HIV Prevention Begins in the Doctor’s Office

Jonathan Mermin, MD, MPH

World AIDS Day every year is a powerful reminder that the fight against HIV is far from over.

Despite advances in treatment that have dramatically extended lives and driven down AIDS-related mortality rates, more than 56,000 people still become infected with HIV each year in the U.S.—one every nine and a half minutes.

Physicians have a critical role to play in preventing the spread of HIV. Though there are significant demands on physicians’ scarce time and resources, with relatively little effort it is possible for every doctor to help their patients know their HIV status, avoid infection or transmission, and reduce the burden of HIV in the U.S.

Three strategies are key:

Screen Every Patient for HIV.

Of an estimated 1.1 million people living with HIV in the U.S., more than 200,000 of them are unaware of their infection. These individuals account for more than 50% of new sexually transmitted HIV infections, and diagnosing them could have a dramatic impact on the U.S. epidemic. This is because once diagnosed, most people with HIV take steps to protect their partners from infection.

Knowledge of status among people with HIV has been associated with a 60% reduction in risk behavior. Among HIV-discordant couples, where one person has HIV and the other does not, knowledge of HIV status and access to condoms and prevention information have been associated with an 80 to 90% reduction in HIV transmission. In addition, being diagnosed with HIV allows for the provision of antiretroviral therapy, which can not only prolong life, but can also reduce viral load and risk of transmission.

Yet far too many HIV-infected individuals walk out of doctors’ offices, clinics, and emergency rooms without learning they have HIV. This is a tragedy, especially when a simple test can ensure they know their status and are able to seek care. Today, about 36% of people with HIV are diagnosed within a year of developing AIDS, when treatment is less effective and they may have unknowingly infected others for years.

Every American between the ages of 13 and 64 should be routinely screened for HIV in healthcare settings. Although testing should remain voluntary and be undertaken only with the patient’s knowledge, simplified testing procedures such as incorporating consent for testing into general consent for medical care should be utilized. In addition, the CDC no longer advises that intensive pretest counseling be required, instead focusing counseling efforts on those individuals who test positive.

Such simplified procedures can give providers the flexibility they need to increase HIV testing and early diagnosis in busy medical settings. It is also important to note that universal screening can reduce the stigma still associated with HIV testing, by making this test as routine for patients as a blood pressure check.

CDC recommendations also advise that all patients with certain risk factors get tested at least once every year (or more frequently if risk behavior dictates). These patients include those with HIV-positive sex partners, men who have sex with men, injection drug users and their sex partners, and those who have had (or their partners have had) more than one partner since their most recent HIV test.

In addition, all patients initiating treatment for tuberculosis or seeking treatment for STDs should be screened because these conditions may be correlated with HIV infection.

Talk With All of Your Patients About HIV

Healthcare providers have the opportunity to speak openly and honestly with all patients about HIV and reducing risk behaviors. It is possible to misjudge patient risk if we don’t open the door to frank conversations. Fewer than 40% of adults say they have talked with their doctor about HIV. And one quarter of African-Americans—who have eight times the prevalence of HIV than whites—report not being tested for HIV because their physician never recommended it.

Putting this into practice can be as simple as a short conversation, but it requires being comfortable discussing HIV and sexual risk with patients who may be initially surprised by the topic. Many people with HIV do not fit traditional risk profiles. Offering testing to every patient avoids this problem.

Talk with Your HIV-Infected Patients About Prevention.

Talking with infected patients about prevention is just as important as talking with uninfected patients. HIV-infected individuals who receive prevention services from a clinician reduce unprotected sex.

And while many doctors avoid talking about risk behaviors because they assume it makes patients uncomfortable, the opposite can be true. We’ve found that many HIV-infected individuals do appreciate having frank conversations with their doctors about risk behaviors and methods for protecting their partners from acquiring HIV.

Increasingly, patients will be asking you about measures they can take to avoid transmitting HIV, including the potential use of antiretroviral therapy, condoms, circumcision, and testing of partners.

There are more options available now than there were 20 years ago, but the principles remain the same: open communication between patients and providers, assisting patients with disclosure of status and encouraging partner testing, and providing patients with the information and tools they need to keep from transmitting HIV and to live longer, healthier lives.

HIV remains a serious but preventable disease. As physicians, we can ensure that our patients are armed with the information they need to protect themselves and their partners from infection.

 

Jonathan Mermin, MD, MPH, is the Director of CDC’s Division of HIV/AIDS Prevention (DHAP). Before being named to that post, Mermin served as the Director of CDC-Kenya and HHS Public Health Attaché for the U.S. Embassy there. He is a graduate of Harvard College and of Stanford University School of Medicine, and received his MPH from Emory University. He currently serves as an Associate Clinical Professor at the University of California, San Francisco School of Medicine. He delivered this speech to a group of physicians on World AIDS Day last December.

 


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