Florida HIV AIDS   

Course Objectives

1.  Identify the psychosocial and cultural considerations necessary when working with HIV positive patients.

2.  Describe the stigma associated with the HIV virus.

3.  Describe counseling techniques that can be used before and after HIV testing.

4.  Identify the treatment protocol most often used with HIV/AIDS patients.


AIDS Defined

HIV stands for Human Immunodeficiency Virus.

The immune system is responsible for fighting off viruses in the body.  White blood cells protect the body from the germs such as viruses, parasites, fungi and bacteria.  The HIV disease is a deterioration of the body’s immune function.

The term AIDS stands for Acquired Immune Deficiency Syndrome. 

A positive HIV test result means that the person has been infected with HIV (Human Immunodeficiency Virus), the vi type of whrus that causes AIDS (Acquired Immune Deficiency Syndrome). HIV disease progresses to AIDS when the CD4+ T cell count drops below 200 cells/mm, and/or you develop an AIDS-defining condition.  CD4+ T cells are aite blood cell that fights infections. When HIV enters a person’s CD4+ T cell, it uses the cell to make copies of itself. This process destroys the CD4+ T cells, weakening the immune system and making it harder for the body to fight infections.The AIDS Surveillance Case Definition of the U.S. Centers for Disease Control and Prevention

A diagnosis of AIDS is made whenever a person is HIV-positive and:

he or she has a CD4+ cell count below 200 cells per micro liter OR his or her CD4+ cells account for fewer than 14 percent of all lymphocytes OR that person has been diagnosed with one or more of the AIDS-defining illnesses listed below.

AIDS Infection   

AIDS is caused by infection with a virus called human immunodeficiency virus (HIV). This virus is passed from one person to another through blood-to-blood and sexual contact. In addition, infected pregnant women can pass HIV to their babies during pregnancy or delivery, as well as through breast feeding.

White blood cells of the immune system provide a first line of defense against viruses and cancers. White blood cells affected with the HIV virus resist treatment by disguising themselves as protease inhibitors. Other cells of the immune system that get infected with AIDS are CD4-possitive T-cells, which orchestrate the immune response, and monocyte macrophage cells, which collect infected cells.

 Body fluids that pass the Virus:   

  • blood
  • semen
  • vaginal fluid
  • breast milk
  • other body fluids containing blood

These are additional body fluids that may transmit the virus that health care workers may come into contact with:

  • cerebrospinal fluid surrounding the brain and the spinal cord
  • synovial fluid surrounding bone joints
  • amniotic fluid surrounding a fetus

HIV and Its Transmission    

Research has revealed a great deal of valuable medical, scientific, and public health information about the human immunodeficiency virus (HIV) and acquired immunodeficiency syndrome (AIDS). The ways in which HIV can be transmitted have been clearly identified.

 HIV is spread by sexual contact with an infected person, by sharing needles and/or syringes (primarily for drug injection) with someone who is infected through transfusions of infected blood or blood clotting factors. Babies born to HIV-infected women may become infected before or during birth or through breast-feeding after birth.

In the health care setting, workers have been infected with HIV after being stuck with needles containing HIV-infected blood or, less frequently, after infected blood gets into a worker’s open cut or a mucous membrane (for example, the eyes or inside of the nose).


 Casual contact through closed-mouth or "social" kissing is not a risk for transmission of HIV. Because of the potential for contact with blood during "French" or open-mouth kissing, the Center for Disease Control recommends against engaging in open mouth kissing with a person that has been infected with the virus. The risk of acquiring HIV during open-mouth kissing is believed to be very low.

 Saliva, Tears, and Sweat

 HIV has been found in saliva and tears in very low quantities from some AIDS patients. It is important to understand that finding a small amount of HIV in a body fluid does not necessarily mean that HIV can be transmitted by that body fluid. HIV has not been recovered from the sweat of HIV-infected persons. Contact with saliva, tears, or sweat has never been shown to result in transmission of HIV.


At the start of every intravenous injection, blood is introduced into needles and syringes. HIV can be found in the blood of a person infected with the virus. The reuse of a blood-contaminated needle or syringe by another drug carries a high risk of HIV transmission. Infected blood can be introduced into drug solutions by:

  • using blood-contaminated syringes to prepare drugs
  • reusing water
  • reusing bottle caps, spoons, or other containers ("spoons" and "cookers") used to dissolve drugs in water and to heat drug solutions
  • reusing small pieces of cotton or cigarette filters ("cottons") used to filter out particles that could block the needle

"Street sellers" of syringes may repackage used syringes and sell them as sterile syringes. For this reason, people who continue to inject drugs should obtain syringes from reliable sources of sterile syringes, such as pharmacies.

 HIV/AIDS and Stigma

 HIV-related stigma refers to all unfavorable attitudes, beliefs, and policies directed toward people perceived to have HIV/AIDS as well as toward their significant others and loved ones, close associates, social groups, and communities. Patterns of prejudice, which include devaluing, discounting, discrediting, and discriminating against these groups of people, play into and strengthen existing social inequalities—especially those of gender, sexuality, and race—that are at the root of HIV-related stigma.

Erving Goffman is widely credited for conceptualizing and creating a framework for the study of stigma. His work was seminal in creating an environment for ongoing academic research on the topic. In his landmark book Stigma: Notes on the Management of Spoiled Identity (1963), Goffman described stigma as “an attribute that is deeply discrediting within a particular social interaction” (p. 3). His explanation of stigma focuses on the public’s attitude toward a person who possesses an attribute that that falls short of societal expectations. The person with the attribute is “reduced in our minds from a whole and usual person to a tainted, discounted one” (p. 3). Goffman further explained that stigma falls into three categories:

1.   Abominations of the body—various physical deformities.

2.   Blemishes of individual character—weak will, domineering or unnatural passions, treacherous and rigid beliefs, or dishonesty. Blemishes of character are inferred from, for example, mental disorder, imprisonment, addiction, alcoholism, homosexuality, unemployment, suicidal attempts, or radical political behavior.

3.  Tribal stigma of race, nation, and religion—beliefs that are transmitted through lineages and equally contaminate all members of a family (Goffman, 1963).

The stigma concept has been applied to myriad circumstances (Link and Phelan, 2001). Goffman’s ideas are a common thread in much of the published research and provide the theoretical underpinnings for much of the literature on stigma and stereotyping.

According to Goffman and other researchers, diseases associated with the highest degree of stigma share common attributes:

  • The person with the disease is seen as responsible for having the illness
  • The disease is progressive and incurable
  • The disease is not well understood among the public
  • The symptoms cannot be concealed.

HIV infection fits the profile of a condition that carries a high level of stigmatization (Goffman, 1963; Herek, 1999; Jones et al., 1988). First, people infected with HIV are often blamed for their condition and many people believe HIV could be avoided if individuals made better moral decisions. Second, although HIV is treatable, it is nevertheless a progressive, incurable disease (Herek, 1999; Stoddard, 1994). Third, HIV transmission is poorly understood by some people in the general population, causing them to feel threatened by the mere presence of the disease. Finally, although asymptomatic HIV infection can often be concealed, the symptoms of HIV-related illness cannot. HIV-related symptoms may be considered repulsive, ugly, and disruptive to social interaction (Herek, 1999).

The discrimination and devaluation of identity associated with HIV-related stigma do not occur naturally. Rather, they are created by individuals and communities who, for the most part, generate the stigma as a response to their own fears. HIV-related stigma manifests itself in various ways. HIV-positive individuals, their loved ones, and even their caregivers are often subjected to rejection by their social circles and communities when they need support the most. They may be forced out of their homes, lose their jobs, or be subjected to violent assault. For these reasons, HIV-related stigma must be recognized and addressed as a life-altering phenomenon.

HIV-related stigma has been further divided into the following categories:

Instrumental HIV-related stigma—a reflection of the fear and apprehension that are likely to be associated with any deadly and transmissible illness (Herek, 1999)

Symbolic HIV-related stigma—the use of HIV/AIDS to express attitudes toward the social groups or “lifestyles” perceived to be associated with the disease (Herek, 1999)

Courtesy HIV-related stigma—stigmatization of people connected to the issue of HIV/AIDS or HIV- positive people (Snyder, 1999, based on Goffman, 1963).

Stigma and Access to Care

The literature devoted to stigma and access to care falls roughly into three categories. Most of the literature deals with barriers to care that HIV-positive individuals encounter across the continuum from HIV diagnosis to end of life. The next largest category of studies documents the reluctance of health care providers to treat individuals with HIV infection. Finally, a few studies cover the stigma experienced by providers of ancillary and support services to people living with HIV/AIDS.


HIV/AIDS-related stigma affects issues related to HIV testing including delays in testing, the effect of delay on further transmission of HIV, and individuals’ responses to testing positive (Chesney and Smith, 1999). Early detection of HIV infection is important. Knowledge of one’s HIV seropositivity can lead to earlier treatment and improved outcomes (Herek, 1990). Knowledge of seropositivity also can lead to changes in risk behaviors that can reduce or eliminate the risk of HIV transmission. A Kaiser Health Poll report (2000) suggested that fear of being stigmatized by HIV/AIDS has some relationship to people’s decisions about getting tested for HIV. One-third of survey respondents said that if they were tested for HIV, they would be “very” or “somewhat” concerned that people would think less of them if they discovered that they had been tested. In addition, 8 percent of people who had never been tested for HIV said that worries about confidentiality played a part in their decision not to have the test.

Studies provide evidence that stigma is associated with delays in HIV testing among individuals who are at high risk of being infected with HIV (Myers et al., 1993; Stall et al., 1996). In a study of gay and bisexual men who were unaware of their HIV status, two-thirds of the participants expressed a fear of discrimination against people with HIV and said it was a reason for not getting tested (Stall et al., 1996). Earlier in the epidemic, HIV stigmatization was shown to influence the way in which at-risk populations approached HIV testing. People at risk for HIV infection were more likely to seek testing that was offered anonymously (i.e., no names were recorded) than testing that was offered confidentially (i.e., names were kept in confidential files) (Fehrs et al., 1988; Johnson et al., 1988).

