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Routine Testing for HIV
Increased HIV testing is being promoted on the state and national level. CDC has recommended that HIV testing be incorporated as a routine part of health care rather than being based on identified risk factors. They estimate that as more than 20% of persons currently infected are not aware of their status. Because of this, they may continue to engage in risky behaviors and continue to infect new partners. The most common reasons for not being tested for HIV include lack of HIV education, no knowledge of possible risk, denial, stigma, being tested and not returning for results and fear of being diagnosed with HIV.
Treatment as Prevention
A new concept for preventing HIV infection is through optimizing treatment of already infected individuals. This makes sense in many ways. We know through Public Health principles of transmission the more infectious someone is the greater the risk of transmission. By maintaining an individual with HIV on effective ART the likelihood increases that they will be able to maintain viral suppression and an undetectable HIV viral load. Taking ART not only reduces the personal risk of developing HIV related illnesses, but has the additional benefit of significantly decreasing the risk of transmission. The lower the viral load the less risk of infection. That is not to say that someone with an undetectable viral load can’t transmit the virus to someone else, but the risk is decreased. An HIV-positive person’s viral load is the single biggest risk factor in the transmission of HIV. The idea of ‘treatment as prevention’ is to use treatment as a prevention strategy to protect sexual partners, or, on a large scale, to reduce HIV transmission among a population (Avert, 2012).
Harm Reduction
Avert (October 2012) reports that IVDU accounts for about 30% of all HIV infections outside of Sub Saharan Africa. In Central Asia and Eastern Europe the use of IVD has increased dramatically over the past decade, and is estimated to be responsible for 80% of all HIV/AIDS infections. Opiate substitution therapy (OST), predominately using methadone (an opioid agonist) and buprenorphine (a partial agonist), is now being used in over 70 countries. Many of the same countries also support needle exchange programs.
These programs have been shown to an effective tool to reduce the number of new HIV infections. A recent study in the British Medical Journal by McArthur, et. al (2012) reported the results of a meta analysis of twelve published and three unpublished observational studies focused on OST and incidence of HIV infection. The authors reported an overall 54% decrease in HIV infection among persons engaged in these programs (CI 95% 0.32-0.67, p= <0.001).
Needle exchange programs have been shown to reduce incidence of both HIV and hepatitis c among IVDU. While still considered to be controversial by some, the Public Health community has shown that rather than increase IVDU, clean syringes along with other harm reduction interventions have helped to decrease blood borne infections in the US and globally (GMHC, 2009).
Pre Exposure Prophylaxis (PrEP)
Truvada is the first medication for HIV PrEP approved by the FDA to decrease the risk of HIV acquisition. It is a combination of two drugs, tenofovir and emtricitabine, both nucleoside analog HIV reverse transcriptase inhibitors. The medication itself is not new since it had been approved for the treatment of HIV for adults and children twelve years of age or older in August 2004. After numerous clinical trails it was approved in July 2012 as a medication that can be used for PrEP for persons at high risk for becoming infected with HIV. High risk individuals include persons who (Gilead, 2012):
- Have a partner(s) known to be HIV infected
- Engage in sexual activity within a high prevalence area or social network
- Practice inconsistent or no condom use
- Have a diagnosis of sexually transmitted infections
- Exchange sex for commodities (such as money, food, shelter, or drugs)
- Use elicit drugs or are alcohol dependent
- Have been incarcerated
- Have partner(s) of unknown HIV status with any of the factors listed above.
Truvada, taken one tablet daily, is recommended to be used as part of a comprehensive prevention strategy along with safe sex practices including barriers. In pre-approval studies, condoms were used by all subjects. Before initiating PrEP, the individual is screened for active HIV infection and must be negative. Once Truvada is initiated, providers stress the importance of adherence to the medication and screen for HIV infection every three months. Heterosexual couples are counseled that, although no adverse effects have been found among infants exposed to Truvada during pregnancy and breastfeeding, these data are incomplete for women in HIV-discordant couples using Truvada to prevent acquisition of HIV (MMWR, 2012).
Male Circumcision
Male circumcision is the surgical removal of some or the entire foreskin from the penis. In comparison to the outside surface of the skin found on the penis, the inner mucosal surfaces contain more target cells for HIV. Male circumcision has been shown to dramatically reduce the risk of HIV infection in Sub Saharan countries and, based on these findings, has been made a recommendation for all countries where heterosexual transmission is prevalent (CDC, 2012c).
When examining the role of adult male circumcision in the US the CDC warns that several other factors should be considered. The majority of evidence collected has shown circumcision to be effective in reducing male to female vaginal transmission. In the US, MSM account for the majority of cases of HIV. Male circumcision is more prevalent in the US than in developing countries, and increasing the emphasis might not result in a significant decline of HIV infections. Finally, the risks and benefits of adult male circumcision should be weighed since adverse outcomes such as pain, bleeding and infection can occur (CDC, 2012c).
Prenatal HIV Screening and ART
Prevention for maternal/fetal transmissions has been very successful in the US. Prenatal screening for HIV promotes early identification of infection and allows the mother to start ART earlier in the pregnancy and prior to delivery. Many antiretrovirals are proved to be effective in reducing infection, although several are toxic and must be avoided. In 2010, only 217 children under the age of thirteen in the US were reported to have HIV, and these cases were almost exclusively related to maternal/fetal transmission (CDC, 2012b). This is a significant improvement from earlier years.
Continue on to HIV: What Doesn’t Work?
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