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Healthcare workers

Can Healthcare Workers Help in HIV Prevention?

revised 4/99

Are healthcare providers important in prevention?

Yes. Healthcare providers have many opportunities to help foster the behavior changes needed to stem the spread of HIV infection. In the US in 1996, the average adult visited a physician 3 times a year. Overall, 82% of visits were in physician offices and 10% in emergency departments.¹ Visits with healthcare providers or other encounters with the healthcare system are “teachable moments”-opportunities for discussing sexual and drug-use risks in a manner relevant to individual patients’ lives. Healthcare providers in environments with large numbers of high-risk patients such as emergency departments, sexually transmitted disease (STD) clinics, methadone maintenance clinics and prison or jail clinics, can be crucial for HIV prevention. For example, men, women and adolescents who have been incarcerated have high rates of HIV, STDs and tuberculosis, as well as substance abuse problems, and would benefit from preventive information and medical services.² In a nationwide survey of adults, only 20% of patients had discussed HIV risks with their doctors in the previous five years. Only 21% of those who did talk to a physician said the physician initiated the discussion. And only 23% of those who reported a behavioral risk for HIV had spoken to their physician about AIDS.³

What are barriers to discussing HIV?

HIV prevention requires the ability to talk about sexuality and drugs in an open manner, which may be uncomfortable. Healthcare providers need training in initiating discussions, negotiating awkward moments, responding to fears and expectations, encouraging patient feedback and being empathic. Ways to help foster these skills include instructors acting as patients for role-play and videotaped feedback on clinical performance.⁴ Lack of time can be a huge barrier to discussing HIV risks for healthcare providers. Many hospitals, clinics and health maintenance organizations (HMOs) require healthcare providers to address prevention in many other areas such as diet and exercise, smoking, depression, diabetes, heart disease and cancer. With a limited amount of time allotted each patient, healthcare providers may feel there is not enough time to also discuss sensitive issues such as sexuality and drug use.

What can healthcare providers do?

Assessing HIV risk behaviors should be a standard part of new patient intake. In-depth AIDS prevention education is not necessary for each and every patient. However, healthcare providers should ask all patients about condom use, number of sexual partners, sexual orientation and injection drug use to assess a patient’s risk for HIV. These quick questions may lead to longer discussions and counseling about safer sex or drug use practices. Healthcare providers who don’t have the time or comfort for these discussions can refer patients to toll-free hotlines or community-based public health programs. Healthcare providers can provide HIV counseling and testing to patients who request it, and recommend testing to patients at high risk for HIV. These include patients with STDs, especially adolescents, injection drug users (IDUs), women whose partners may be IDUs and patients who are unsure of their partner’s HIV status.⁵ Helping patients get into drug treatment can be an effective HIV prevention tool. Healthcare providers can have a profound effect on patients’ lives by showing an interest in drug-using patients and encouraging willing patients to enter a drug or alcohol treatment program. Because relapse is common in treating addictions, healthcare providers should use a non-judgmental attitude.⁶ Healthcare providers who work with HIV+ patients can help prevent HIV transmission by assessing patients’ risky sexual and needle-use behaviors and counseling them to reduce those unsafe behaviors.⁷ This is especially important with the advent of more effective treatments for HIV. For example, HIV+ patients may believe that if they have a low or undetectable viral load, they cannot transmit HIV. Opportune moments for counseling are: at diagnosis, at onset of symptoms and when beginning drug treatment.⁸

Can treatment promote prevention?

Yes. Diagnosing and treating STDs such as syphilis and gonorrhea can help protect against HIV transmission. Early detection and treatment of STDs can be crucial, as STD infections make it easier to both get HIV and transmit it to others. In areas and populations with high rates of STDs and low rates of HIV infection, treating STDs is an effective means to prevent HIV infection.⁹ In recent years, great advances have been made in preventing HIV transmission from mother to infant. Healthcare providers should offer HIV testing to all pregnant women. Treating HIV+ mothers and their babies with AZT has been shown to reduce transmission by two-thirds. HIV+ mothers should also be counseled on the risk of breastfeeding and provided with alternates to breast milk if needed.¹⁰ Post-exposure prophylaxis (PEP) is a method for potentially preventing HIV transmission by administering AZT and other anti-HIV drugs within 72 hours of an accidental exposure to HIV. Studies of occupational PEP have found that HIV transmission can be prevented by post-exposure treatment, and PEP is now recommended by the Centers for Disease Control and Prevention (CDC) for occupational exposure among healthcare workers.¹¹ PEP is currently being piloted for exposure via sexual or drug use activities, including sexual assault. The CDC has not yet endorsed this due to lack of research data directly from drug and sexual exposure.¹²

What’s being done?

Healthcare providers need access to training and medical updates. One program trained rural healthcare providers in HIV/AIDS information, how to conduct risk assessments, advances in treatments, and sensitivity to diverse populations. The most effective training was achieved with a self-study booklet which helped increase prevention, early intervention and health promotion among rural health care providers. This booklet is now available free of charge on the Internet. Interactive teleconference training and personal training from visiting educators were also effective.¹³ Healthcare providers need to address the multiple needs of patients. In Bangalore, India, the Well Woman Clinic was established as part of an HIV control program. Poor women, especially commercial sex workers, had been underserved, had high rates of STDs and were at high risk for HIV. Because women are conditioned to ignore or tolerate health problems, patients at the Clinic are automatically screened for STDs without having to admit to any symptoms.¹⁴ Healthcare providers need to take advantage of community-based services. Children’s Hospital Los Angeles teamed with community-based prevention organizations to provide an integrated care model for youth with and at high risk for HIV infection. The model offers a general medical clinic for youth and psychosocial services such as counseling and case management. Peer educators also conduct extensive street outreach where high-risk youth congregate. The program developed a computerized referral system for local youth services available on the Internet.¹⁵

Will enhancing healthcare providers’ involvement be enough?

Enhancing healthcare providers’ involvement is only one aspect of a broad prevention policy. A comprehensive HIV-prevention strategy uses multiple elements to protect as many people at risk of HIV infection as possible. HIV prevention is not a “one-shot” effort; it is an ongoing process that demands the involvement of many sectors of society. This includes the physicians, nurses, health educators, therapists, dentists and other healthcare providers to whom people look for advice on how to stay healthy.

Says who?

