HIV PREVENTION AND RISK REDUCTION STRATEGIES

HIV is preventable. Nevertheless, new infections continue to occur despite the knowledge available about how the virus is transmitted and the means to prevent its transmission or acquisition.

Individual Risk Reduction

A patient’s individual HIV risk can be determined through risk screening based on self-reported behavioral risk and clinical signs or symptoms. In addition to an assessment of behavioral risk, a comprehensive STI and HIV risk assessment includes screening for HIV and STIs. After a sexual history has been obtained, all providers can encourage risk reduction by offering prevention counseling to all sexually active adolescents and to all adults who have received an STD diagnosis, have had an STD during the prior year, or who have had multiple sex partners. Such counseling can reduce behaviors that result in higher risk of HIV infection.

ASSESSING BEHAVIORAL RISKS

Behavioral risks can be identified either through open-ended questions by the provider or through screening questions (e.g., a self-administered questionnaire). An example of an open-ended question is: “What are you doing now or what have you done in the past that you think may put you at risk of HIV infection?”

Common risk assessment questions can include:

• Have you or your sexual partner(s) had other sexual partners in the past year?
• Have you ever had a sexually transmitted infection?
• Are you pregnant or considering becoming pregnant?
• Have you or your sexual partner(s) injected drugs or other substances and/or shared needles or syringes with another person?
• Have you ever had sex with a male partner who has had sex with another male?
• Have you ever had sex with a person who is HIV infected?
• Have you ever been paid for sex (e.g., money, drugs) and/or had sex with a prostitute/sex worker?
• Have you engaged in behavior resulting in blood-to-blood contact (e.g., S&M, tattooing, piercing)?
• Have you been the victim of rape, date rape, or sexual abuse?
• Have you had unprotected anal or vaginal sex?
• How do you identify your gender (male, female, trans, other)?
  (Skidmore College, 2023)

PREVENTION COUNSELING AND BEHAVIORAL STRATEGIES

Studies have shown that risk reduction and prevention counseling decreases the risk of sexually transmitted diseases, including HIV. Counseling can range from brief messages, to group-based strategies, to high-intensity behavioral discussions tailored to the person’s risk. It is most effective if provided in a manner appropriate to the patient’s culture, language, sex and gender identity, sexual orientation, age, and developmental level. Client-centered counseling and motivational interviewing can also be effective. Training in these methods is available through the National Network of STD Prevention Centers (see also “Resources” at the end of this course) (CDC, 2021f).

Healthcare providers can counsel patients in behavioral strategies to prevent the spread of HIV infection, including:

• Sexual abstinence, since not having oral, vaginal, or anal sex is the only 100% effective option to prevent the sexual transmission of HIV
• Limiting the number of sex partners, since the more sex partners one has, the more likely one of them has poorly controlled HIV or has a partner with an STI
• Condom use, since using condoms correctly and every time when engaging in sexual activity will reduce HIV transmission risk as well as that of other STIs (see box below)
• For women who are unable to convince their partners to use a condom, assessing other barrier methods
• HIV testing, both for the patient and their partner(s)
• Screening and treatment for STDs, due to the shared risk factors for HIV and other STDs
• Stopping injection drug use, or if unable to stop injecting drugs, using only sterile drug injection equipment and rinse water and never sharing equipment with others
• Circumcision, which has demonstrated efficacy in reducing risk among heterosexual men

For people who inject drugs, additional risk reduction interventions can include:

• Voluntary opioid substitution or buprenorphine-naltrexone therapy and participation in needle exchange programs, which has been found to decrease illicit opioid use, injection use, and sharing injection equipment
• Participating in needle exchange or supervised injection programs, which have been found to decrease needle reuse and sharing and to increase safe disposal of syringes and more hygienic injection practices
  (HIV.gov, 2023f)

Antiretroviral-Based Prevention Strategies

In addition to behavioral strategies, antiretroviral-based strategies have proven highly effective in preventing and reducing HIV transmission.