HIV/AIDS-related stigma also influences individuals’ responses to testing positive: It aggravates the psychological burden of receiving a positive HIV test (Chesney and Smith, 1999). Earlier in the epidemic, there were reports of severe psychological responses to notification, including denial, anxiety, depression, and suicidal ideation (Coates et al., 1987; Ostrow et al., 1989). Over time, studies have shown a decrease in severe reactions to being notified of positive test results; however, research continues to show that notification is associated with high distress. Distress is greatest immediately after notification and typically declines within 2 to 10 weeks (Ironson et al., 1990; Perry et al., 1990). Stigma also affects the care of HIV-positive individuals. After a person tests positive, he or she faces decisions that include how to enter and adhere to care and whether to disclose HIV seropositivity to partners, friends, family, colleagues, employers, and health care providers (Chesney and Smith, 1999). At each level, a decision to disclose seropositivity may either enhance access to support and care or expose the individual to stigmatization and potential discrimination.


Accessing health care can be a challenge for people who are HIV positive, because the health care system itself is often a source of stigma. Health care professionals, particularly those who infrequently encounter HIV-positive people, can be insensitive to their patients’ concerns about stigma. In addition, health care professionals are not always knowledgeable about appropriate procedures for maintaining patient confidentiality (Herek et al., 1998).

The literature on caregiving reveals that stigmatization is evident among health care providers. Fear of contagion and fear of death have clear negative effects on health care providers’ attitudes toward and treatment of HIV-positive patients (Gerbert et al., 1991; Weinberger et al., 1992).  Health care providers also may fear stigmatization themselves because of their work with HIV-positive patients (Durham, 1994). Caregivers, whether professionals or volunteers, risk what Goffman called “courtesy stigma,” in which they are stigmatized as a result of their association with HIV/AIDS and people living with HIV disease. That stigma may influence their willingness to work with people with HIV or may make their work more difficult (Snyder et al., 1999).

United States Statistics

HIV ranks 5th among the leading causes of death for all persons between the ages of 35 and 44, but 2nd among Hispanic males of that age group and 1st among African-American males of that age.

HIV/AIDS was the 5th leading cause of death for U.S. women aged 25-44. Among African American women in this same age group, HIV/AIDS was the third leading cause of death in 1999.

Areas Reporting Most Cases


Number of Cumlative AIDS Cases

New York








New Jersey






Puerto Rico






Men Who Have Sex with Men

In the United States, HIV-related illness and death historically have had a tremendous impact on men who have sex with men. Even with the increase among drug users, men having sex with men continues to account for the largest number of people reported with AIDS each year.

Impact of HIV Infection on African Americans

In the early 1980s, HIV/AIDS was primarily considered a gay white disease in the U.S. Today, however, the epidemic has expanded and the disease is also a major health problem in the African-American community.

The HIV/AIDS epidemic continues to be a major health crisis facing the African-American community.  Although African Americans make up about 12 percent of the U.S. population, they accounted for half of the new HIV cases reported in the United States in 2001.  African-American women accounted for nearly 64 percent of HIV cases reported among women in 2001.

Overall, it is estimated that half of new HIV infections occur among teenagers and young adults aged 25 years and younger.

Hispanic Population and Aids

The Hispanic population accounts for 19% of the number of new U.S. AIDS cases reported each year. 81% of the Hispanic population infected with the AIDS virus is male.  In 1993, 18% of those estimated to be living with AIDS were Hispanic, while in 1999, 20% were Hispanic. In comparison, non-Hispanic whites represented 46% of people estimated to be living with AIDS in 1993, but only 38% in 1999. . Sixty percent of Hispanics reported with AIDS in 2000 were born in the U.S. 47% of the Hispanic AIDS cases are linked to heterosexual sex.

HIV Testing

The tests commonly used to detect HIV infection actually look for antibodies produced by the body to fight HIV. Most people will develop detectable antibodies within 3 months after infection, the average being 25 days. In rare cases, it can take up to 6 months.

Many places provide testing for HIV infection. Common testing locations include local health departments, offices of private doctors, hospitals, and sites specifically set up to provide HIV testing.  It is important to seek testing at a place that also provides counseling about HIV and AIDS. Counselors can answer any questions the person might have about risky behavior and ways they can protect themselves and others in the future. In addition, they can help you understand the meaning of the test results and describe what AIDS-related resources are available in the local area.

Only the Home Access test is approved by the Food and Drug Administration. The Home Access test kit can be found at most local drug stores. The testing procedure involves pricking your finger with a special device, placing drops of blood on a specially treated card, and then mailing the card in to be tested at a licensed laboratory. Customers are given an identification number to use when phoning for the test results. Callers may speak to a counselor before taking the test, while waiting for the test result, and when getting the result.

A rapid test for detecting antibody to human immunodeficiency virus (HIV) is a screening test that produces very quick results, in 30 minutes or less. In comparison, results from the commonly used HIV antibody screening test, the enzyme immunoassay (EIA), are not available for 1-2 weeks.  OraQuick is a test that can detect antibodies to HIV in finger-stick whole-blood specimens and provide results in as little as 20 minutes.

The viral load is to be tested 2–8 weeks after the start of treatment. If the drugs are working, the viral load should decrease. It should continue to decrease as they continue to take the medication. Throughout HIV treatment, the viral load should be tested every 3–4 months to make sure the drugs are still working. If the viral load is still detectable within 4–6 months after starting treatment, they should talk to the doctor about possibly changing the HIV drugs.

Anonymous HIV testing should be available to increase options for individuals seeking to learn their HIV status. In this age of effective treatment, it is increasingly important for people to know their HIV status. Recent studies show that eliminating the availability of anonymous HIV testing services has a deterrent effect on some people's willingness to come forward for testing. People with legitimate concerns about discrimination or people who are unfamiliar with or distrust the public health system are able to gain access to the system through anonymous testing and subsequently receive referrals for needed treatment, care, or prevention services. Partner counseling also can be provided following anonymous testing, if requested.

Voluntary, confidential notification of potentially exposed partners is to be an essential component of a comprehensive HIV prevention program. Partner counseling is a primary prevention service with the following objectives:

  • To provide prevention information to people who are at very high risk of becoming HIV infected, but who may be unaware of or misunderstand their risks
  • To assist these individuals in obtaining HIV prevention counseling and voluntary testing, and referral
  • To provide access to partners who are already infected to prevention and treatment services that can improve their health and quality of life.

Effectiveness of Condoms

Condoms are classified as medical devices and are regulated by the Food and Drug Administration (FDA). Condom manufacturers in the United States test each latex condom for defects, including holes, before it is packaged. The proper and consistent use of latex or polyurethane (a type of plastic) condoms when engaging in sexual intercourse--vaginal, anal, or oral--can greatly reduce a person’s risk of acquiring or transmitting sexually transmitted diseases, including HIV infection.

There are many different types and brands of condoms available--however, only latex or polyurethane condoms provide a highly effective mechanical barrier to HIV. In laboratories, viruses occasionally have been shown to pass through natural membrane ("skin" or lambskin) condoms, which may contain natural pores and are therefore not recommended for disease prevention (they are documented to be effective for contraception). Women may wish to consider using the female condom when a male condom cannot be used.

For condoms to provide maximum protection, they must be used consistently (every time) and correctly. Several studies of correct and consistent condom use clearly show that latex condom breakage rates in this country are less than 2 percent. Even when condoms do break, one study showed that more than half of such breaks occurred prior to ejaculation.


Treatment of HIV Infection

When AIDS was first recognized in 1981, patients with the disease were unlikely to live longer than a year or two. Since then, scientists have developed an effective arsenal of drugs that can help many people infected with HIV (human immunodeficiency virus) live longer and healthier lives.

Drugs for Treating HIV 

As of 2003, antiretroviral drugs have been approved for treating HIV infection. They are called antiretroviral because they attack HIV, which is a retrovirus. Once inside the cell, HIV uses specific enzymes to survive. Antiretroviral drugs work by interfering with the virus' ability to use these enzymes.

Reverse transcriptase inhibitors interfere with an enzyme called reverse transcriptase or RT that HIV needs to make copies of itself. There are two main types of RT inhibitors and they each work differently

Nucleoside/nucleotide drugs provide faulty DNA building blocks, halting the DNA chain that the virus uses to make copies of itself.

Non-nucleoside RT inhibitors bind RT so the virus cannot carry out its copying function.

Protease inhibitors interfere with the protease enzyme that HIV uses to produce infectious viral particles.

In March 2003, the Food and Drug Administration (FDA) announced the accelerated approval of Fuzeon (enfuvirtide) for use in combination with other anti-HIV medications to treat advanced HIV-1 infection in adults and children ages 6 years and older.

FDA’s accelerated approval of Fuzeon makes it the first product in a new class of medications called fusion inhibitors to receive marketing approval anywhere in the world. Drugs in this class interfere with the entry of HIV-1 into cells by inhibiting the fusion of viral and cellular membranes. This inhibition blocks the virus’ ability to infect certain components of the immune system. The approved labeling for Fuzeon warns physicians to carefully monitor patients for signs and symptoms of pneumonia. Patients receiving Fuzeon are advised to seek medical evaluation immediately if they develop signs or symptoms suggestive of pneumonia such as cough with fever, rapid breathing and shortness of breath. In addition, Fuzeon can cause both serious systemic allergic reactions and local skin reactions at the site of injection.