1. Schappert SM. Ambulatory care visits to physician offices, hospital outpatient departments, and emergency departments: United States, 1996 . Vital and Health Statistics. 1998;134:1-37. 2. Hammett TM, Gaiter JL, Crawford C. Reaching seriously at-risk populations: health interventions in criminal justice settings . Health Education and Behavior. 1998;25:99-120. 3. Gerbert B, Bleecker T, Bernzweig J . Is anybody talking to physicians about acquired immunodeficiency syndrome and sex? A national survey of patients. Archives of Family Medicine. 1993;2:45-51. 4. Epstein RM, Morse DS, Frankel RM, et al. Awkward moments in patient-physician communication about HIV risk. Annals of Internal Medicine. 1998;128:435-442. 5. American Medical Association. Physician Guide to HIV Prevention. June 1996. 6. Herman M, Gourevitch MN. Integrating primary care and methadone maintenance treatment: implementation issues . Journal of Addictive Diseases. 1997;16:91-102. 7. Gerbert B, Brown B, Volberding P, et al. Physicians’ transmission assessment and counseling practices with their HIV-seropositive patients. AIDS Education and Prevention. In press. 8. Gerbert B, Love C, Caspers N et al. “ Making all the difference in the world”: how physicians can help HIV-seropositive patients become more involved in their healthcare . AIDS Patient Care and STDs. 1999;13:29-39. 9. Centers for Disease Control and Prevention. HIV prevention through early detection and treatment of other sexually transmitted diseases-United States . Morbidity and Mortality Weekly Report. 1998;47(RR-12):1-25. 10. Centers for Disease Control and Prevention. Update: perinatally acquired HIV/AIDS-United States, 1997 . Morbidity and Mortality Weekly Report. 1997;46:1086-1092. 11. Centers for Disease Control and Prevention. Management of health-care worker exposures to HIV and recommendations for postexposure prophylaxis . Morbidity and Mortality Weekly Report. 1998;47(RR-7):1-33. 12. Centers for Disease Control and Prevention. Management of possible sexual, injecting drug-use, or other non-occupational exposure to HIV, including considerations related to antiretroviral therapy . Morbidity and Mortality Weekly Report. 1998;47(RR-17):1-14. 13. Martin SJ. HIV/AIDS prevention, early intervention and health promotion: results of training for rural health care providers. Presented at the 9th National AIDS Update Conference, San Francisco, CA. March 19, 1997. 14. Baksi CM, Harper I, Raj M. A `Well Woman Clinic’ in Bangalore: one strategy to attempt to decrease the transmission of HIV infection . International Journal of STDs & AIDS. 1998;9:418-423. 15. Schneir A, Kipke MD, Melchior LA, et al. Children’s Hospital Los Angeles: a model of integrated care for HIV-positive and very high risk youth. Journal of Adolescent Health. 1998;23(2Suppl):59-70. Computerized referral system:www.caars.net

Prepared by Pamela DeCarlo*, Barbara Gerbert, PhD** and the Center for Health Improvement and Prevention Studies** *CAPS, **Division of Behavioral Sciences, UCSF April 1999. Fact Sheet #6ER

Reproduction of this text is encouraged; however, copies may not be sold, and the Center for AIDS Prevention Studies at the University of California San Franciso should be cited as the source of this information. For additional copies of this and other HIV Prevention Fact Sheets, please call the National Prevention Information Network at 800/458-5231. Comments and questions about this Fact Sheet may be e-mailed to [email protected]. © April 1999, University of California

Resource

Hepatitis C

Can hepatitis C (HCV) transmission be prevented?

Prepared by Alice Asher RN, MS, CNS and Kimberly Page PhD MPH Fact Sheet: 46 September 2010

What is the hepatitis C virus (HCV)?

Hepatitis C virus is blood borne virus affects the liver. It is principally acquired and transmitted by blood-to-blood contact, most commonly among injection drug users (IDU). Other common infectious viruses that affect the liver are Hepatitis A and B which have other routes of infection. Unlike hepatitis A and B, there is no vaccine for HCV. About 3.2 – 4 million Americans are estimated to be infected with HCV.¹ In the US, 8,000 to 10,000 deaths per year are attributed to HCV-associated liver disease and that is expected to triple in the next 10-20 years.

Who’s at risk for HCV?

The population at highest risk for HCV are people who inject drugs; principally through sharing of syringes directly or through sharing of drug preparation equipment. Among newly reported HCV cases with known risk factors, 50%-60% are attributable to injecting drugs. However, this may be underestimated due to underreporting both due to the illicit nature of IDU and lack of HCV surveillance in high risk groups.² HCV is usually acquired rapidly after a person first starts injecting drugs. As a result, prevalence of HCV among IDU is very high, ranging from 40-90%, depending on a person’s age and number of years injecting.³ Persons who received blood transfusions or an organ transplant before 1992 and hemophiliacs who received clotting factor concentrates before 1987 are also at risk for HCV. At moderate risk are persons receiving continual care (hemodialysis) for kidney failure. Others at risk include healthcare workers exposed to needlesticks with HCV+ blood.and, rarely, infants born to infected mothers. Sexual transmission of HCV is uncommon, although recent studies of HIV+ gay men show that it does occur.⁴Rough sex, fisting, sex with multiple partners and having a sexually transmitted disease (STD) or HIV appear to increase a person’s risk of HCV.⁵ This is likely due to blood contact during sex.

What does HCV infection look like?

HCV infection can range of in severity from a mild illness lasting a few weeks to a serious, lifelong illness that damages the liver.5 The majority of people infected with HCV do not experience symptoms related to their infection. Because of this, testing is the only way to confirm HCV infection. The first period after HCV infection is referred to as the “acute” period. Acute HCV infection generally lasts about 6 months after someone is infected with the virus. About 25% of people who become infected with HCV will spontaneously clear the virus on their own in the first 6 months. Studies have shown that women are more likely to spontaneously clear the virus than men. Even for those who have cleared HCV, re-infection can occur. While many who become re-infected will clear the virus again, this is not guaranteed, and a subsequent infection may become chronic. Those who do not clear or resolve their HCV infection are considered chronically infected. Most people with chronic infection remain asymptomatic for 20-30 years, and some will never develop symptoms of advanced disease. However, 60-70% of people with chronic HCV ultimately will develop some degree of liver disease.⁵ People with chronic infection whose liver disease has started to progress often report increasing levels of fatigue and stomach pain. The symptoms of chronic HCV are often are vague and unspecific and may go undiagnosed. This again underlines the importance of testing for anyone at risk of HCV. Chronic HCV infection causes liver damage that can turn into cirrhosis (scarring of the liver) and liver cancer.⁵ Up to 20% of chronically infected individuals will develop cirrhosis and 5% will develop liver cancer. Alcohol and drugsincluding marijuana and even tobaccocan speed up the rate of liver damage significantly.

Can HCV be treated?

