Despite substantial advances in the treatment of human immunodeficiency virusHIV AIDS infection, the estimated number of annual new HIV infections in the United States has remained at 40,000 for over 10 years. HIV prevention in this country has largely focused on persons who are not HIV infected, to help them avoid becoming infected. However, further reduction of HIV transmission will require new strategies, including increased emphasis on preventing transmission by HIV-infected persons. People who are infected with HIV and are aware tend to reduce risky behaviors that might transmit HIV to others. Nonetheless, recent reports suggest that such behavioral changes often are not maintained and that a substantial number of HIV-infected persons continue to engage in behaviors that place others at risk for HIV infection.
Reverting to risky behavior can be as important in the transmission of HIV as the orignal failure to adopt safer sex practices. Unprotected anal sex seems to be happening more often in some urban centers, especially amoung young men who have sex with other men. Viral and bacterial STDs in HIV infected patients receiving care has been noticed more frequently, indicating ongoing risky behaviors. Despite the decline in syphilis infection rate in the general U.S. population, continued outbreaks of syphilis in MSM, many of whom are co-infected with HIV, continue to happen in some areas; rates of gonorrhea and chlamydial infection have risen in this population as well. Rising STD rates among MSM indicate increased potential for HIV transmission, both because these rates suggest ongoing risky behavior and because STDs have a synergistic effect on HIV infectivity and susceptibility. Studies suggest that optimism about the effectiveness of highly active antiretroviral therapy (HAART) for HIV may be contributing to relaxed attitudes toward safer sex practices and increased sexual risk-taking by some HIV-infected persons.
Injection drug use also continues to play a key role in the HIV epidemic; at least 28% of AIDS cases among adults and adolescents with known HIV risk category reported to CDC in 2000 were associated with injection drug use. In some large drug-using communities, HIV seroincidence and seroprevalence among injection drug users (IDUs) have declined in recent years. The decline has been a result of several things, including a increased use of sterile needles, lower rates of needle sharing, shifts from injection to noninjection methods of using drugs, and the cessation of drug use. Injection drug use amoung heroin users has helped to increase HIV infection substantially in some areas, serving as a reminder that avoiding all high risk behavior is important.
Clinicians providing medical care to HIV-infected persons can play a key role in helping their patients reduce risk behaviors and maintain safer practices and can do so with a feasible level of effort, even in constrained practice settings. Clinicians can greatly affect patients’ risks for transmission of HIV to others by performing a brief screening for HIV transmission risk behaviors; communicating prevention messages; discussing sexual and drug-use behavior; positively reinforcing changes to safer behavior; referring patients for such services as substance abuse treatment; facilitating partner notification, counseling, and testing; and identifying and treating other STDs. These steps may also help to decreaste a patients’ risks of getting other STDs and bloodborne infections (e.g., hepatitis). Managed care plans can play an important role in HIV prevention by incorporating these recommendations into their practice guidelines, educating their providers and enrollees, and providing condoms and educational materials. In the context of care, prevention services might be delivered in clinic or office environments or through referral to community-based programs. Some clinicians have expressed concern that reimbursement is often not provided for prevention services and note that improving reimbursement for such services might enhance the adoption and implementation of these guidelines.
Filed under Health by on Jun 28th, 2009. 
Each HIV-infected patient initially entering into care should have a complete medical history, physical examination, laboratory evaluation, and counseling. This is to confirm the presenence of HIV, get historical and laboratory data, discuss treatment of HIV with patient, and initiate care as suggested by HIV primary care guidelines. Baseline information then is used to define management goals and plans.
The following laboratory tests should be performed for a new patient during initial patient visits:
• HIV antibody testing (if prior documentation not available) or if HIV RNA is undetectable (AI);
• CD4 T-cell count (AI);
• Plasma HIV RNA (viral load) (AI);
– Blood count, a chemistry profile, transaminase readings, BUN and creatinine, urinalysis, and screening test
for syphilis (e.g., RPR, VDRL, or treponema EIA), tuberculin skin test (TST) or interferon-γ release assay
(IGRA) (unless there is a history of prior tuberculosis or positive TST or IGRA), anti-Toxoplasma gondii IgG,
hepatitis A, B, and C serologies, and Pap smear in women;
• Fasting blood glucose and serum lipids if the patient is considered at risk for cardiovascular disease and for
baseline evaluation prior to initiation of combination antiretroviral therapy (AIII); and
• For patients who have pretreatment HIV RNA >1,000 copies/mL, genotypic resistance testing when the
patient enters into care, regardless of whether therapy will be initiated immediately (AIII). For patients who
have HIV RNA levels of 500–1,000 copies/mL, resistance testing also may be considered, even though
amplification may not always be successful (BII). If therapy is deferred, repeat testing at the time of
antiretroviral initiation should be considered (CIII).
People living with HIV/AIDS must often deal with several social, psychiatric, and health related issues that are best addressed with a multidisciplinary approach to HIV. The evaluation also must include assessment of drug abuse, economic factors (e.g., unstable housing), social support, mental illness, comorbidities, high-risk behaviors, and other factors that are known to impair the ability to adhere to treatment and to promote education about HIV. Once evaluated, these factors should be managed accordingly.
Lastly, risk behaviors and effective strategies to prevent HIV transmission. to others should be
provided at all of a patient’s clinical visits.
Filed under Health by on Jun 7th, 2009.