Symptoms of a serious systemic allergic reaction with Fuzeon can include: trouble breathing, fever and skin rash, chills, vomiting and low blood pressure. Patients taking Fuzeon should contact their healthcare provider right away if they get any of these symptoms. People with HIV must take complicated treatment regimens, often taking several drugs on a daily basis. Patients may forget to take their medicine, find the food restrictions difficult to deal with, and may experience unpleasant side effects. Aside from the complicated dosing regimens, antiretroviral drugs themselves may cause serious medical problems. Metabolic changes are occurring in people with chronic HIV infection Researchers have found garlic supplements can cause a potentially harmful side effect when combined with a type of medication used to treat HIV/AIDS. Investigators from the National Institutes of Health (NIH) observed that garlic supplements sharply reduced blood levels of the anti-HIV drug saquinavir.

 The Pharmaceutical Research and Manufacturers Association list nearly two dozen new anti-HIV drugs now in development. They include new protease inhibitors and more potent, less toxic RT inhibitors, as well as drugs that interfere with entirely different steps in the virus' lifecycle. These new categories of drugs include:

  • Fusion inhibitors -- drugs that interfere with HIV's ability to enter a cell
  • Integrase inhibitors -- drugs that interfere with HIV's ability to insert its genes into a cell's normal DNA.  

HIV and Pregnancy

For those who are pregnant or want to become pregnant, they must consider the general risks and benefits of drug treatment to both themselves and the child. Some of the drugs (such as efavirenz and hydroxyurea) should be avoided, because they may cause birth defects if taken early in pregnancy.

Most women with HIV/AIDS in the United States reside in the Northeast and the South. The highest numbers of cases were first observed in the Northeast, but the South has reported the greatest increases in recent years. African-American and Hispanic women are disproportionately affected by the epidemic and account for 80% of AIDS cases reported in U.S. women in 1999. Over time, the proportion of cases in women attributable to injection-drug use has declined, whereas the proportion of cases from heterosexual contact has increased, particularly among young women. Worldwide, approximately 600,000 infants each year become infected through mother-to-child transmission of the HIV virus. In the United States, widespread implementation of the PHS guidelines for universal counseling and testing and perinatal use of ZDV has sharply reduced transmission risk and the number of perinatally acquired HIV infections.

Despite the declines, cases of perinatal HIV transmission continue to occur, largely because of missed opportunities for prevention, particularly among women who lack prenatal care or who are not being offered voluntary HIV counseling and testing during pregnancy. The estimated 280–370 infants born with HIV infection each year represent populations in which prevention efforts are impeded by lack of timely HIV testing and treatment of pregnant women.

Dynamics of Perinatal HIV Transmission

 Perinatal transmission can occur during pregnancy (intrauterine), during labor and delivery (intrapartum), or after delivery through breast-feeding (postpartum). In the absence of breast-feeding, intrauterine transmission accounts for 25%–40% of infection, and 60%–75% of transmission occurs during labor and delivery. Among women who breast-feed, approximately 20%–25% of perinatal infections are believed to be associated with intrauterine transmission, 60%–70% with intrapartum transmission or very early breast-feeding, and 10%–15% with later postpartum transmission through breast-feeding. In a randomized trial of formula feeding versus breast-feeding, approximately 44% of HIV infection was attributed to breast-feeding. In breastfeeding populations, a shift toward an increasing proportion of transmission related to breast-feeding is likely to occur as a consequence of successful preventive interventions directed at late prenatal and intrapartum transmission.

Intrapartum transmission can occur during labor through maternal-fetal exchange of blood or during delivery by contact of the infant’s skin or mucous membranes with infected blood or other maternal secretions. Several studies have indicated that most infections transmitted through breast-feeding probably occurred during the first few weeks to months of life. Risk factors during breast-feeding include viral load in breast milk, subclinical or clinical mastitis, breast abscesses and maternal seroconversion during the lactation period.

Several risk factors are associated with perinatal HIV transmission. Clinical factors that increase the likelihood of transmission include immunologically or clinically advanced HIV disease in the mother, high plasma viral load, maternal injection-drug use during pregnancy, preterm delivery, nonreceipt of the PACTG 076 regimen, and breastfeeding. No link has been established between perinatal HIV transmission and maternal age, race/ethnicity, or history of having a previously infected child.

Obstetric factors also influence HIV transmission risk. The risk for perinatal transmission increases per hour duration of membrane rupture after controlling for other risk factors. Delivery >4 hours after the rupture of the fetal membranes can double the risk for HIV transmission. Maternal infection with another sexually transmitted disease (STD) during pregnancy and certain obstetrical procedures can also increase risk. Chorioamnionitis (i.e., uterine infection) has been associated with an increased risk for HIV transmission.

Most of these risk factors were identified before the recommended use of ZDV to prevent perinatal HIV transmission. Their effects are unknown now that most pregnant women infected with HIV are receiving ZDV chemoprophylaxis to prevent mother-to child transmission, as well as combination therapy for their own health. Because of the sharp reductions in perinatal HIV transmission associated with effective antiretroviral interventions, factors that interfere with women or their infants receiving ZDV treatment (e.g., barriers to prenatal care, lack of HIV testing for some pregnant women) are increasingly important.

 Prevention of Perinatal Transmission

The birth of every perinatally HIV-infected infant is a sentinel health event signaling either a missed prevention opportunity or, more rarely, a failure of prophylaxis. An opportunity is missed whenever a woman of childbearing age is unaware of her HIV status or her risk for HIV or when an HIV-infected pregnant woman a) does not receive prenatal care, b) is not offered HIV testing, c) is unable to obtain HIV testing, d) is not offered chemoprophylaxis, e) is unable to obtain chemoprophylaxis, or f) does not complete the chemoprophylaxis regimen. Prophylaxis failures occur when an infant becomes infected despite chemoprophylaxis and other preventive interventions. Each of these missed opportunities or failures deserves attention from service providers and prevention programs.

 Early Prenatal Care

Maximum reduction of perinatal transmission depends on preventing HIV infection in women or identifying HIV infection before pregnancy or as early as possible during pregnancy. Diagnosis allows a woman to receive effective antiretroviral therapies for her own health and preventive drugs (e.g., ZDV) to improve the chances that her infant will be born free of infection. Early knowledge of maternal HIV status is also important for decisions regarding obstetrical management. Achieving these goals requires increased access to and use of prenatal care.

HIV Treatment Adherence

 Adherence is a major issue in HIV treatment for two reasons.

  • First, adherence affects how well the HIV drugs decrease viral load. When patients skip medication doses even once, the virus has the opportunity to make copies of itself more rapidly. This makes it difficult for the drugs to be effective. Other factors that may affect treatment effectiveness include the baseline viral load and CD4+ T cell count, whether they have any AIDS-related illnesses, and whether you they used HIV drugs before.
  • Second, adherence to HIV treatment is very important to prevent drug resistance. Studies have shown that when the patient skips doses, they may develop strains of HIV that are drug-resistant. This may leave them with fewer treatment options if the viral load does not decrease. Because drug-resistant strains can be transmitted to others, it has serious consequences for anyone with whom they engage in risky behavior.
  • There are several reasons why many patients have difficulty adhering to an HIV treatment plan.
  • One reason is that HIV treatment plans are very complicated. Studies have shown that many people may have difficulty adhering to even simple treatment plans. Yet HIV treatment may involve taking 25 or more pills each day. In addition, some HIV drugs must be taken on an empty stomach, while others must be taken with meals. This can be difficult for many people, especially those who are sick or experiencing HIV symptoms. Also, HIV-infected patients may need to continue their treatment regimens for a long time, perhaps for their entire lives.
  • HIV-infected patients have reported other reasons for poor adherence, including unpleasant side effects (like nausea), sleeping through doses, traveling away from home, being too busy, feeling sick or depressed, or simply forgetting to take their medications.

 AIDS Wasting

 AIDS wasting is the involuntary loss of more than 10% of body weight, plus more than 30 days of either diarrhea, or weakness and fever. Wasting is linked to disease progression and death. Losing just 5% of body weight can have the same negative effects.  Wasting is still a problem for people with AIDS.

Part of the weight lost during wasting is fat. More important is the loss of muscle mass. This is also called "lean body mass," or "body cell mass." Lean body mass can be measured by bioelectrical impedance analysis (BIA). This is a simple, painless office procedure.

AIDS wasting and lipodystrophy both can cause some body shape changes. Wasting is the loss of muscle. Lipodystrophy is a loss of fat. They are not the same thing. However, wasting in women can start with a loss of fat.

Several factors contribute to AIDS wasting:

Low food intake: Low appetite is common with HIV. Also, some AIDS drugs have to be taken with an empty stomach, or with a meal. It can be difficult for some people with AIDS to eat when they're hungry. Drug side effects such as nausea, changes in the sense of taste, or tingling around the mouth also decrease appetite. Opportunistic infections in the mouth or throat can make it painful to eat. Infections in the gut can make people feel full after eating just a little food. Finally, lack of money or energy may make it difficult to shop for food or prepare meals.

Poor nutrient absorption: Healthy people absorb nutrients through the small intestine. In HIV disease, several infections (including parasites) can interfere with this process. HIV may directly affect the intestinal lining and reduce nutrient absorption. Diarrhea causes loss of calories and nutrients.

Altered metabolism: Food processing and protein building are affected by HIV disease. Even before any symptoms show up, you need more energy. This might be caused by the increased activity of the immune system. People with HIV need more calories just to maintain their body weight.

Hormone levels can affect the metabolism. HIV seems to change some hormone levels. Also, cytokines play a role in wasting. Cytokines are proteins that produce inflammation to help the body fight infections. People with HIV have very high levels of cytokines. This makes the body produce more fats and sugars, but less protein.

Unfortunately, these factors can work together to create a "downward spiral." For example, infections may increase the body's energy requirements. At the same time, they can interfere with nutrient absorption and cause fatigue. This can reduce appetite and make people less able to shop for or cook their meals. They eat less, which accelerates the process.

Wasting Treatment

The best prevention for AIDS Wasting is a baseline nutrition assessment by a Registered Dietitian, with general healthy eating nutrition counseling at diagnosis of HIV.  As weight loss occurs, or with the development of symptomatology that interfere with maintaining an adequate intake, follow-up visits to the Dietitian can allow an evaluation with a detailed individualized plan of treatment.   Once weight is lost, it is difficult to return to pre-illness weight with similar body composition.