The short answer is yes, there is a treatment for HCV, but currently available treatments will not work for everybody. Before starting a treatment regimen, it is important to stabilize any mental or other health problems. Undergoing antiviral treatment for HCV is a long, difficult and expensive process, so determining whether treatment is the right choice is a decision that should be made between a patient and a care provider. There are two approved antiviral medications used for the treatment of HCV: pegylated interferon alpha (often referred to as “peg”) and ribavirin. Peg interferon is taken by injection once a week. Ribavirin is an oral tablet that is taken daily. When taken together, the medications are effective in clearing the HCV virus 40-80% of the time, depending on the genotype of the virus.⁷ Hepatitis C has 6 chemical types (1-6), called genotypes, and they differ in how they respond to treatment. People of color, especially African-Americans and Latinos, have lower response rates to treatment, compared to other groups.⁷ New drugs are being developed that may be more effective than currently available treatments and may be available in the very near future. Treatment during the acute phase of infection is significantly more likely to be effective⁸, so identifying HCV early can be beneficial. While herbal remedies are popular among people living with HCV, none have been proven effective at clearing the HCV virus or in improving liver health.⁹ HCV treatment can be successful for active drug users. Nonetheless, daily drug and alcohol use can adversely affect treatment eligibility and completion. Engaging in drug or alcohol treatment programs while being treated for HCV can be helpful.

How does HCV affect HIV?

About one-quarter of all people in the US living with HIV are also infected with HCV. Persons who are both HIV+ and HCV+ (coinfected), can experience a much faster progression of liver disease and have higher HCV viral loads and higher rates of cirrhosis than do people who have HCV but not HIV.¹⁰ Liver damage from HCV infection also can increase the toxicity of medications used to treat HIV. As persons living with HIV who are on effective medications lead longer lives, liver disease has become the leading cause of non-AIDS-related deaths among HIV+ persons, due to HCV and HBV infection.¹¹ Treatment for HCV infection in an HIV+ person can be effective. Side effects and drug interactions, however, can be hard to manage. It is important the coinfected person be on well-managed HIV treatment before starting treatment for HCV.

How can HCV be prevented?

HCV prevention can take many forms.¹² Currently, targeted prevention strategies and harm reduction programs, including increased availability of clean syringes and increased access to drug treatment programs have the greatest potential to slow transmission of HCV. Educating those at risk, especially about the risks associated with shared injecting and ancillary equipment is very important. Encouraging the use of condoms, lubrication and gloves during high-risk sexual practices also can help reduce HCV transmission. Behavioral risk reduction prevention programs have had mixed results in decreasing risks associated with HCV transmission. Two peer-led interventions were effective in reducing injection risk behaviors in HIV negative and positive IDUs. The Study to Reduce Intravenous Exposures (STRIVE) and Drug Users Intervention Trials (DUIT) both provided information, enhanced risk-reduction skills, and motivated behavior change through peer education training. Although participants in these programs reported decreases in sharing syringes and drug preparation equipment,^13,14 rates of new HCV infections among HCV negative participants in the DUIT Study did not decrease (neither did HIV infections). The UFO Study conducts HCV-related research and provides hepatitis, HIV and STD prevention services including testing, counseling, support and education tailored to young adult IDUs under age 30 in San Francisco, CA. Young injection drug users comprise a group for whom few health-related resources or programs are targeted.¹⁵ For persons who are infected with HCV or at risk of becoming infected with HCV, it is important to get regular healthcare. A healthcare provider can help monitor HCV infection and liver health and make important decisions about prevention and treatment. Support and education groups are valuable in learning more about HCV infection and about the experience of living with HCV, treating HCV and preventing HCV transmission to others. People infected with HCV should be screened and vaccinated for HBV and should be strongly encouraged to stop or decrease alcohol use.

What needs to be done?

Over the next 15 years, the global costs associated with HCV infection are projected to increase from $30 billion to $85 billion.¹⁶ Development of an HCV vaccine will significantly decrease rates of new HCV infections. Research is needed on the development of a vaccine and effective models for delivery. Increasing access to HCV testing and screening, HCV treatment, drug treatment, clean syringes and effective behavioral interventions is crucial.

Says who?

1. Armstrong GL, Wasley A, Simard EP, et al. The prevalence of hepatitis C virus infection in the United States, 1999 through 2002. Annals of Internal Medicine. 2006;144:705-714. 2. Hagan H, Snyder N, Hough E, et al. Case-reporting of acute hepatitis B and C among injection drug users. Journal of Urban Health. 2002;79:579-585. 3. Hagan H, Pouget ER, Des Jarlais DC, et al. Meta-regression of hepatitis C virus infection in relation to time since onset of illicit drug injection: the influence of time and place. American Journal of Epidemiology. 2008;168:1099-1109. 4. Urbanus AT, van de Laar TJ, Stolte IG, et al. Hepatitis C virus infections among HIV-infected men who have sex with men: an expanding epidemic. AIDS. 2009;23:F1-7. 5. Hepatitis C Fact Sheet. Prepared by the Centers for Disease Control and Prevention. 6. Page K, Hahn JA, Evans J, et al. Acute hepatitis C virus infection in young adult injection drug users: a prospective study of incident infection, resolution, and reinfection. Journal of Infectious Diseases. 2009;200:1216-1226. 7. Ghany MG, Strader DB, Thomas DL, et al. Diagnosis, management, and treatment of Hepatitis C: An update. Hepatology. 2009;49:1335-1374. 8. Kamal SM. Acute hepatitis C: a systematic review. American Journal of Gastroenterology. 2008;103:1283-1297 9. Liu JP, Manheimer E, Tsutani K, et al. Medicinal herbs for hepatitis C virus infection. Cochrane Database of Systematic Reviews. 2001;4. 10. Verucchi G, Calza L, Manfredi R, et al. Human immunodeficiency virus and hepatitis C virus coinfection: epidemiology, natural history, therapeutic options and clinical management. Infection. 2004;32:33-46. 11. Tuma P, Jarrin I, Del Amo J, et al. Survival of HIV-infected patients with compensated liver cirrhosis. AIDS. 2010;24:745-753. 12. Page-Shafer K, Hahn J, Lum PJ. Preventing hepatitis C virus infection in injection drug users: risk reduction is not enough. AIDS. 2007;21:1967-1969. 13. Latka MH, Hagan H, Kapadia F, et al. A randomized intervention trial to reduce the lending of used injection equipment among injection drug users infected with hepatitis C. American Journal of Public Health. 2008;98:853-861. 14. Garfein RS, Golub ET, Greenberg AE, et al. A peer-education intervention to reduce injection risk behaviors for HIV and hepatitis C virus infection in young injection drug users. AIDS. 2007;21:1923-1932. 15. Lum PJ, Ochoa KC, Hahn JA, et al. Hepatitis B virus immunization among young injection drug users in San Francisco, Calif: the UFO Study. American Journal of Public Health. 2003;93:919-23. 16. Shah BB, Wong JB. The economics of hepatitis C virus. Clinics in Liver Disease. 2006;10:717-34.

