices and can do so with a feasible level of effort, even in constrained practice settings. Clinicians can greatly affect patients' risks for transmission of HIV to others by performing a brief screening for HIV transmission risk behaviors; communicating prevention messages; discussing sexual and drug-use behavior; positively reinforcing changes to safer behavior; referring patients for such services as substance abuse treatment; facilitating partner notification, counseling, and testing; and identifying and treating other STDs. These steps may also help to decreaste a patients' risks of getting other STDs and bloodborne infections (e.g., hepatitis). Managed care plans can play an important role in HIV prevention by incorporating these recommendations into their practice guidelines, educating their providers and enrollees, and providing condoms and educational materials. Prevention services might be delivered in a clinical or office setting or even through referral to community programs. Some clinicians have expressed concern that reimbursement is often not provided for prevention services and note that improving reimbursement for such services might enhance the adoption and implementation of these guidelines.
