Special Report
MIEC Claims Alert
Number 31
September 2001

The 20th year of AIDS: A time to re-energize prevention¹

• MMWR Weekly article
• MIEC recommendations
• How to reach MIEC

Since the first acquired immunodeficiency syndrome (AIDS) cases were reported in 1981, human immunodeficiency virus (HIV) has caused approximately 22 million deaths worldwide. In the United States, approximately 400,000 persons have died, and approximately one million have been infected. However, numerous persons have avoided infection through prevention efforts, and many lives have been prolonged through advances in treatment. 

The 20th year of AIDS is a milestone in the fight against HIV/AIDS; it is a time to remember persons who have become ill and died from the disease and to reflect on the progress made in both HIV prevention and treatment. A way to commemorate those persons who have died from AIDS is to accelerate efforts to stop HIV transmission. Accordingly, at this milestone, CDC has outlined a new strategy to reduce further HIV infection. 

The response to HIV/AIDS in the United States has demonstrated the necessity of collaboration between health officials and affected communities. Since the mid-to-late 1980s, CDC has worked with all sectors of society (e.g., state and local public health, media, business, religious, medical, and academic and community-based organizations) to inform the public about AIDS and implement prevention efforts. These efforts evolved from public information campaigns to highly targeted community-based programs using proven behavior interventions. During this time, U.S. infection rates declined dramatically. 

New strategies are needed to maintain and accelerate progress in HIV/AIDS prevention that sustain and reinvigorate communities most severely affected during the early years of the epidemic, particularly men who have sex with men and to meet the evolving needs of an increasingly diverse epidemic. Efforts also must be tailored to equip racial/ethnic minority communities with the skills and knowledge to prevent HIV infection. 

Highly active antiretroviral therapies have improved the length and quality of life for HIV-infected persons. However, some infected persons on treatment assume that they are not infectious and engage in behavior that increases risk for transmission.2 In addition, some persons may have decreased concern about infection because of advances in treatment. Increases in risk behaviors and rates of sexually transmitted diseases among men who have sex with men have been reported from multiple cities, which may herald an increase in HIV transmission. 

CDC begins the third decade of HIV/AIDS with a new strategic plan designed to reduce annual infections by half within 5 years. This three-part plan includes: 1) intensifying efforts to help all infected persons learn their HIV status; 2) establishing new prevention programs to help HIV-infected persons establish and maintain safer behaviors, combined with improved linkages to treatment and care; and 3) expanding highly targeted prevention programs to reach all HIV-negative persons at greatest risk. Additional information about the HIV strategic plan is available at http://www.cdc.gov/nchstp/od/news/prevention.pdf 

HIV prevention programs contribute to healthier behaviors and reduce the number of new HIV infections in the United States. An expanded and sustained commitment to prevention on a global, national, community, and personal level is required to further reduce the number of new infections and of persons living with HIV. 

Reference

1. MMWR Weekly. 50(21); 444-445. June 1, 2001. Reprinted with permission from the Centers for Disease Control and Prevention (CDC)

2. Dukers NHTM, Goudsmit J, de Wit JBF, Prins M, Weverling G-J, Coutinho RA. Sexual risk behavior relates to the virological and immunological improvements during highly active antiretroviral therapy in HIV-1 infection. AIDS 2001;15:369-78

MIEC Recommendations

Some physicians suggest they are too busy to engage in conversations about patients’ sexual behavior. In some cases, they may be inadequately trained or uncomfortable with discussions about sexual issues, or sensitive to potential discomfort on their patients’ behalf with such discussions. MIEC encourages physicians to make the time to evaluate patients for HIV exposure; to increase their competence and decrease their discomfort related to discussion of related issues; and to intensify their participation in the CDC’s newly invigorated strategies to further reduce HIV infection. The absence of physician collaboration in the fight against HIV and AIDS would leave a gaping hole between governmental and community efforts to retaliate against recent increased rates of high-risk behaviors and STD diagnoses that many believe will lead to a resurgence in HIV transmission.

What can physicians do to identify and treat patients with HIV and to encourage safer sex practices to reduce the transmission of HIV?

• Ask open-ended questions (those that must be answered with more than “yes” or “no”) to maximize the lines of communication. (e.g., “What safe sex techniques do you use?” or “Tell me a bit about how you practice safe sex.”)
• Ask about high-risk behaviors, rather than about high-risk groups. (“Have you had sex with men, women, or both?” rather than, “Are you a homosexual?”) Not all men who have sex with other men identify themselves as homosexuals.
• Phrase questions and responses in straightforward, nonjudgmental words. Say, “What is your partner’s HIV status?” and “What sexual experiences, if any, has your partner(s) had with someone other than you while you have been together?”
• Use simple terms with which you are comfortable. When possible, take cues from your patient’s vocabulary and use his or her terms for discussing sexual matters.
• Weave questions about sexual practices, “recreational” drug use, STDs, and “recreational” drug use as part of sexual experiences, into general discussions of health.
• Ask whether the patient has had sex with prostitutes, anonymous partners, or with IV drug users.
• Suggest HIV testing to all patients. As recommended by the CDC, in an effort to help all infected patients learn their HIV status and obtain treatment, and to reach HIV-negative patients at greatest risk, be prepared to either offer HIV testing to patients or make available information about sites for anonymous testing.
• Emphasize the confidentiality of anonymous testing to encourage voluntary tests. Know your state laws about exceptions to the confidentiality of HIV test results.
• Re-evaluate your personal attitudes about the subjects of sex, drug and needle use, and HIV transmission to ensure that your attitudes do not interfere with your professional and ethical obligations.
• Provide pre-and post-test counseling to all patients who request to be tested. The pre-test counseling should include discussion of why the patient wants the test, the meaning of the test results, the potential impact of a positive test result, the patient’s responsibility if HIV positive, and some of the treatment options available for HIV positivity. Patients should be told that a positive test result is not a diagnosis of AIDS; that occasional false-positive and false-negative results are reported; and that if the patient was recently infected with the virus, it may be too early to detect it, and a repeat test may be advisable.

When indicated, patients should be informed of high-risk sexual and needle-sharing behaviors that may transmit HIV, and techniques that reduce the risk of transmission.

Post-test counseling should include the results of the test; anxiety reduction for patients who experience stress related to the test; and for HIV positive patients, appropriate counseling and referrals for medical, emotional, social, and psychological support services. 

• Devise your own guidelines for sexual behavior risk assessment, and STD/HIV screening and counseling, or adapt those developed by state and local health departments. (Example: All men who have had sex with another man in the past year should be tested for HIV serology, syphilis serology, and a pharyngeal culture for Neisseria gonorrhoeae.)
• Dispense educational literature to all patients about high-risk behaviors; safer sex behaviors; the relationships between HIV exposure, drug use and needle-sharing; and the demographics of those at greater risk for HIV infection. 
• Develop a safety policy in your office to protect patients, staff and physicians from inadvertent exposure to HIV. Use universal precautions as established by OSHA (Occupational Safety and Health Administrations). Use a needle-less system. Dispose of biohazardous materials appropriately.

How to reach MIEC