Nutrition Guidelines for People with HIV

 Good nutrition means getting enough macronutrients and micronutrients. Macronutrients contain calories (energy): proteins, carbohydrates, and fats. They help maintain body weight. Micronutrients include vitamins and minerals. They keep cells working properly, but will not prevent weight loss. Good nutrition can be a problem for many people with HIV. When the body fights any infection, it uses more energy and the patient needs to eat more than normal. But when one feels sick, they eat less than normal.

Some medications can upset the stomach, and some opportunistic infections can affect the mouth or throat. This makes it difficult to eat. Also, some medications and infections cause diarrhea. With diarrhea, the body actually uses less of what you eat.  With weight lose, they might be losing fat, or they might be losing lean body weight like muscle. If they lose too much lean weight, the body chemistry changes. This condition is called wasting syndrome or cachexia. Wasting can kill. If the patient loses more than 5% of their body weight, it could be a sign of wasting.

A moderate exercise program will help the body turn food into muscle. Take it easy, and work exercise into daily activities. Drinking enough liquids is very important when the person has HIV. Extra water can reduce the side effects of medications. It can help avoid a dry mouth and constipation. Be aware that drinking tea, coffee, colas, chocolate, or alcohol can actually make you lose body liquid.

Important Nutrients
There has not been a lot of research on specific nutrients and HIV disease. Also, many nutrients interact with each other. Most nutritionists believe in designing an overall program of supplements.

  • People with HIV may benefit from taking supplements of the following vitamins and minerals:
  •  B Vitamins: Vitamin B-1 (Thiamine), Vitamin B2 (Riboflavin), Vitamin B6 (Pyridoxine), Vitamin B12 (Cobalamin), and Folate (Folic Acid).
  • Antioxidants, including beta-carotene (the body breaks down beta-carotene to make Vitamin A), selenium, Vitamin E (Tocopherol), and Vitamin C.
  • Magnesium and Zinc

 HIV counseling seeks to reduce HIV acquisition and transmission through the following:

• Information. Clients should receive information regarding HIV transmission and prevention and the meaning of HIV test results. Provision of information is different from informed consent.

• HIV prevention counseling. Clients should receive help to identify the specific behaviors putting them at risk for acquiring or transmitting HIV and commit to steps to reduce this risk. Prevention counseling can involve >1 sessions. Inform all clients who are recommended or who request HIV testing should receive the following information, even if the test is declined:

• Information regarding the HIV test and its benefits and consequences.

• Risks for transmission and how HIV can be prevented.

• The importance of obtaining test results and explicit procedures for doing so.

• The meaning of the test results in explicit, understandable language.*

• Where to obtain further information or, if applicable, HIV prevention counseling.

• Where to obtain other services (see Typical Referral Needs).

* For example, “A negative test means no HIV was found. But if you were exposed to HIV

   recently — in the last 1–2 months — this test may not be able to pick that up.” See Negative

HIV Test Results

In certain settings where HIV testing is offered, other useful information includes

a) descriptions or demonstrations of how to use condoms correctly

b) information regarding risk-free and safer sex options 

c) information regarding other sexually transmitted and bloodborne diseases

d) descriptions regarding the effectiveness of using clean needles, syringes, cotton, water, and other drug paraphernalia

e) information regarding drug treatment; and f) information regarding the possible effect of HIV vaccines on test results for persons participating in HIV vaccine trials (see Additional Counseling Considerations for Special Situations and Positive HIV Test Results).

For efficiency, information can be provided in a pamphlet, brochure, or video rather than a face-to-face encounter with a counselor. This approach allows the provider to focus face-to-face interactions on prevention counseling approaches proven effective with persons at increased risk for HIV infection. Information should be provided in a manner appropriate to the client’s culture, language, sex, sexual orientation, age, and developmental level. Certain informational videos and large-group presentations that provide explicit information regarding correct use of condoms have proven effective in reducing new STDs and could be effective in reducing HIV.

HIV Prevention Counseling

HIV prevention counseling should focus on the client’s own unique circumstances and risk and should help the client set and reach an explicit behavior-change goal to reduce the chance of acquiring or transmitting HIV. HIV prevention counseling is usually, but not always, conducted in the context of HIV testing. The client-centered* HIV prevention counseling model involves two brief sessions, whereas other effective models are longer or involve more sessions. Regardless of the model used, in HIV prevention counseling, the counselor or provider focuses on assessing the client’s personal risk or circumstances and helping the client set and reach a specific, realistic, risk-reduction goal. These guidelines avoid using the terms “pretest” and “posttest” counseling to underscore that prevention counseling is a risk-reduction process that might involve only one or >1 session.

Several models for HIV prevention counseling in conjunction with HIV testing have been developed, evaluated in controlled studies, and documented to be efficacious in changing behavior or reducing sexually transmitted infections, including individual face-to-face counseling, large and small-group counseling with a facilitator, and video-based counseling.

Client-Centered HIV Prevention Counseling

Since 1993, CDC has recommended one interactive counseling model, called client centered HIV prevention counseling, which involves two face-to-face sessions with a provider or counselor. This model has traditionally used a two-step HIV script.

* Client-centered is used here to mean that the counseling sessions focus on the client’s own risk circumstances, risk behaviors, and prevention needs. This term should not be confused with the more intensive, client-centered approach advocated by psychologist Carl R. Rogers, although some skills and strategies that involve the client in the prevention counseling process might be similar (Rogers CR. Client-centered therapy: its current practice, implications, and theory. Boston, MA: Houghton Mifflin, 1951). Vol. 50 / No. RR-19 MMWR 15 testing approach in which clients are physically present at a setting for the HIV test (initial session) and then return for HIV test results (follow-up session). Each session might require 15–20 minutes (including testing and referral) for clients at increased risk for HIV, but could take only a few minutes for those at lower risk. In the first session, a personalized risk assessment* encourages clients to identify, understand, and acknowledge the behaviors and circumstances that put them at increased risk for acquiring HIV. The session explores previous attempts to reduce risk and identifies successes and challenges in these efforts. This in-depth exploration of risk allows the counselor to help the client consider ways to reduce personal risk and commit to a single, explicit step to do so. In the second session, when HIV test results are provided, the counselor discusses the test results, asks the client to describe the risk-reduction step attempted (and acknowledges positive steps made), helps the client identify and commit to additional behavioral steps, and provides appropriate referrals (e.g., to PCRS).

In one large, randomized, controlled trial, this model was reported to be;

• effective at reducing high-risk sexual behaviors and new STDs;

• feasible to use even in busy publicly funded clinics;

• acceptable to clients, counselors, and health-care providers; and

• cost-effective at preventing STDs in persons at increased risk for HIV.

The model was reported to be especially effective among adolescents and persons with ongoing sexual risk behaviors (e.g., newly diagnosed STDs). Although the benefits of client-centered HIV prevention counseling in reducing high-risk drug behaviors are unknown, studies have indicated that similar counseling approaches that help clients explore risks and set specific risk-reduction goals reduce risky drug use behaviors.

Observational studies and reviews of programs in various settings have indicated that many counselors are still unfamiliar with the specific goals of the client-centered HIV prevention counseling model (Amy S. DeGroff, M.P.H., written communication, 2000). Because “client-centered” is sometimes misinterpreted as “face-to-face,” providers in many HIV test sites deliver face-to-face informational messages in response to a generic checklist risk assessment. This type of counseling provides advice rather than encouraging client participation or discussion of personal risk; it seldom focuses on personal goal setting. “Client-centered” can also be misinterpreted to mean that the counselor should avoid directing the session. Although attentive listening and respect for clients’ concerns are important elements of effective counseling, the primary goal of client-centered HIV prevention counseling is risk reduction. HIV prevention counseling usually requires provider training and support and ongoing quality assurance to achieve optimal benefit. Providers can contact their state health department’s HIV/AIDS program office for information on local training opportunities.

* Personal risk assessment is an essential element of HIV prevention counseling in which the client and counselor work to understand and acknowledge the client’s personal risk for HIV. Risk assessment is not synonymous with risk screening, which helps determine which clients should be recommended HIV CTR.

Elements of HIV Prevention Counseling

Regardless of the HIV prevention counseling model used, some counseling elements have been used repeatedly in effective interventions and are recognized by many specialists as critical in counseling success.

The following elements should be part of all HIV prevention counseling sessions:

• Keep the session focused on HIV risk reduction. Each counseling session should be tailored to address the personal HIV risk of the client rather than providing a predetermined set of information. Although counselors must be willing to address problems that pose barriers to HIV risk reduction (e.g., alcohol use in certain situations), counselors should not allow the session to be distracted by the client’s additional problems unrelated to HIV. Certain counseling techniques (e.g., open ended questions [Box 5], role-play scenarios, attentive listening, and a nonjudgmental and supportive approach) can encourage the client to remain focused on personal HIV risk reduction.

• Include an in-depth, personalized risk assessment. Sometimes called “enhancing self-perception of risk,” risk assessment allows the counselor and client to identify, acknowledge, and understand the details and context of the client’s HIV risk. Keeping the assessment personal, instead of global, will help the client identify concrete, acceptable protective measures to reduce personal HIV risk (Box 6). The risk assessment should explore previous risk-reduction efforts and identify successes and challenges in those efforts. Factors associated with continued risk behavior that might be important to explore include using drugs or alcohol before sexual activity, underestimating personal risk, perceiving that precautionary changes are not an accepted peer norm, perceiving limited self-efficacy for successful change efforts, receiving reinforcement for frequent unsafe practices (e.g., a negative HIV test result after risk behaviors), and perceiving that vulnerability is associated with “luck” or “fate”.

