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)
CONDOMS AND THEIR CORRECT USE

To reduce the risk of HIV and other sexually transmitted infections, a male (external) condom or a female (internal) condom for each sexual contact can be used. A male condom is a thin layer of latex, polyurethane (plastic) worn over the penis during sex. A female condom is a thin pouch made of synthetic latex designed to be worn in the vagina during sex. Condoms provide the best protection against HIV.

Do’s of condom use include:

  • Do use a condom every time you have sex.
  • Do put on a condom prior to having sex.
  • Do read the package and check the expiration data.
  • Do make sure there are no tears or defects.
  • Do store condoms in a cool, dry place.
  • Do use latex or polyurethane condoms.
  • Do use water-based or silicone-based lubricant to prevent breakage.

Don’t’s of condom use include:

  • Don’t store condoms in a wallet, as heat and friction can damage them.
  • Don’t use nonoxynol-9 (a spermicide), which can cause irritation.
  • Don’t use oil-based products like baby oil, lotion, petroleum jelly, or cooking oil, as they may cause the condom to break.
  • Don’t use more than one condom at a time.
  • Don’t reuse a condom.
    (CDC, 2022f)

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).

UNIVERSAL PRECAUTIONS AND STANDARD PRECAUTIONS

Universal Precautions were introduced and then mandated by OSHA in the early 1990s to protect both patients and healthcare staff members. The CDC expanded the concept of Universal Precautions by incorporating major safeguard features of the past into a new set of safety measures. These expanded measures are termed Standard Precautions. Regardless of a patient’s infection status, Standard Precautions must be used in the care of all patients to protect staff from the elements of blood, any body fluids, and secretions and excretions. These precautions include diligent hand hygiene and the use of personal protective equipment (PPE) (Broussard & Kahwaji, 2022; OSHA, 2021).

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)