Special thanks to the following reviewers of this Fact Sheet: Laura Mae Alpert, Orlando Chavez, Myrna Cozen, Richard Garfein, Holly Hagan, Judy Hahn, Emalie Huriaux, Steve Livingston, Megan Mahoney, Brian McMahon, Jay Ryan, Jim Stillwell, Leslie Tobler, Anouk Urbanus. Reproduction of this text is encouraged; however, copies may not be sold, and the University of California San Francisco should be cited as the source. Fact Sheets are also available in Spanish. To receive Fact Sheets via e-mail, send an e-mail to [email protected] with the message “subscribe CAPSFS first name last name.” ©September 2010, University of CA. Comments and questions about this Fact Sheet may be e-mailed to [email protected].

Resource

HIV vaccine

Can an HIV Vaccine make a Difference?

why do we need an HIV vaccine?

Vaccines are among the most powerful and cost-effective disease prevention tools available. A vaccine that could prevent HIV infection or stop progression of the disease would greatly help in the fight against the AIDS pandemic. Vaccines have been pivotal in worldwide smallpox elimination efforts, have nearly eliminated polio and have drastically reduced the incidence of infectious diseases like measles and pertussis in the US. A crucial question is whether a vaccine based on one strain of HIV would be effective for populations in which a different strain is predominant. There are also questions about how an HIV vaccine would protect individuals: the vaccine might not be able to actually prevent infection, but could prevent or delay progression to disease, or simply reduce the infectiousness of people who do become infected with HIV. HIV prevention education and counseling are important components of vaccine programs. Even after the release of a vaccine, there will be an ongoing need for effective behavioral prevention programs. An HIV vaccine will not be a “magic bullet” but it could play an extremely powerful role as part of a package of prevention interventions.

has progress been made?

Twenty-two years into the epidemic, researchers are still struggling with the daunting scientific challenges involved in HIV vaccine research: 1) traditional approaches to vaccine design (i.e. use of inactivated or attenuated viruses) are considered too dangerous with HIV; 2) the virus is highly variable and mutates rapidly; 3) the viral infection is permanent, full recovery from HIV has not been documented, and thus, it is unclear how the body could mount an effective immune response and 4) there is no perfect animal model for use in AIDS vaccine research.¹ There is still no HIV vaccine that has been tested and found to be effective. There have been over 70 small-scale human clinical trials of over 35 different candidate HIV vaccines, but only one product, AIDSVAX, produced by VaxGen, has been tested in a large-scale (Phase III) trial. Unfortunately, two separate trials of AIDSVAX conducted in 1) North America, Puerto Rico and the Netherlands² and 2) Thailand, found that the vaccine did not prevent HIV infection in the overall study populations and did not slow progression of disease among participants who became HIV-infected during the trial.³ A successful HIV vaccine would train the immune system to recognize HIV before it does extensive damage. Vaccine concepts now in development use a variety of methods to train the immune system to recognize parts of HIV without exposing people to HIV itself. Early AIDS vaccine research focused on developing bio-engineered vaccines that represent a portion of HIV’s outer surface (envelope) protein. Different vaccine approaches are currently in development, none of which include the actual virus (HIV) and none of which can cause a recipient to acquire HIV from the vaccine itself.

what is the impact on HIV prevention?

An effective HIV vaccine cannot take the place of HIV prevention efforts, any more than prevention efforts can take the place of a vaccine. The best way to address the HIV pandemic is using multiple interventions at multiple levels, and the protective power of a vaccine could one day be of enormous benefit in HIV prevention. There have been increases in sexual risk behavior in men who have sex with men (MSM) since the advent of ART (antiretroviral treatment).⁴ There is concern that when a vaccine becomes available there could be similar increases in risk behavior among people who receive the HIV vaccine because they feel they can’t become infected with HIV. In the VaxGen efficacy trial in North America, younger participants and MSM who believed they had received the actual vaccine rather than a placebo were more likely to report unprotected anal intercourse during the trial. Overall, self-reported risk behavior did not increase throughout the trial.⁵ In the VaxGen efficacy trial in Thailand, injecting drug users reported decreases in injection drug use and needle sharing during the first 12 months of the trial.⁶ This may have been due to the prevention education and risk-reduction counseling received.

what are the ethical issues?

HIV vaccines can only be tested for safety and effectiveness if thousands of individuals are willing to participate in clinical trials. These trials raise concerns about the potential harm to trial participants. Certain HIV vaccines may cause trial volunteers to test HIV+ on standard HIV antibody tests, even though they are not infected with the virus. A positive HIV test result could expose individuals to discrimination in health insurance, employment and immigration, or lead to social stigma. The simple act of participating in an HIV vaccine trial may result in someone being labeled as a “high risk” individual, a gay person or a drug user, and discrimination against these and other groups is a very real issue in many places. It is the responsibility of researchers to ensure that vaccine trial participants receive assistance to alleviate the risks of discrimination or other harm that may result.⁷ Communities must be closely involved in clinical trial design and implementation. Researchers also need to ensure that true informed consent is acquired before individuals are enrolled in a vaccine trial. Community members and potential volunteers need to be fully informed about the vaccine trial process and must understand such concepts as “placebo,” “randomization” and “blinding” to be able to truly evaluate whether participation is right for them. Using community educators and peers to help with the community education that accompanies HIV vaccine research will also help increase participants’ understanding and acceptance of vaccine trials.⁸

what are barriers?

Much of the expertise to develop and manufacture HIV vaccines rests in private-sector pharmaceutical and biotechnology companies. Yet industry commitment to HIV vaccines has not matched the enormity of the public health need.^9,10 An HIV vaccine will only bring the pandemic under control if it is widely available in the developing world, where more than 95% of new HIV infections are occurring. People in resource-poor countries have often had to wait a decade or more for vaccines after they have been licensed for use in industrialized nations.^11,12 There are numerous challenges to HIV vaccine access in addition to price. Marginal health care infrastructures in some developing countries may make it difficult to distribute a vaccine. Even countries that can afford vaccines may not see them as a high priority and may not allocate adequate resources to fund research or vaccine purchase. Vaccination programs generally focus on children. With HIV, it is sexually active adolescents and adults who will need a vaccine most immediately, necessitating new approaches to immunization. Vaccine acceptance may be problematic in communities where there is a distrust of government or stigma in being associated with HIV/AIDS.

what needs to be done?