• Acknowledge and provide support for positive steps already made. Exploring previous risk-reduction efforts is essential for understanding the strengths and challenges faced by the client in reducing risk. Support for positive steps already taken increases the clients’ beliefs that they can successfully take further HIV risk reduction steps. For some clients, simply agreeing to an HIV test is an important step in reducing risk.

• Clarify critical rather than general misconceptions. In most situations, counselors should focus on reducing the client’s current risk and avoid discussions regarding HIV transmission modes and the meaning of HIV test results. However, when clients believe they have minimal HIV risk but describe more substantial risk, the counselor should discuss the HIV transmission risk associated with specific behaviors or activities the clients describe and then discuss lower-risk alternatives. For example, if clients indicate that they believe oral sex with a risky sex partner poses little or no HIV risk, the counselor can clarify that, although oral sex with an infected partner might result in lower HIV transmission risk than anal sex, oral sex is not a risk-free behavior, particularly when commonly practiced. If clients indicate that they do not need to be concerned about HIV transmission among needle-sharing partners if they use clean needles, the counselor can clarify that.

Examples of closed-ended versus open-ended questions Closed-ended questions, which might interfere with client-centered human immunodeficiency virus (HIV) prevention counseling.

Have you ever injected drugs?


Have you (for a male client) ever had sex with a man?


Have you (for a female client) ever had sex with a bisexual man?

Have you ever had sex when you were under the influence of alcohol or drugs?

Do you (always) use condoms when you have sex?


Can you always use condoms when you have sex?

Can you always use clean works (i.e., needles, syringes, cottons, or cookers*) when you inject?

Open-ended questions, which promote client-centered HIV prevention counseling;

  • What are you doing that you think may be putting you at risk for HIV infection?
  • What are the riskiest things that you are doing?
  • If your test comes back positive, how do you think you may have become infected?
  • When was the last time you put yourself at risk for HIV? What was happening then?
  • How often do you use drugs or alcohol?
  • How do you think drugs or alcohol influence your HIV risk?
  • How often do you use condoms when you have sex?
  • When/with whom do you have sex without a condom? When with a condom?
  • What are you currently doing to protect yourself from HIV? How is that working?
  • What kinds of things do you do to protect your partner from getting infected with HIV? (for HIV-infected clients)
  • Tell me about specific situations when you have reduced your HIV risk. What was going on that made that possible?
  • How risky are your sex/needle sharing partners? For example, have they been recently tested for HIV?
  • Cottons are filters used to draw up the drug solution. Cookers include bottle caps, spoons, or other containers used to dissolve drugs.
  • Examples of global versus specific risk-reduction steps for HIV prevention counseling Global risk-reduction steps, which are unlikely to be effective in changing behavior;
  • Always use condoms.
  • Have fewer or less risky partners.
  • Have safer sex.
  • Stop injecting drugs.
  • Specific risk-reduction steps, which are more likely to be effective in changing behavior
  • Buy a condom tomorrow and try it on.
  • Carry a condom next time I go out (e.g., to the bar/nightclub).
  • Starting today, put condoms on the night stand beside the bed.
  • Starting tonight, require my partner to use a condom next time, or I will not have vaginal (anal) sex.
  • Stop seeing (specific partner) who is seeing other people.
  • Break up with (specific partner) before getting together with someone new.
  • Talk honestly with (specific partner) about my HIV status and ask about his/her HIV status.
  • Next time I’m out with friends and may have sex, avoid getting “high” on drugs or alcohol.
  • Only kissing, etc., with (specific partner) until we both have an HIV test.
  • Tomorrow, ask (specific partner ) if he or she has had a recent HIV test and has been tested for other sexually transmitted diseases.
  • Obtain clean works (i.e., needles, syringes, cottons, or cookers*) tomorrow so I have them before I use next time.
  • Contact drug treatment center and make appointment.

Cottons are filters used to draw up the drug solution. Cookers include bottle caps, spoons, or other containers used to dissolve drugs.

HIV can be transmitted through the cooker, cotton, or water used by several persons sharing drugs. With newly identified or uninformed HIV-infected clients, the counselor should discuss HIV transmission risks associated with specific sexual or drug-use activities, including those in which the client might not be currently engaged.

• Negotiate a concrete, achievable behavior-change step that will reduce HIV risk. Although the optimal goal might be to eliminate HIV risk behaviors, small behavior changes can reduce the probability of acquiring or transmitting HIV. Behavioral risk-reduction steps should be acceptable to the client and appropriate to the client’s situation. For clients with several high-risk behaviors, the counselor should help clients focus on reducing the most critical risk they are willing to commit to changing. The step does not need to be a personal behavior change. For many clients, knowledge of a partner’s recent HIV status (and talking with the partner about getting an HIV test) might be more critical than personal behavior changes.

The step should be relevant to reducing the client’s own HIV risk and should be a small, explicit, and achievable goal, not a global goal. Identifying the barriers and supports to achieving a step, through interactive discussion, role-play modeling, recognizing positive social support, or other methods will enhance the likelihood of success. Writing down the goal might be useful. For clients with ongoing risk behaviors, referral to additional prevention and support services is encouraged.

• Seek flexibility in the prevention approach and counseling process. Counselors should avoid a “one-size-fits-all” prevention message (e.g., “always use condoms”). Behaviors that are safe for one person might be risky for another.

For example, unprotected vaginal intercourse might be unsafe with anonymous partners whose HIV status is unknown, but safe for uninfected persons in a mutually monogamous relationship. The length of counseling sessions will vary depending on client risk and comfort (e.g., adolescents might require more time than adults).

• Provide skill-building opportunities. Depending on client needs, the counselor can demonstrate or ask the client to demonstrate problem-solving strategies such as a) communicating safer sex commitments to new or continuing sex partners; b) using male latex condoms properly; c) trying alternative preventive methods (e.g., female condoms); d) cleaning drug-injection equipment if clean syringes are unavailable; or e) communicating safer drug-injection commitments to persons with whom the client shares drug paraphernalia.

• Use explicit language when providing test results. Test results should be provided at the beginning of the follow-up session. Counselors should never ask the client to guess the test results. Technical information regarding the test can be provided through a brochure or other means so the session can focus on personal HIV risk reduction for clients with negative tests and other considerations for clients with positive or indeterminate test results (see Additional Counseling Considerations for Special Situations). In-depth, technical discussions of the “window period (i.e., the time from when a person is infected until they develop detectable HIV antibody) should be avoided because they could confuse the client and diffuse the importance of the HIV prevention message. Counselors should clarify that negative test results do not mean the client has no HIV risk and work with the client to reconsider ongoing HIV risk behaviors and the benefits of taking steps to reduce those risks. A client with ongoing risk behaviors should not be given a false sense of the safety of those behaviors (i.e., avoid statements like “whatever you were doing seems to be safe” or “continue to do whatever you are doing now”). These counseling elements are considered necessary for high-quality counseling. Specialists in the field (Technical Expert Panel Review of CDC HIV Counseling, Testing, and Referral Guidelines; February 18–19, 1999; Atlanta, Georgia) also suggested adoption of the following:

• Ensure that the client returns to the same counselor. Consistency of the client and counselor relationship helps the client feel secure, reduces misunderstanding, and promotes the likelihood of effective risk reduction. Effective counseling models tended to use the same counselor for all sessions. When follow-up prevention counseling sessions must be provided by a different counselor, careful record keeping is recommended to ensure high-quality counseling.

• Use a written protocol to help counselors conduct effective sessions. A structured protocol outlining session goals can help keep the counselor focused on risk reduction. The protocol can include examples of open-ended questions (to help a new counselor avoid closed-ended questions) and a list of explicit risk-reduction steps (to help a new counselor avoid accepting a client’s suggestion of global risk reduction steps).

• Ensure ongoing support by supervisors and administrators. Supervisory support is essential for effective counseling. Training in HIV counseling approaches that focus on personal risk reduction is recommended for persons supervising counselors. Staff appraisals should acknowledge that completion of critical counseling elements has higher priority than completion of paperwork.

• Avoid using counseling sessions for data collection. If required, paperwork should be completed at the end of the counseling session or by staff members who are not counseling. Checklist risk assessments driven by data collection forms are detrimental to effective counseling because they can encourage even skilled counselors to use closed-ended questions, limit eye contact, and miss critical verbal and nonverbal cues. The relevance of any routinely collected data should be periodically assessed.

• Avoid providing unnecessary information. An emphasis on providing information might prompt counselors to miss critical HIV prevention opportunities and cause clients to lose interest. Discussion of theoretical HIV risks (e.g., sex with a person with hemophilia or needle exposures through tattoos) tends to shift the focus away from the client’s actual HIV risk situations to topics that are more “comfortable” or easy to discuss but irrelevant to the client’s risk.


The essential elements of comprehensive prevention programs are based on several key principles and include a number of essential activities. These are highlighted below.

  •  A community planning process to ensure efforts are directed to communities at greatest risk
  •  Epidemiologic and behavioral surveillance to effectively guide prevention efforts
  •  Voluntary HIV counseling, testing, referral, and partner counseling to provide a pathway to needed prevention and treatment services
  •  Health education and risk-reduction activities, including individual-, group-, and community-level programs to provide the skills and support necessary for reducing risks
  • Accessible diagnosis and treatment of other sexually transmitted diseases to decrease risk of HIV transmission
  • School-based prevention efforts for youth to provide young people the skills and support they need to keep from initiating risky behaviors and to adopt healthy ones
  • Public information programs to ensure that knowledge and awareness of how to prevent HIV remain high
  • Training and quality assurance to provide those implementing programs needed skills
  • Laboratory support to keep pace with diagnostic and testing services and related research efforts
  • HIV prevention capacity-building activities to support organizations in expanding their abilities to implement effective programs
  • An HIV prevention technical assistance assessment and plan to ensure that programs keep pace with prevention technologies
  • Evaluation of major program activities, interventions, and services to ensure efforts are effective

 The following components should be part of all HIV prevention counseling sessions:

Keep the session focused on HIV risk reduction. Each counseling session should be tailored to address the personal HIV risk of the client rather than providing a predetermined set of information.