Pre-exposure prophylaxis (PrEP) is for adults who are not infected by HIV but who are at high risk of becoming infected. As a part of PrEP, ART medication is taken consistently every day to reduce the risk of HIV infection through sexual contact.

Post-exposure prophylaxis (PEP) involves taking ART medication to prevent HIV infection after a recent exposure. PEP must be started within 72 hours after a possible exposure and taken daily for 28 days (CDC, 2023e).

For couples in which one is HIV infected and the other uninfected (i.e., serodiscordant), recommendations include:

• Initiation of ART in the infected partner in order to prevent transmission to the uninfected partner; PrEP for the uninfected partner
• Continued use of condoms even when the infected partner has achieved viral suppression and the risk of HIV transmission is negligible, in order to reduce the risk of STD transmission and in case there is a failure in viral suppression

The risk of transmitting HIV from mother to child can be 1% or less if the mother takes HIV treatment as prescribed throughout pregnancy and delivery and the baby is given HIV medications for 2–6 weeks following birth. If the mother’s viral load is not low enough, a cesarean delivery can help prevent HIV transmission. Antiretroviral treatment also can reduce the risks of transmitting HIV through breast milk to less than 1% (CDC, 2023f).

Reducing Occupational Exposure to Bloodborne Pathogens

In the United States from 1985 to 2013, a total of 58 confirmed and 150 possible cases of occupational transmission of HIV were reported. Only one of those confirmed cases occurred after 1999. Of the 58 confirmed cases, 49 resulted from a percutaneous cut or puncture. From 2000 onward, occupationally acquired HIV infection in the United States has become exceedingly rare, a finding that supports the efficacy of post-exposure prophylaxis (PEP) (Spach & Kalapila, 2023).

Washington Administrative Code (WAC) 296-823 mandates that the rules for Safety Standards be followed for occupational exposure to bloodborne pathogens as adopted under the Washington Industrial Safety and Health Act of 1973 (Chapter 49.17 RCW) and as enforced by the Department of Labor and Industries Division of Occupational Safety and Health.

EXPOSURE CONTROL PLAN (ECP)

Under WAC 296-823, each employer covered must develop and implement a written exposure control plan and training that contains the following elements:

• A plan for protecting employees from risk of exposure to blood or other potentially infectious materials (OPIM)
• Training to employees about risk of exposure to bloodborne pathogens and ways to protect themselves
• Additional training when tasks or procedures are added or changed that affect an employee’s occupational exposure
• Maintaining training records
• Making the hepatitis B vaccination available to employees
• Using feasible controls to eliminate or minimize occupational exposure to blood or other potentially infectious material (OPIM)
• Using controls, including appropriate equipment and safer medical devices, to eliminate or minimize occupational exposure
• Making sure items are appropriately labeled
• Prohibiting food, drink, and other personal activities in the work area
• Prohibiting pipetting or suctioning by mouth
• Handling regulated waste properly and safely
• Providing and ensuring personal protective equipment is used when work practices and controls will not fully protect employees from risk of exposure
• Ensuring employees who have been exposed to blood or other potentially infectious materials (OPIM) have appropriate post-exposure evaluation and follow-up available
• Establishing and maintaining medical records and recording all occupational injuries resulting from contaminated needle sticks or cuts from contaminated sharps
• Implementing and enforcing additional rules in research laboratories and production facilities engaged in the culture, production, concentration, experimentation, and manipulation of HIV and HBV
  (Washington State Legislature, 2020a)

BLOODBORNE PATHOGENS STANDARD TRAINING

In 1991, the Occupational Safety and Health Administration (OSHA) introduced and published the Occupational Exposure to Bloodborne Pathogens Standard, designed to protect workers in healthcare and related occupations from risk of exposure to bloodborne pathogens such as HIV and HBV. In Washington State, all new employees or employees being transferred into jobs involving tasks or activities with potential exposure to blood or other potentially infectious material (OPIM) must receive training in accordance with WAC 296-823-120 prior to taking on those tasks (Washington State Legislature, 2020a).