Public sector funding for research on HIV vaccines has increased in recent years, and additional resources are needed. The private sector must be encouraged to invest in HIV and other priority vaccines through a range of incentives, including direct funding, public support for clinical research infrastructure and product manufacture, and through public/private partnerships.⁹ Wealthy governments should commit in advance to purchase AIDS vaccines for people in the developing world. Continued political leadership is needed to prioritize resources for vaccines. Vaccine trials conducted to date have included HIV prevention education and risk reduction counseling. Vaccine trials can further benefit participants by offering drug treatment services and STD screening and treatment. Combining medical, behavioral and psychological efforts as part of a vaccine initiative can be a powerful tool for combatting the HIV pandemic. Vaccines are an integral part of an effective disease prevention strategy, and vaccine development is critical in arresting the spread of HIV. Yet, a vaccine alone will not eliminate the social and structural conditions that created and fuel the epidemic. Even when HIV vaccines are available, communities will continue to need quality behavioral interventions to control the HIV epidemic and policies that ensure access to vaccines. Prepared by Chris Collins, MPP, AIDS Vaccine Advocacy Coalition

Says who?

1. National Institute of Allergy and Infectious Diseases. Challenges in designing AIDS vaccines. May 2003. www.niaid.nih.gov/factsheets/challvacc.htm 2. AIDS Vaccine Advocacy Coalition. Understanding the results of the AIDSVAX trial. May 2003. https://www.avac.org/sites/default/files/resource-files/understanding_a…; 3. VaxGen Announces Results of its Phase III HIV Vaccine Trial in Thailand: Vaccine Fails to Meet Endpoints. Press release from VaxGen. www.vaxgen.com/pressroom/ 4. Valdiserri RO. Preventing new HIV infections in the US: what can we hope to achieve? Presented at the 10th Conference on Retroviruses and Opportunistic Infections, Boston, MA. February 10-14, 2003. 5. Bartholow B. Risk behavior and HIV seroincidence in the US trial of AIDSVAX B/B. Presented at the AIDS Vaccine 2003 Conference, New York, NY. September 2003. 6. Vanichseni S, van Griensven F, Phasithiphol B, et al. Decline in HIV risk behavior among injection drug users in the AIDSVAX B/E vaccine trial in Bangkok, Thailand. Presented at the XIV International AIDS Conference, Barcelona, Spain. July 2002. 7. UNAIDS. Guidance Document on Ethical Considerations in HIV Preventive Vaccine Research. June 2002. 8. van Loon KV, Lindegger GC, Slack CM. Informed consent: A review of the experiences of South African clinical trial researchers. Presented at the XIV International AIDS Conference, Barcelona, Spain. July 2002. Abst #TuOrG1170. 9. AIDS Vaccine Advocacy Coalition. https://www.avac.org/avac-report 10. Klausner RD, Fauci AS, Corey L, et al. The need for a global HIV vaccine enterprise. Science. 2003;300:2036-2039. 11. Public health considerations for the use of a first generation HIV vaccine: Report from a WHO-UNAIDS-CDC Consultation, Geneva, 20-21 November 2002. AIDS. 2003;17:W1-W10. 12. International AIDS Vaccine Initiative. AIDS Vaccines for the New World: Preparing Now to Assure Access. July 2000. www.iavi.org Resources AIDS Vaccine Advocacy Coalition (AVAC) 101 West 23rd St. #2227 New York, NY 10011 212/367-1021 www.avac.org HIV InSite: Vaccine Overview http://hivinsite.ucsf.edu/InSite?page=kb-08-01-11 HIV Vaccine Trials Network http://www.hvtn.org International AIDS Vaccine Initiative (IAVI) 110 William Street New York, NY 10038-3901 212/847-1111 www.iavi.org National Institute of Allergy and Infectious Diseases (NIAID) Division of AIDS Vaccines www.niaid.nih.gov/aidsvaccine NIAID Vaccine Research Center https://www.niaid.nih.gov/about/vrc

January 2004. Fact Sheet #38ER Special thanks to the following reviewers of this Fact Sheet: Barbara Adler, Emily Bass, Mark Boaz, Susan Buchbinder, Jose Esparza, Jorge Flores, Paula Frew, Ingelise Gordon, Ashraf Grimwood, Margaret McCluskey, Catherine Slack, Robert Smith, Steven Tierney, Steven Wakefield, Doug Wassenaar, Sandra Wearins, Dan Wohlfeiler.

Resource

HIV+ persons

What are HIV+ persons’ HIV prevention needs?

revised 9/05

do HIV+ persons need prevention?

Yes. Over 1 million persons in the US are living with HIV/AIDS.¹ Advances in the early diagnosis, treatment and care of HIV+ persons have helped many people enjoy increased health and longer life. Some HIV+ persons have experienced a renewed interest in sexual or drug-using activity. This can place them at risk for acquiring additional STD infections and for transmitting HIV to their uninfected partners.² Many HIV+ persons, therefore, require programs to help them stay safe. Most HIV+ persons are concerned about not infecting others and make efforts to prevent transmission.³ However, a significant percentage of HIV+ persons struggle with prevention: from 20-50% of HIV+ persons report unprotected sex with partners who are HIV- or whose HIV status they do not know. For many HIV+ persons, the same structural, inter-personal and behavioral challenges that put them at risk for HIV persist beyond their HIV diagnosis and play a role in their inability to prevent HIV transmission.⁴ Prevention with HIV+ persons may include education and skills building interventions, efforts to test more persons who are HIV+ but do not know their status, support and testing for partners of HIV+ persons and integrating prevention into routine medical care.⁵

how is it different?

HIV prevention programs with HIV+ persons are different than programs with HIV- persons in that they must address clinical, mental and social support needs as well as build skills to prevent HIV transmission to current and future partners. Stigma. Pre-existing stigma towards gay men, women, drug users, sex workers and persons of color has helped fuel the HIV epidemic in this country by creating social conditions that foster HIV transmission.⁶ Added to this is the additional stigma of living with HIV. Previous experience of stigma (coming out as gay or as a drug user) may lead to trauma that impacts the ability to cope with HIV transmission.⁷ It is important to address these structural factors to build strength and resiliency in HIV+ communities. Disclosure. One of the foremost concerns for HIV+ persons is how, when, where and to whom to disclose their HIV status.⁸ The traditional message has been that HIV+ persons should always disclose their HIV status to partners. In reality, disclosure is complex and difficult. Some HIV+ persons decide not to disclose and not engage in risk behavior. HIV+ persons often fear that disclosure may bring partner or familial rejection, limit sexual opportunities or increase risk for physical and sexual violence. A survey of HIV+ persons found that 42% of gay men, 19% of heterosexual men and 17% of women had sex without disclosing their HIV status.⁹ HIV+ persons may disclose differently with doctors, family, friends, work colleagues and sexual and injecting partners. Responsibility. Persons with HIV live with both the experience of being infected (sometimes by someone they love and trust) and the tremendous responsibility of knowing that they can infect other people. Although the subject of responsibility is complex, prevention programs can provide support to HIV+ persons to explore and understand what it means for them individually.¹⁰

what can HIV+ persons do?