Include an in-depth, personalized risk assessment. This assessment allows the counselor and client to identify, acknowledge, and understand the details and context of the client's HIV risk.  Keeping the assessment personal, instead of global, will help the client identify concrete, acceptable protective measures to reduce personal HIV risk.

Acknowledge and provide support for positive steps already made. Exploring previous risk-reduction efforts is essential for understanding the strengths and challenges faced by the client in reducing risk.

Clarify critical rather than general misconceptions. In most situations, counselors should focus on reducing the client's current risk and avoid discussions regarding HIV transmission modes and the meaning of HIV test results. However, when clients believe they have minimal HIV risk but describe more substantial risk, the counselor should discuss the HIV transmission risk associated with specific behaviors or activities the clients describe and then discuss lower-risk alternatives. 

Negotiate a concrete, achievable behavior-change steps that will reduce HIV risk. Although the optimal goal might be to eliminate HIV risk behaviors, small behavior changes can reduce the probability of acquiring or transmitting HIV. Behavioral risk-reduction steps should be acceptable to the client and appropriate to the client's situation.

Seek flexibility in the prevention approach and counseling process.  Behaviors that are safe for one person might be risky for another.

Use explicit language when providing test results. Test results should be provided at the beginning of the follow-up session. Counselors should never ask the client to guess the test results. Technical information regarding the test can be provided through a brochure or other means so the session can focus on personal HIV risk reduction for clients with negative tests and other considerations for clients with positive or indeterminate test results.

Ensure that the client returns to the same counselor. Consistency of the client and counselor relationship helps the client feel secure, reduces misunderstanding, and promotes the likelihood of effective risk reduction. 

Additional Counseling Considerations

Clients with newly identified HIV infection have immediate and long-term needs. Some clients might be better prepared to receive positive test results than others. The emotional impact of hearing an HIV-positive test result might prevent clients from clearly understanding information during the session in which they receive their results. Providers should provide appropriate referrals and, when necessary, additional sessions.

When a client receives the test result, the provider should ensure that the client understands it. As part of HIV prevention counseling, providers should explicitly discuss and clarify any misconceptions regarding HIV transmission risk to partners associated with specific sexual or needle-sharing activities. Clients should be advised to refrain from donating blood, plasma, or organs. For sexually active clients who are not in mutually monogamous partnerships, providers should also address strategies to prevent other sexually transmitted or blood borne infections (e.g., gonorrhea, syphilis, chlamydia, herpes simplex virus, human herpes virus type 8, hepatitis B virus, hepatitis C virus, and cytomegalovirus).

The first few months after persons learn they are HIV infected are important for accessing medical and other support services to help them obtain treatment and establish and maintain behavior changes that reduce the likelihood of transmitting the virus to others. For example, persons with ongoing risks might be referred for prevention counseling to prevent transmission to others or for prevention case management. For all newly identified clients, a follow-up appointment 3--6 months after diagnosis is recommended.

Psychological Impact of AIDS

Communicating with children and extended family members can be very difficult for parents with HIV infection. Many parents appropriately choose to defer discussing their illness during the early stages of infection when health problems are minimal or nonexistent. As the disease progresses, parents may feel increased pressure to talk about the illness with children and family members, especially during times when parental functioning is disrupted (e.g., during hospitalizations or when the illness becomes debilitating).

Because parents may feel guilt or shame about behaviors associated with HIV infection (e.g., drug use, choice of partner), they may have difficulty communicating with their children and families about the disease. In addition, many adults believe that not telling children painful facts will somehow reduce the impact. Ultimately, children cannot be protected from the realities of parental illness and loss. Children need their parents to acknowledge the illness and to indicate, particularly as the parents’ health worsens, that the children’s needs will continue to be met. Emphasis is usually placed on parents simply disclosing their HIV status to their children; however, children need ongoing communication concerning parents’ health status and prognosis. Such communication could play an important role in decreasing children’s anxiety and increasing their ability to adapt to parental illness.

Nevertheless, health care providers should respect the wishes of parents who are either unwilling or unable to explain the nature of their illness to their children. Parents should be encouraged to discuss the more general issues surrounding illness and prognosis with their children. If, however, during the late stages of HIV disease, parents are still unable to discuss the situation with family members, primary care practitioners should consider referring patients to mental health or social services. Often the complex mental health and psychosocial issues holding parents back from revealing the truth about their illness require ongoing mental health intervention before parents can open up to their children or families.

Treatment of psychiatric disorders that result from or are comorbid with HIV infection

Psychiatric disorders associated with HIV/AIDS should be accurately identified and treated. In adults and children with HIV infection, changes in mental status or the emergence of new psychiatric or cognitive disorders require ruling out treatable and reversible causes; medical causes are of increasing concern if CD4 counts are low or viral load has begun to rise.

 The more common diagnoses found in association with HIV/AIDS are dementia and the spectrum of cognitive disorders; delirium; mood disorders; substance use disorders; anxiety disorders; psychotic disorders; adjustment disorders; sleep disorders; disorders occurring in infants, children, and adolescents; and HIV-associated syndromes with psychiatric implications. Both psychopharmacologic and psychotherapeutic treatment strategies are often indicated.

 The management of disturbances in mood, such as major depression or mania, for patients with HIV infection is similar to that for other patients with medical comorbidity [I]. Choice of an antidepressant or mood-stabilizing agent may be influenced by the antiretroviral regimen in place, and dose adjustments may be necessary if drug-drug interactions are likely. A wide array of antidepressant agents are effective in the treatment of HIV-associated major depression, including newer agents such as the selective serotonin reuptake inhibitors (SSRIs)  and medications such as psychostimulants and testosterone. Psychotherapy, particularly interpersonal psychotherapy, either alone or in combination with antidepressant agents, is also an effective treatment for HIV-related depression. Mania associated with HIV infection, particularly late in the course of HIV disease, may be difficult to treat; however, treatment studies suggest that traditional antimanic agents are effective and tolerated.

 The constellation of other disorders associated with HIV infection require treatment. Substance use disorders are prevalent among persons with or at risk for HIV infection, and treatment is a high priority. Psychotherapist should be aware that by treating substance abuse, they may well be preventing HIV infection. One component of a comprehensive approach to HIV prevention among injection drug users is access to sterile syringes. Treatment of anxiety and sleep disorders among HIV-infected patients has not been well studied. For patients who are taking protease inhibitors, benzodiazepines are generally contraindicated because of drug-drug interactions. Thus, benzodiazepines should be given only as a short-term intervention in most instances. Psychotic symptoms in late-stage HIV infection are generally managed with atypical antipsychotic medications at the lowest effective dose, since standard neuroleptic medications have been associated with severe and difficult-to-treat extrapyramidal side effects. Adjustment disorders may require treatment with psychotherapy or medication to prevent progression to a more severe psychiatric disturbance. HIV-associated syndromes with psychiatric implications encompass wasting syndrome, fatigue, pain, and sexual dysfunction. Wasting syndrome has been effectively treated with testosterone (or its derivatives), growth hormone, and thalidomide. Psychostimulants are one of the main interventions used for fatigue. Chronic pain from peripheral neuropathy is often treated with tricyclic antidepressants and anticonvulsant medications, but published treatment studies of pain syndromes in patients with HIV infection have not supported their use. In men, HIV-related hypogonadism can be treated with testosterone replacement.

 Treatment of children and adolescents with antiretroviral medications has increased survival rates and slowed progression to AIDS. The effectiveness of treatment of other mental and behavioral disorders associated with HIV infection in children and adolescents is largely unstudied.


Clinical depression is the most commonly observed psychiatric disorder among patients with HIV infection and affects up to 20% of such patients.  Multiple risk factors for depression exist in this group. The diagnosis of HIV infection itself may lead to sadness and fears of stigmatization.  People with HIV infection who are members of stigmatized minorities may find it difficult to avoid internalizing negative self-images; moreover, HIV infection may result in wasting, weakness, pain, confusion, and disfigurement, which add to patients’ negative feelings. Although sadness and grief are normal responses to these factors, clinical depression, which causes substantial morbidity and may increase mortality, is not.

Practitioners should screen for depression on a yearly basis and more often when symptoms suggest. If the practitioner’s evaluation indicates depression, even though the patient denies that he or she is depressed, the diagnosis should be made and treatment should be strongly recommended. For diagnosis of depression, practitioners should be familiar with and use the diagnostic criteria established in the Diagnostic and Statistical Manual of Mental Disorder-IV (DSM-IV).

Practitioners should be aware of potential side effects of all medications patients are taking. Specifically, efavirenz for HIV/AIDS and interferon-[1][1] for HCV are associated with episodes of depression varying in intensity. These medications may need to be discontinued or used with antidepressant therapy. Should these medications be continued, the primary care practitioner should work closely with a psychiatrist.

Because weight loss, irritability, restlessness, disturbed sleep, fatigue, anorexia, lethargy, or diminished interest in sex (all symptoms commonly observed in HIV-infected persons) may indicate depression, it is important for primary care practitioners to determine if patients are experiencing the effects of HIV, side effects of medications, or clinical depression.

HIV infection can lead to a confluence of severe medical, psychological, and social stresses that can result in alienation from family and friends, loss of job and income, and chronic physical pain. While many people who are infected with HIV think of suicide at some time, only a small minority of HIV-infected persons commit suicide. A great many people with HIV infection lead fulfilling lives (sometimes even more fulfilling after the HIV diagnosis); nevertheless, the potential for suicide in this population should be recognized.