Full details for training requirements are found in the Washington Occupational Exposure to Bloodborne Pathogens, Chapter 296-823 WAC. (See “Resources” at the end of this course.)

EMPLOYER PROTOCOL FOR MANAGING OCCUPATIONAL EXPOSURES

If a healthcare worker experiences an HIV exposure in the workplace, the person should follow OSHA’s Bloodborne Pathogens Standard (29 CFR 1910.1030), which requires employers to make immediate confidential medical evaluation and follow-up available at no cost to workers who have an exposure incident. Management of exposure requirements include:

• Initial management. The first response is to cleanse the area thoroughly with soap and water. For punctures and small lacerations, the area is cleaned with alcohol-based hand hygiene. Exposed mucous membranes are irrigated copiously with water or saline.
• HIV testing. Healthcare personnel should immediately report a possible exposure to the occupational health department so the source patient can be screened for HIV as soon as possible.
• Offering post-exposure prophylaxis (PEP):
• If the source has known HIV infection
• When the HIV status of the source patient is unknown, while awaiting HIV testing results, particularly if the source patient has symptoms consistent with acute HIV infection or is at high risk for HIV infection
• If the source cannot be identified
(Zachary, 2023)

ADMINISTRATION OF POST-EXPOSURE PROPHYLAXIS

For most individuals, post-exposure prophylaxis should be started as early as possible, ideally within 1–2 hours. If more than 72 hours have elapsed, PEP is not initiated.

For most individuals, a three-drug regimen is utilized. However, there are special considerations for certain populations, including persons who are or could become pregnant and those persons with reduced kidney function.

PEP is continued for four weeks but can be discontinued if testing shows that the source patient is HIV negative. People receiving PEP are monitored for adverse reactions to the drugs and for drug toxicity.

For all individuals who have had an exposure to HIV, repeat HIV testing with an antibody-antigen test is performed at six weeks and four months post exposure. If an antibody test is used, repeat HIV testing is performed at six weeks, three months, and six months post exposure (Zachary, 2023).

HIV Transmission Prevention in the Home

Patients with HIV, family, and informal caregivers are educated in methods to prevent transmission of bloodborne pathogens in the home and to lower the risk of infection for the person living with HIV.

GLOVES AND HANDWASHING

Disposable gloves (latex, vinyl, or nitrile in case of the latex allergy) are worn if coming into contact with blood or body fluids. Any cuts, sores, or breaks in exposed skin are to be covered. Rubber gloves are worn when cleaning articles soiled with urine, feces, or vomitus, which may all contain nonvisible blood or other infectious material.

When a task is completed, gloves are carefully removed by pulling them off inside-out, one at a time, avoiding contact with any potentially infectious material. Gloves are changed and hands washed as soon as possible. Rubbing the eyes, mouth, or face while wearing gloves must be avoided. Disposable gloves are never washed and reused. Correct handwashing is critically important (Kaiser Permanente, 2022; St. Maarten AIDS Foundation, 2023).

HANDLING SHARPS AND SYRINGES

Needles, lancets, and syringes used in the home must be safely handled and disposed of properly. Needles must not be broken off from a syringe. All used sharps and syringes are placed in a safe container with at least a one-inch opening and a lid that will seal tightly, such as an empty plastic laundry detergent container or glass bottle or jar. If a glass jar is used, it is placed in a larger plastic bucket or container that has a tight-fitting lid. Containers are taped shut for added safety and labeled with the warning: “SHARPS, DO NOT RECYCLE!” Such containers are place well out of reach of children. The local health department can provide information on nearby disposal sites.

If needlestick injury does occur, the wound is to be washed with soap and water and medical attention sought as soon as possible for consideration of post-exposure prophylaxis (Kaiser Permanente, 2022).