Many HIV+ persons are using strategies that limit HIV transmission. One strategy is having sex mainly with other known HIV+ persons.¹¹ Knowing that your sexual partner is also HIV+ avoids the risk of transmission and allows for sex without consistent condom use. There have been recent concerns about superinfection among HIV+ couples, where one HIV+ person might acquire another strain of HIV from their HIV+ partner. However, superinfection among such couples appears to be rare.¹² Another strategy is switching from high-risk to lower risk activities. HIV+ persons can avoid high-risk activities such as being an insertive partner (top) during anal and vaginal sex, having sex while menstruating, breastfeeding and sharing syringes. Lower risk activities can be having oral sex and being a receptive partner (bottom).¹¹

what can my agency/clinic do?

HIV+ persons are a diverse group and require prevention programs that fit their specific needs. Programs need to see the whole person, not just sex and drug use. Relationships, employment, healthcare, housing, stigma and discrimination should be addressed as needed. Listening to HIV+ persons and involving them in the design, delivery and evaluation of programs ensures that programs are relevant and useful.¹³ Prevention programs with HIV+ persons can require institutional change and adjustment for agencies and clinics that may be integrating care and prevention services for the first time. Healthcare clinics may train providers and staff to deliver prevention counseling, link with prevention and social service agencies or provide referrals to agencies. Prevention programs may train staff in treatment and care issues, forge relationships with clinics and service agencies or provide referrals. It is critical for healthcare providers to maintain a non-judgmental tone about situations and behaviors with HIV+ clients.¹⁴ It is equally important to work in collaboration with HIV+ persons to develop a concrete risk reduction plan based on the client’s needs and abilities.¹⁴ Providers should be supportive, empathic, goal-oriented and focus on a client’s strengths and resiliencies. Prevention programs need to provide clients with the knowledge, skills and resources (such as condoms, clean needles and a plan to decrease alcohol and drug use) to put the risk reduction plan in place.

what’s being done?

There are currently many programs and interventions addressing prevention with HIV+ persons in service agency and clinical settings across the US. The following programs are part of the CDC’s Replicating Effective Programs initiative.¹⁵ Healthy Relationships is a five-session risk-reduction group intervention for men and women. The program focuses on developing decision-making and problem-solving skills for making informed and safe decisions about disclosure and behavior. The groups allow HIV+ persons to interact, examine their risks, develop skills to reduce their risks and receive feedback from others. Participants reported significantly less unprotected intercourse and greater condom use at six-month follow-up.¹⁶ Choosing Life: Empowerment, Action, Results (CLEAR) offers HIV+ youth 18 one-on-one 90-minute sessions with a counselor. CLEAR seeks to build motivation and enhance self-esteem so that youth can learn to choose healthy activities over self destructive behaviors. CLEAR is divided into three modules: substance use, sexual decision-making and self care. Youth also can choose telephone sessions instead of in person sessions. Youth participating reported having fewer sexual partners, using fewer drugs and feeling less emotional distress.¹⁷ CLEAR is now known as Street Smart. Partnership for Health trained staff in HIV medical clinics to provide brief, safer-sex counseling supplemented by written information and clinic posters. The program found that counseling emphasizing the negative consequences of unsafe sex helped reduce risky behaviors with patients who reported 2 or more partners.¹⁸

what needs to be done?

Prevention programs with HIV+ persons need to pay attention to structural barriers to safer sexual and drug use behavior. For some HIV+ persons, barriers may include housing instability, lack of access to HIV care and repeated incarceration. The challenges of sexual and drug risk behavior, disclosure and responsibility need to be placed in social and structural contexts that are meaningful to HIV+ persons. There is a need to further examine how early childhood and adult trauma, sexual abuse, coming out, racism and homophobia affect an HIV+ person’s ability to maintain safer behaviors. More emphasis should be placed on couples and sexual partners, both in research and in prevention programs, because sexual risk behavior among HIV+ persons is often a shared risk decision within couples/partners.¹⁹ Prevention with positives programs present the opportunity and challenge of forging relationships and integrating services in areas that have not traditionally worked together. Treatment, prevention and social services need to work in tandem, helping clients deal with the multiple issues they may face. Involving HIV+ persons is key. Prepared by Kelly Knight MEd and Carol Dawson-Rose RN PhD, CAPS

Says who?

