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US guidelines on prevention with people living with HIV now emphasise engagement with care, HIV treatment and social factors
Roger Pebody, 2015-01-05 09:00:00
The American public health agency, the Centers for Disease Control and Prevention (CDC) has published new recommendations on the HIV
prevention interventions and advice that should be offered to people who are
The CDC last issued guidelines on what is sometimes called
‘prevention with positives’ in 2003. Those guidelines ran to 24
pages and emphasised screening for behavioural risk factors and sexually
transmitted infections, one-to-one prevention counselling and advice delivered
by clinicians, other behavioural interventions, and partner notification.
All those elements remain but the scope of the new
guidelines is much broader, with the recommendations now running to 240 pages.
Whereas previous guidelines were clearly focused on the individual’s knowledge
and behaviour, the new recommendations take greater account of social and
structural factors as well as the profound impact that antiretrovirals have on
HIV transmission. For example, an individual may need support with poverty, mental
illness, substance use or unstable housing in order to be able to fully engage
with medical care and adhere to HIV treatment.
Moreover, the document reaffirms the central role of people
living with HIV in prevention. “A prevention strategy that aims to increase
access to effective biomedical, behavioral, and structural interventions for
the more than one million persons with HIV is more likely to decrease HIV
transmission than a strategy that attempts to change sexual and drug-injection
behaviors of the many millions of persons at risk for infection,” it states.
The recommendations have been developed in partnership with
the Health Resources and Services Administration, the National Institutes of
Health, the American Academy of HIV Medicine, the Association of Nurses in AIDS
Care, the International Association of Providers of AIDS Care, the National
Minority AIDS Council and the Urban Coalition for HIV/AIDS Prevention Services.
On many issues, the guidelines bring together and repeat
guidelines that have already been developed by those and other organisations. The
recommendations have also been made in light of the 2010 National HIV/AIDS
Strategy, notable for its concern with improving health equity and with a
better targeting of HIV prevention.
Setting out the context for the guidelines, the
weaknesses of the United States’ treatment cascade are described
straightaway. Far too many individuals who are diagnosed with HIV are not
linked to care and are unable to remain in care, with the result that only a
quarter of those living with HIV have an undetectable viral load. Furthermore,
less than half of those in care receive HIV prevention counselling and many do not have sexual health check ups.
Interventions to improve linkage to and retention in medical
care are seen as central to HIV prevention. Rather than simply offering
appointments or making referrals, services are expected to take a proactive
approach and to track outcomes (such as whether an appointment was attended). For
example, services providing HIV testing should assess
barriers and facilitators to starting medical care, make referrals to medical and
social services that could deal with underlying problems, and provide practical
help with making and attending appointments.
Health professionals are asked to help people living with
HIV enrol in private health insurance or programmes such as Medicare, Medicaid,
the AIDS Drug Assistance Program and the Department of Veterans Affairs. Several
recommendations tackle problems with obtaining healthcare; for example, recommending
that the programmes mentioned should be promoted as a population-level
strategy, or that information should be provided on options for obtaining
medication during a break in coverage.
Many of the recommendations on behavioural risk-reduction interventions are broadly
similar to those in the guidelines a decade ago. However, providers are now
expected to recommend biomedical as well as behavioural strategies.
Healthcare workers should inform all people with HIV about
the role of effective antiretroviral treatment in reducing HIV transmission, as
well as in improving their own health and lifespan. While some limitations of
antiretroviral treatment should be described (the need for adherence and lifelong
treatment, possible side-effects, the transmission risk not being entirely eliminated),
providers are urged to encourage patients to start antiretroviral
therapy within three months of diagnosis, regardless of CD4 cell count.
People with HIV must also be informed about the availability
– for their HIV-negative partners – of pre-exposure prophylaxis (PrEP) and
post-exposure prophylaxis (PEP).
A large part of the recommendations concern advice around
conception for men or women living with HIV who wish to have a child and specific
recommendations for women who are pregnant. Both men and women living with HIV
should receive reproductive health counselling. People in a relationship with
an HIV-negative partner should be informed of ways to reduce the risk of
transmission while conceiving, including antiretroviral therapy, timed
unprotected intercourse and PrEP.
The recommendations are notable for recommending that health
departments use routinely collected surveillance data in order to identify
individuals and social groups who are falling through the cracks. For
example, a person who has been diagnosed with HIV but has not had a CD4 cell count
may be sent an outreach worker who will attempt to help with linkage to care.
Similarly, a person taking antiretroviral treatment who has a rising viral load
may be identified as needing more effective treatment or adherence support. However,
the document notes that this approach must be handled with respect to patient
confidentiality, data security and local legislation (which differs from state
However, when it comes to the 33 American states which use
the criminal law to prosecute people for behaviours thought to run a risk of
HIV transmission (even including spitting and biting), the guidance sits on the
fence. It notes that the laws are controversial and have been subject to public
debate, but rather than suggesting steps to limit their application, asks
health professionals to make people with HIV aware of their legal obligations.
Detailed recommendations which are largely consistent with
existing guidelines are provided on topics including adherence support, partner
notification and other partner services, and the screening and treatment of
sexually transmitted infections.