Prevalence studies of suicidality in patients infected with HIV have yielded varied results. One early retrospective study of medical examiner reports indicated a 36-fold greater prevalence of suicide in persons with HIV infection than in age-matched persons without HIV. A more recent study by the same investigators found only a small increase in the rate of suicide compared to other populations. In the general population, approximately 70% of suicides are committed by those who are depressed. Because anyone with HIV infection is likely to experience periods of intense sadness, thoughts of suicide are not uncommon. However, such factors as improved social support and prognosis can decrease the depth of true clinical depression and, therefore, the potential for suicide. The risk of suicide today may be less than that during earlier years of the epidemic when patients had fewer treatment options and a greater sense of isolation.

Anxiety Disorders

 Mental Health Clinicians should recognize the distinct anxiety disorders that are common in persons with HIV infection.  Anxiety is a common symptom in patients with HIV infection. When anxiety is severe or persistent, patients may have an anxiety disorder. These disorders include adjustment disorder, obsessive compulsive disorder (OCD), panic disorder, post-traumatic stress disorder (PTSD), and generalized anxiety disorder. Primary care practitioners need to be aware of the differences among the specific disorders in order to appropriately treat or refer patients and to help them receive optimal care. People with histories of anxiety disorders or major depression and those with limited social support are particularly susceptible, although anyone can experience severe anxiety during the course of HIV infection. As HIV disease progresses, anxiety may increase.


When patients present with common medical symptoms (e.g., chest pain, diaphoresis, dizziness, gastrointestinal disturbances, and/or headache), practitioners should consider anxiety disorders when medical etiologies can not be established.

Mental health practitioners should be aware that disturbances of sleep patterns, which may result from illness or medication schedules, may lead to symptoms of anxiety and poor concentration during the day. Sleep management should be an adjunctive component of treatment in these patients.

A diagnosis of panic disorder or panic attack should be considered if the patient experiences episodic anxiety with multiple, overwhelming somatic symptoms that adversely affect his or her life (e.g., the patient dreads having another attack and avoids situations that might evoke panic) or the symptoms are sufficiently severe to require repeated emergency room visits.

Medical Conditions and Medications That May Cause Anxiety

 Practitioners may need to exclude HIV-related central nervous system (CNS) disease or other medical conditions in patients who present with severe anxiety.

Practitioners should review the medication regimens of patients who present with sudden onset of anxiety without clear emotional cause and should obtain a thorough substance use history.

 Patients can present with anxiety-like symptoms due to delirium, other medical conditions, medications, or substance use. For example, anxiety may be triggered by CNS pathologies, including HIV-related infections, hypoxia, and decreased perfusion of the brain, sepsis, delirium, dementia, metabolic imbalances, or endocrinopathies. In addition, patients may present with anxiety from the effects of withdrawal from caffeine, nicotine, alcohol, cocaine, and/or amphetamines.

PTSD (Post Traumatic Stress Disorder)

 Although PTSD has a lifetime prevalence rate of approximately 1.3% to 7.8% in the general population, the rates of PTSD in the HIV-infected population are much higher. Although chronic illness can sometimes in itself be a traumatic experience leading to PTSD, more often a history of physical or psychological trauma (and diagnosis of PTSD) co-occurs with an individual’s HIV status.

Trauma can affect both psychological and physical functioning. Some research has suggested that the physical effects of trauma have been related to significant health problems such as diminished functioning of the immune system and increased susceptibility to infections. The psychological effects of PTSD may manifest themselves in increased risk-taking behavior, such as substance use, poor eating habits, or unsafe sexual activity. In addition, patients with PTSD may suffer from depression, self-isolation, impairments in trust and attachments, and feelings of anger. Patients with HIV/AIDS may also be affected by past trauma to the point that it manifests in disease-management problems such as disrupted or negative interactions with medical personnel and/or medication non-adherence.

Family Issues for Patients with HIV/AIDS

General Recommendations:

Practitioners should assess family configuration, functioning, and existing social support as part of the routine evaluation of patients who are primary caretakers of children. These assessments should ideally be done during times of stability. Practitioners should be aware of the impact of single parent homes, same sex parent homes, and teenage parent homes where there is little to no adult presence. Practitioners should refer children who present with behavioral changes in response to illness of a family member for mental health evaluation.

As more women of childbearing age become HIV infected, HIV/AIDS increasingly becomes a disease that involves the family. Primary care practitioners working with HIV-infected parents should, therefore, be aware of the needs of their patients' families, as the burden of HIV infection becomes much greater when children are involved. By providing treatment and solutions for common problems found in HIV-affected families, primary care practitioners help ease the pressure on these patients.

Family members of an HIV-infected person also may face particular difficulties. When confronted with the knowledge of a person's illness or lifestyle, family members can become confused or angry. If not addressed, these emotions can be turned against the HIV-infected person. Children who are infected must cope with and adapt to their own chronic and perhaps terminal illness. They often lack the emotional maturity that can help adults, yet they still must try to deal with the psychological effects that the disease can have on them and their families. Similarly, children who live with an HIV-infected family member must bear the psychological impact of this situation. The impact can be especially traumatic if the infected family member is the child's parent or sibling.

Assessing the family's configuration, functioning, and existing social support should be a routine part of evaluating an HIV-infected patient who is the primary caretaker of children. Determining how a family functioned and how family members interacted before the patient was diagnosed with HIV infection will allow primary care practitioners to assess more effectively family problems that may develop over the course of HIV disease.

Components of a basic assessment can be compiled by asking the following questions:

  • Who makes up the household (including adults and children)?
  • What are the relationships among household members?
  • What are the ages of children and adolescents?
  • If they don't live with the parents being assessed, with whom do they live?
  • How do the patient's children and adolescents function?
  • Are there problems at home or at school or during times of parent's illness?
  • Are there people in the patient's extended families or social networks who
  • can be called on during times of crisis?



Practitioners should encourage patients with HIV infection to communicate with their children, family members, and significant others about the disease. If patients are reluctant to engage in these discussions, however, practitioners should respect their wishes (see Section V: Domestic Violence and HIV Infection).

Practitioners should consider referring patients with HIV infection for mental health or social services if they present with advanced HIV/AIDS without having informed their children and other relations about their disease.

Communicating with children and extended family members can be very difficult for parents with HIV infection. Many parents appropriately choose to defer discussing their illness during the early stages of infection when health problems are minimal or nonexistent. As the disease progresses, parents may feel increased pressure to talk about the illness with children and family members, especially during times when parental functioning is disrupted (e.g., during hospitalizations or when the illness becomes debilitating).

Because parents may feel guilt or shame about behaviors associated with HIV infection (e.g., drug use, choice of partner), they may have difficulty communicating with their children and families about the disease. In addition, many adults believe that not telling children painful facts will somehow reduce the impact. Ultimately, children cannot be protected from the realities of parental illness and loss. Children need their parents to acknowledge the illness and to indicate, particularly as parents' health worsens, that the children's needs will continue to be met. Emphasis is usually placed on parents simply disclosing their HIV status to their children; however, children need ongoing communication concerning parents' health status and prognosis. Such communication could play an important role in decreasing children's anxiety and increasing their ability to adapt to parental illness.

Nevertheless, health care providers should respect the wishes of parents who are either unwilling or unable to explain the nature of their illness to their children. Parents should be encouraged to discuss the more general issues surrounding illness and prognosis with their children. If, however, during the late stages of HIV disease, parents are still unable to discuss the situation with family members, primary care practitioners should consider referring patients to mental health or social services. Often the complex mental health and psychosocial issues holding parents back from revealing the truth about their illness require ongoing mental health intervention before parents can open up to their children or families.



Primary care practitioners should refer parents to social service providers for assistance with formal and informal options, each having unique advantages and disadvantages, for the placement of children.

Primary care practitioners should also be aware of the permanency planning resources available to their patients.

When preparing for the possibility of death, HIV-infected parents face the difficult task of planning for their children's living arrangements. Any such planning is best done by taking into account family wishes and resources. Options that involve family court or children's services can take months to implement and, therefore, should be considered early enough in the course of the disease so that the plan may be operative and available when needed. In general, this planning is best carried out with the help of personnel familiar with the various options available to parents.

Counseling the HIV client Despite substantial advances in the treatment of human immunodeficiency virus (HIV) 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. HIV-infected persons who are aware of their HIV infection tend to reduce 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 .

Reversion to risky sexual behavior might be as important in HIV transmission as failure to adopt safer sexual behavior immediately after receiving a diagnosis of HIV. Unprotected anal sex appears to be occurring more frequently in some urban centers, particularly among young men who have sex with men (MSM). Bacterial and viral sexually transmitted diseases (STDs) in HIV-infected men and women receiving outpatient care have been increasingly noted, indicating ongoing risky behaviors and opportunities for HIV transmission. Further, despite declining syphilis prevalence in the general U.S. population, sustained outbreaks of syphilis among MSM, many of whom are HIV infected, continue to occur in some areas; rates of gonorrhea and chlamydial infection have also risen for this population . 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. This decline has been attributed to several factors, including increased use of sterile injection equipment, declines in needle-sharing, shifts from injection to noninjection methods of using drugs, and cessation of drug use (31--33). However, injection-drug use among young adult with sexual behaviors, changes to less risky behaviors may be difficult to sustain.

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 measures may also decrease patients' risks of acquiring other STDs and bloodborne infections (e.g., viral 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.

This report provides general recommendations for incorporating HIV prevention into the medical care of all HIV-infected adolescents and adults, regardless of age, sex, or race/ethnicity. The recommendations are intended for all persons who provide medical care to HIV-infected persons (e.g., physicians, nurse practitioners, nurses, physician assistants). They may also be useful to those who deliver prevention messages (e.g., case managers, social workers, health educators). Special considerations may be needed for some subgroups (e.g., adolescents, for whom laws and regulations might exist governing providing of services to minors, the need to obtain parental consent, or duty to inform). However, it is beyond the scope of this report to address special considerations of subgroups. Furthermore, the recommendations focus on sexual and drug-injection behaviors, since these behaviors are responsible for nearly all HIV transmission in the United States. Separate guidelines have been published for preventing perinatal transmission.