1. Glynn M, Rhodes P. Estimated HIV prevalence in the United States at the end of 2003. Presented at the National HIV Prevention Conference, Atlanta, GA. 2005. Abst #595. 2. Janssen RS, Valdiserri RO. HIV prevention in the Unites States: increasing emphasis on working with those living with HIV. Journal of AIDS. 2004;37:S119-S121. 3. Marks G, Crepaz N, Senterfitt JW, et al. Meta-analysis of high-risk sexual behavior in persons aware and unaware they are infected with HIV in the United States. Journal of AIDS. 2005;39:446-453. 4. Crepaz N, Marks G. Towards an understanding of sexual risk behavior in people living with HIV: a review of social, psychological and medical findings. AIDS. 2002;16:135-149. 5. Centers for Disease Control and Prevention. Advancing HIV prevention: new strategies for a changing epidemic – United States, 2003. Morbidity and Mortality Weekly Report. 2003;52:329-332. 6. Herek GM, Capitanio JP, Widaman KF. Stigma, social risk, and health policy: public attitudes toward HIV surveillance policies and the social construction of illness. Health Psychology. 2003;22:533-540. 7. Knight KR. With a little help from my friends: community affiliation and perceived social support. In HIV+ Sex. PN Halkitis, CA Gómez, RJ Wolitsky, eds. American Psychological Association; Washington DC. 2005. 8. Parsons JT, Missildine W, Van Ora J, et al. HIV serostatus disclosure to sexual partners among HIV-positive injection drug users. AIDS Patient Care and STDs. 2004;18:457-469. 9. Ciccarone DH, Kanouse DE, Collins RL, et al. Sex without disclosure of positive HIV serostatus in a US probability sample of persons receiving medical care for HIV infection. American Journal of Public Health. 2003;93:949-954. 10. Wolitski RJ, Bailey CJ, O’Leary A, et al. Self-perceived responsibility of HIV-seropositive men who have sex with men for preventing HIV transmission. AIDS and Behavior. 2003;7:363-372. 11. Parsons JT, Schrimshaw EW, Wolitski RJ, et al. Sexual harm reduction practices of HIV-seropositive gay and bisexual men: serosorting, strategic positioning, and withdrawal before ejaculation. AIDS. 2005;19:S13-S25. 12. Grant RM, McConnell JJ, Herring B, et al. No superinfection among seroconcordant couples after well-defined exposure. Presented at the International Conference on AIDS. 2004. Abst #ThPeA6949. 13. National Association of People with AIDS. Principles of HIV prevention with positives. www.napwa.org/pdf/PWPPrinciples.pdf (Accessed 4/20/06) 14. Dawson-Rose C, Shade SB, Lum P, et al. The healthcare experience of HIV positive injection drug users. Journal of Multicultural Nursing and Health. 2005;11:23-30. 15. https://www.cdc.gov/hiv/effective-interventions/index.html (Accessed 4/20/06) 16. Kalichman SC, Rompa D, Cage M, et al. Effectiveness of an intervention to reduce HIV transmission risks in HIV-positive people. American Journal of Preventive Medicine. 2001;21:84-92. 17. Rotheram-Borus MJ, Swendeman D, Comulada WS, et al. Prevention for substance-using HIV-Positive young people: telephone and in-person delivery. Journal of AIDS. 2004;37:S68-S77. 18. Richardson JL, Milam J, McCutchan A, et al. Effect of brief safer-sex counseling by medical providers to HIV-1 seropositive patients: A multi-clinic assessment. AIDS.2004;18:1179-1186. 19. Remien RH, Wagner G, Dolezal C, et al. Factors associated with HIV sexual risk behavior in male couples of mixed HIV status. Journal of Psychology and Human Sexuality. 2001;13:31-48.

September 2005. Fact Sheet #37ER Special thanks to the following reviewers of this Fact Sheet: Latoya Conner, Keith Folger, Mari Gasiorowicz, Trevor Hart, Gregory Herek, Jessica Merron-Brainerd, Katie Mosack, Judith Moskowitz, Lisa Orban, Robert Remien, Kurt Schroeder, Stephen Trujillo, Tim Vincent.

Resource

Prevention in health care settings

How can HIV prevention be integrated into health care settings?

Prepared by Carol Dawson-Rose RN PhD, Janet Myers PhD MPH, and Karen McCready MA; CAPS Fact Sheet 68, July 2010

Why is HIV prevention important in health care settings?

HIV prevention is an important part of health care for all individuals. It is particularly key for those at risk of becoming infected, as well as for those who are already infected, who can then avoid transmitting HIV to others and stay healthy themselves. Many strategies can be used in health care settings to optimize HIV prevention, including: assessing HIV risk; enhancing access to HIV testing; providing HIV-infected patients with disclosure and partner services; screening and treating patients for problem drinking, drug use and sexually transmitted infections (STIs); and providing the best possible care to HIV-infected individuals including access to anti-retroviral therapy (ARVs) and adherence counseling.

Do health care settings have a role in finding new infections?

Health care settings are important sites for providing access to HIV testing and prevention messages, for finding new infections and for linking infected individuals into HIV care. In 2006, the CDC issued guidelines for primary health care providers suggesting expanded access to HIV testing for all patients 13 to 64 years old.¹ Providing HIV testing as a routine part of care has been most productive in emergency room and labor and delivery settings,^2,3 although community health centers have also provided important new access.⁴ Testing programs have also proven effective in helping pregnant women to not transmit HIV to their babies.³ One key strategy for expanding testing is rapid test technology.⁵ Rapid tests allow providers to perform a test and deliver the results in under an hour, although a confirmatory test is required for positive rapid test results. Appropriate follow-up care can be planned before the patient leaves the health care facility. Especially when HIV testing is newly introduced, providers in health care settings need to learn how to integrate HIV testing into regular care, and to refer patients for additional support services if needed. Providers should also be trained in documenting test results to ensure they are shared with other health care providers and to maintain the confidentiality of client information. Providers must ensure that HIV-infected persons get the care and support they need. Linkage to care is an important and often overlooked piece of integrating HIV testing into health care. Individuals who are just finding out they are infected often need a great deal of help and support to find an HIV provider, to make an appointment and to show up at that appointment. Intensive case management models show promise in enhancing linkages to care for newly-diagnosed individuals.⁶

What other HIV prevention strategies work in health care settings?

Risk assessment. Assessing HIV risk behaviors should be a standard part of new patient intake, regardless of HIV status. In-depth HIV prevention education is not necessary for every patient. However, health care providers should ask all patients about their sexual behavior, condom use, number of sexual partners, and alcohol and illicit drug use to assess a patient’s risk for acquiring or transmitting HIV. These quick questions may lead to longer discussions and counseling about safer sex or alcohol and drug use practices.⁷ Drug treatment. Helping patients get into alcohol or drug treatment can be an effective HIV prevention tool and can help HIV-infected persons stay healthy. Health care providers can have a profound effect on patients’ lives by showing an interest in drug-using patients and encouraging willing patients to enter drug or alcohol treatment programs. Because relapse is common in treating addictions, health care providers should use a non-judgmental approach. Screening and treating for STIs. Providers should encourage screening for STIs. They should also provide STI education, emphasize the link between HIV and STIs, and encourage screening for partners.⁹

How does positive prevention work in health care settings?

Prevention counseling. Brief prevention counseling delivered in health care settings at every visit has been shown to decrease the likelihood that HIV-infected individuals transmit HIV to others, particularly if interventions are tailored to sub-populations of HIV-infected patients.¹⁰ Important messages include: helping people understand the relative risks of their actions and the effectiveness of different prevention strategies such as using condoms; disclosing HIV status to sex and drug using partners; and understanding their responsibility with regard to prevention. Formal provider training is important to facilitate these approaches.^11,12 Viral suppression. A unique component that health care settings play in HIV prevention is helping HIV-infected persons find and adhere to an effective ARV regimen to help keep their viral load low. Some research has demonstrated that keeping the viral load below a threshold that is detectable with lab tests can help prevent up to 60% of new STIs.¹³ New research suggests that effective detection of HIV and treatment to reduce the viral load could reduce the overall community viral load and have a population-level impact on HIV transmission.¹⁴

How can HIV prevention capacity be increased in health care settings?