KITCHEN SAFETY AND SAFE FOOD HANDLING

Kitchens can harbor bacteria that may prove life threatening to a person with HIV/AIDS due to their compromised immune system. Separate dishes or eating utensils are not required, and dishes used by a person infected with HIV do not require special methods of cleaning. A person with HIV may prepare meals if they choose to, as the virus cannot be spread through food handling.

To avoid becoming infected by food-borne pathogens, foods that should not be eaten by the person with HIV include:

• Raw eggs or foods that contain raw eggs (e.g., homemade cookie dough, eggnog)
• Raw or undercooked poultry, meat, and seafood
• Unpasteurized milk or dairy products and fruit juices

It is important to wash hands, cooking utensils, and countertops often when preparing foods and to keep foods separate in order to prevent the spread of infectious agents from one food to another. A food thermometer is used to make certain foods are cooked to safe temperatures. Meat, poultry, eggs, seafood, or other foods likely to spoil within two hours of cooking or purchasing must be refrigerated or frozen (HIV.gov, 2021b).

CLOTHING AND OTHER LAUNDRY

Clothing and linens used by a person infected with HIV do not need to be separated from the rest of the household laundry. Clothes, washable uniforms, towels, or other laundry stained with blood/OPIM should be washed and disinfected before further use. If necessary, gloves are worn to remove or handle such items. Items are placed in the washing machine and soaked/washed first in cold, soapy water to remove any blood from the fabric. A second hot-water washing cycle and detergent will act as a disinfectant. Items are dried in a clothes dryer. Wool clothing or uniforms may be rinsed with cold, soapy water then dry cleaned to remove and disinfect the stain (Kaiser Permanente, 2022; St. Maarten AIDS Foundation, 2023).

TOILET AND BEDPAN SAFETY

It is safe to share toilets/toilet seats without special cleaning, unless the surface becomes contaminated with blood or OPIM. If this occurs, spray the surface with 1:10 bleach solution. Wearing gloves, wipe the seat dry with disposable paper towels.

Persons with open sores on their legs, thighs, or genitals should disinfect the toilet seat after each use. Urinals and bedpans should not be shared between family members unless these items are thoroughly disinfected after each person’s use (Kaiser Permanente, 2022; St. Maarten AIDS Foundation, 2023).

PERSONAL HYGIENE ITEMS

People should not share razors, toothbrushes, personal towels, washcloths, or other personal hygiene items. All items that are soiled with blood, semen, or vaginal fluid and are not flushable (such as paper towels, sanitary pads and tampons, and wound dressings) are placed in a plastic bag and securely closed before being placing in a trash container. The local health department can provide information on nearby disposal sites (Kaiser Permanente, 2022; St. Maarten AIDS Foundation, 2023).

HOUSEHOLD PETS

Household pets are not dangerous to people infected with HIV as long as the animals are healthy and have up-to-date immunizations. If the infected person cleans litter boxes, fish tanks, or birdcages, rubber gloves are worn and hands washed immediately following removal of gloves. All pet care is followed by thorough handwashing.

• Cats’ claws and dogs’ nails should be kept trimmed.
• Latex or nitrile gloves should be worn to clean up any pet urine, feces, vomit, or OPIM. The soiled area should be cleaned with a fresh 1:10 bleach solution.
• Pet food and water bowls should be washed regularly in warm, soapy water and rinsed clean.
• Cat litter boxes should be emptied out regularly and washed at least monthly.
• Fish tanks should be kept clean. Heavy latex gloves that reach to the upper arms, such as “calf-birthing” gloves, can be purchased from a veterinarian for immunocompromised individuals to wear to clean a fish tank.
• Pets should not be allowed to drink from the toilet or eat other animal feces, any type of dead animal, or garbage.
• Cats should be restricted to indoors. Dogs should be kept indoors or on a leash.
  (Kaiser Permanente, 2022; St. Maarten AIDS Foundation, 2023)