Risk assessment. Knowing how to assess risk among patients is key to HIV prevention of any kind. Having risk assessment tools and training providers to use them is critical. Written protocols. It is important to make sure that procedures are in place to guide testing efforts in health care settings.¹⁵ Having a “prevention plan” tailored to the clinic size, the service delivery model, the types of providers and the patient population is critical. Leadership. Successful clinic programs often have identified staff leaders who function as counselors or team leaders for positive prevention.¹⁶ Training. Underlying all of these important components is training. Training can facilitate buy-in from clinic providers and can address provider attitudes and beliefs about risk reduction and counseling.¹⁷ Training should outline staff responsibilities and anticipate changes to clinic flow.¹⁶

What are effective models for use in health care settings?

Positive STEPs¹⁷ is a training intervention to help HIV care providers deliver prevention counseling to their patients. The model was effective in improving provider attitudes, comfort, self-efficacy and frequency of delivering prevention counseling. Partnership for Health¹⁸ is an EBI (CDC’s Effective Behavioral Intervention) for providers in HIV clinics. Medical providers are trained to deliver brief risk-reduction counseling to their patients. All clinic staff are trained to integrate prevention messages into the clinic setting, and counseling is supplemented with written information for all patients. The intervention was effective in reducing unprotected intercourse by 38% among patients who had two or more sexual partners. Positive Choice¹⁹ is an interactive “Video Doctor.” Patients at HIV clinics completed an in-depth computerized risk assessment and received tailored risk-reduction counseling from a “Video Doctor” via laptop computer and a printed educational worksheet. Providers received a Cueing Sheet on reported risks for discussion during the clinical encounter. Provider-Delivered Counseling.^10,16 In a large federal demonstration project, brief counseling messages delivered by primary care providers in clinic settings were most effective in reducing risk among HIV-infected patients, although there were also benefits in programs delivered by prevention specialists and HIV-infected peers.

What needs to be done?

Health care providers need more and repeated training on how HIV prevention can be integrated into the care they deliver. There are still significant misperceptions among health care providers about who should be tested for HIV and when to implement rapid testing. Provider attitudes, beliefs and self-efficacy can affect whether or not they address prevention through HIV testing or by providing risk-reduction counseling. Methods that enhance provider uptake of HIV prevention in health care delivery settings need attention and further research. Leaders in health care settings can establish written protocols that guide HIV prevention practices, including HIV testing in their clinics. Establishing protocols, documentation and quality assurance practices can enhance testing and prevention practices in all types of health care settings.

Says who?

1. Branson BM, Handsfield HH, Lampe MA, et al. Revised recommendations for HIV testing of adults, adolescents, and pregnant women in health-care settings.Morbidity and Mortality Weekly Report. 2006;55:1-17. 2. Haukoos JS, Hopkins E, Byyny RL, et al. Patient acceptance of rapid HIV testing practices in an urban emergency department: assessment of the 2006 CDC recommendations for HIV screening in health care settings. Annals of Emergency Medicine. 2008;51:303-309. 3. Tepper NK, Farr SL, Danner SP, et al. Rapid human immunodeficiency virus testing in obstetric outpatient settings: the MIRIAD study. American Journal of Obstetrics and Gynecology. 2009;201:31-36. 4. Myers JJ, Modica C, Bernstein C, Kang M, McNamara K. Routine rapid HIV screening in six Community Health Centers serving populations at risk. Journal of General Internal Medicine. 2009;24:1269–1274. 5. Branson BM. State of the art for diagnosis of HIV infection. Clinical Infectious Diseases. 2007;15:S221-225. 6. Christopoulos K, Koester K, Weiser S, et al. A comparative evaluation of the development and implementation of three emergency department HIV testing programs (forthcoming) 7. Schechtel J, Coates T, Mayer K, et al. HIV risk assessment: physician and patient communication. Journal of General Internal Med. 1997;12:722-723. 8. Bruce RD. Methadone as HIV prevention: High volume methadone sites to decrease HIV incidence rates in resource limited settings. International Journal of Drug Policy. 2010;21:122-124. 9. McClelland RS, Baeten JM. Reducing HIV-1 transmission through prevention strategies targeting HIV-1-seropositive individuals. Journal of Antimicrobial Chemotherapy. 2006;57:163-166. 10. Myers JJ, Shade S, Dawson Rose C, et al. Interventions delivered in clinical settings are effective in reducing risk of HIV transmission among people living with HIV. AIDS and Behavior. 2010;14:483-492. 11. Gilliam PP, Straub DM. Prevention with positives: A review of published research, 1998-2008. Journal of the Association of Nurses in AIDS Care. 2009;20:92-109. 12. Harder & Co. Community Research. Prevention with positives: Best practices Guide. Prevention with Positives Workgroup. 2009. 13. Porco TC, Martin JN, Page-Shafer KA, et al. Decline in HIV infectivity following the introduction of highly active antiretroviral therapy. AIDS. 2004;18:81-88. 14. Das M, Chu PL, Santos G-M, et al. Decreases in community viral load are accompanied by reductions in new HIV infections in San Francisco. PLoS ONE. 2010;5:e11068. 15. Myers JJ, Steward, WT, Koester KA, et al. Written procedures enhance delivery of HIV “prevention with positives” counseling in primary health care settings. Journal of AIDS. 2004;37:S95-S100. 16. Koester KA, Maiorana A, Vernon K, et al. Implementation of HIV prevention interventions with people living with HIV/AIDS in clinical settings: Challenges and lessons learned. AIDS and Behavior. 2007;1:S17-S29. 17. Thrun M, Cook PF, Bradley-Springer LA, et al. Improved prevention counseling by HIV care providers in a multisite, clinic-based intervention: Positive STEPs. AIDS Education and Prevention. 2009;21:55-66. 18. Richardson J, Milam J, McCutchan A, et al. Effect of brief safer-sex counseling by medical providers to HIV-1 seropositive patients: A multi-clinic assessment. AIDS. 2004;18:1179-1186. 19. Gilbert P, Ciccarone D, Gansky SA, et al. Interactive “Video Doctor” counseling reduces drug and sexual risk behaviors among HIV+ patients in diverse outpatient settings. PLoS One. 2008;3.

Special thanks to the following reviewers of this Fact Sheet: Lucy Bradley-Springer, Kimberly Carbaugh, Mark Cichocki, Renata Dennis, Josh Ferrer, Mark Molnar, Quentin O’Brien, Jim Sacco. Reproduction of this text is encouraged; however, copies may not be sold, and the University of California San Francisco should be cited as the source. Fact Sheets are also available in Spanish. To receive Fact Sheets via e-mail, send an e-mail to [email protected] with the message “subscribe CAPSFS first name last name.” ©July 2010, University of CA. Comments and questions about this Fact Sheet may be e-mailed to [email protected].