These recommendations were developed by using an evidence-based approach. The strength of each recommendation is indicated on a scale of A (strongest recommendation for) to E (recommendation against); the quality of available evidence supporting the recommendation is indicated on a scale of I (strongest evidence for) to III (weakest evidence for), and the outcome for which the recommendation is rated is provided. The recommendations are categorized into three major components: 1) screening for HIV transmission risk behaviors and STDs, 2) providing brief behavioral risk-reduction interventions in the office setting and referring selected patients for additional prevention interventions and other related services, and 3) facilitating notification and counseling of sex and needle-sharing partners of infected persons.

This report was developed by CDC, the Health Resources and Services Administration (HRSA), the National Institutes of Health (NIH), and the HIV Medicine Association (HIVMA) of the Infectious Diseases Society of America (IDSA). The recommendations will evolve as results from ongoing behavioral intervention trials become available.

Risk Screening

Risk screening is a brief assessment of behavioral and clinical factors associated with transmission of HIV and other STDs.  Risk screening can be used to identify patients who should receive more in-depth risk assessment and HIV risk-reduction counseling, other risk-reduction interventions, or referral for other services (e.g., substance abuse treatment). Risk screening identifies patients at greatest risk for transmitting HIV so that prevention and referral recommendations can be focused on these patients. Screening methods include probing for behaviors associated with transmission of HIV and other STDs, eliciting patient reports of symptoms of other STDs, and laboratory testing for other STDs. Although each of these methods has limitations, a combination of methods should increase the sensitivity and effectiveness of screening. In conducting risk screening, clinicians should recognize that risk is not static. Patients' lives and circumstances change, and a patient's risk of transmitting HIV may change from one medical encounter to another. Also, clinicians should recognize that working with adolescents may require special approaches and should be aware of and adhere to all laws and regulations related to providing services to minors.

Screening for Behavioral Risk Factors

Clinicians frequently believe that patients are uncomfortable disclosing personal risks and hesitant to respond to questions about sensitive issues, such as sexual behaviors and illicit drug use. However, available evidence suggests that patients, when asked, will often disclose their risks and that some patients have reported greater confidence in their clinician's ability to provide high-quality care if asked about sexual and STD history during the initial visits.

Screening for behavioral risk factors can be done with brief self-administered written questionnaires; computer-, audio-, and video-assisted questionnaires; structured face-to-face interviews; and personalized discussions. Screening questions can be either open-ended or closed (directed)). Use of open-ended questions avoids simple "yes" or "no" responses and encourages patients to discuss personal risks and the circumstances in which risks occur. Open-ended questions also help the clinician gather enough detail to understand potential transmission risks and make more meaningful recommendations. However, although well received by patients, the open-ended approach may initially be difficult for clinicians schooled in directed questioning, who tend to prefer directed screening questions. Directed questions are probably useful for identifying patients with problems that should be more thoroughly discussed. Among directed approaches, technical tools like computer-, audio-, and video-assisted interviews have been found to elicit more self-reported risk behaviors than did interviewer-administered questionnaires, particularly among younger patients (41,51--53,55). Studies suggest that clinicians who receive some training, particularly that including role-play and feedback concerning clinical performance, are more likely to perform effective risk screening (46--49).

Sex-related behaviors important to address in risk screening include whether the patient has been engaging in sex; number and sex of partners; partners' HIV serostatus (infected, not infected, or unknown); types of sexual activity (oral, vaginal, or anal sex) and whether condoms are used; and barriers to abstinence or correct condom use (e.g., difficulty talking with partners about or disclosing HIV serostatus, alcohol and other drug use before or during sex). Also, because the risk for perinatal HIV transmission is high without appropriate intervention, clinicians are advised to assess whether women of childbearing age might be pregnant, are interested in becoming pregnant, or are not specifically considering pregnancy but are sexually active and not using reliable contraception. Women who are unable to become pregnant because of elective sterilization, hysterectomy, salpingo-oophorectomy, or other medical reasons might be less likely to use condoms because of a lack of concern for contraception; these women should be counseled regarding the need for use of condoms to prevent transmission of HIV. Patients who wish to conceive and whose partner is not infected also might engage in risky behavior. Patients interested in pregnancy, for themselves or their partner, should be referred to a reproductive health specialist.

Injection-drug--related behaviors important to address in screening include whether the patient has been injecting illicit drugs; whether the patient has been sharing needles and syringes or other injection equipment; how many partners the patient has shared needles with; whether needle-sharing partners are known to be HIV infected, not infected, or of unknown HIV serostatus; whether the patient has been using new or sterilized needles and syringes; and what barriers exist to ceasing illicit drug use or, failing that, to adopting safer injection practices (e.g., lack of access to sterile needles and syringes).

Approaches to Screening for Behavioral Risk Factors

The most effective manner for screening for behavioral risk factors is not well defined; however, simple approaches are more acceptable to both patients and health-care providers. Screening tools should be designed to be as sensitive as possible for identifying behavioral risks; a more detailed, personalized assessment can then be used to improve specificity and provide additional detail. The sensitivity of screening instruments depends on obtaining accurate information. However, accuracy of information can be influenced by a variety of factors: recall, misunderstanding about risk, legal concerns, concern about confidentiality of the information and how the information will be used, concern that answers may affect ability to receive services, concern that answers may affect social desirability (i.e., the tendency to provide responses that will avoid criticism), and the desire for social approval (the tendency to seek praise). Interviewer factors also influence the accuracy of information. Surveys indicate that patients are more likely to discuss risk behaviors if they perceive their clinicians are comfortable talking about stigmatized topics such as sex and drug use and are nonjudgmental, empathetic, knowledgeable, and comfortable counseling patients about sexual risk factors. These factors need to be considered when interpreting responses to screening questions. To the extent possible, screening and interventions should be individualized to meet patient needs. Examples of two screening approaches are provided).

Incorporating Screening for Behavioral Risk Factors into the Office Visit

Before the patient is seen by the clinician, screening for behavioral risks can be done with a self-administered questionnaire; a computer-, audio-, or video-assisted questionnaire; or a brief interview with ancillary staff; the clinician can then review the results on the patient's medical record. Alternatively, behavioral risk screening can be done during the medical encounter (e.g., as part of the history); either open-ended questions or a checklist approach with in-depth discussion about positive responses can be used. Because, given patients' immediate health needs, it can be difficult in the clinical care setting to remember less urgent matters such as risk screening and harm reduction, provider reminder systems (e.g., computerized reminders) have been used by health-care systems to help ensure that recommended procedures are done regularly. Multicomponent health-care system interventions that include a provider reminder system and a provider education program are effective in increasing delivery of certain prevention services. Risk screening might be more likely to occur in managed care settings if the managed care organization specifically calls for it.

Screening for Clinical Risk Factors

Screening for STDs

Recommendations for preventive measures, including medical screening and vaccinations, that should be included in the care of HIV-infected persons (16,2,54,61--69) have been published previously. This report is not intended to duplicate existing recommendations; it addresses screening specifically to identify clinical factors associated with increased risk for transmission of HIV from infected to noninfected persons. In this context, STDs are the primary infections of concern for three reasons. First, the presence of STDs often suggests recent or ongoing sexual behaviors that may result in HIV transmission. Second, many STDs enhance the risk for HIV transmission or acquisition. Early detection and treatment of bacterial STDs might reduce the risk for HIV transmission. Third, identification and treatment of STDs can reduce the potential for spread of these infections among high-risk groups (i.e., sex or drug-using networks).

Screening and diagnostic testing serve distinctly different purposes. By definition, screening means testing on the basis of risk estimation, regardless of clinical indications for testing, and is a cornerstone of identifying persons at risk for transmitting HIV to others. Clinicians should routinely ask about STD symptoms, including urethral or vaginal discharge; dysuria; intermenstrual bleeding; genital or anal ulcers or other lesions; anal pain, pruritus, burning, discharge, or bleeding; and, for women, lower abdominal pain with or without fever. Regardless of reported sexual behavior or other epidemiologic risk information, the presence of such symptoms should always prompt diagnostic testing and, when appropriate, treatment. However, clinical symptoms are not sensitive for identifying many infections because most STDs are asymptomatic ; therefore, laboratory screening of HIV-infected persons is an essential tool for identifying persons at risk for transmitting HIV and other STDs.

Laboratory Testing for STDs

Identification of syphilis requires direct bacteriologic (i.e., dark-field microscopy) or serologic testing. However, noninvasive, urine-based nucleic acid amplification tests (NAATs) have greatly simplified testing for Neisseria gonorrhoeae and Chlamydia trachomatis. Although they are more costly than other screening tests, their ease of use and sensitivity---similar to the sensitivity of culture for detection of N. gonorrhoeae and substantially higher than the sensitivity of all other tests for C. trachomatis (including culture)---for detecting genital infection are great advantages. Detection of rectal or pharyngeal gonorrhea still requires culture. Pharyngeal infection with C. trachomatis is uncommon, and routine screening for it is not recommended). NAATs have not been approved for use with specimens collected from sites other than the urethra, cervix, or urine. Recommended screening strategies and diagnostic tests for detecting asymptomatic STDs are described cal and state health departments have reporting requirements, which vary among states, for HIV and other STDs. Clinicians need to be aware of and comply with requirements for the areas in which they practice; information on reporting requirements can be obtained from health departments. CEU

Screening for Pregnancy

Women of childbearing age should be questioned during routine visits about the possibility of pregnancy. Women who state that they suspect pregnancy or have missed their menses should be tested for pregnancy. Early pregnancy diagnosis would benefit even women not receiving antiretroviral treatment because they could be offered treatment to decrease the risk for perinatal HIV transmission.

Behavioral Interventions

Behavioral interventions are strategies designed to change persons' knowledge, attitudes, behaviors, or practices in order to reduce their personal health risks or their risk of transmitting HIV to others. Behavioral change can be facilitated by environmental cues in the clinic or office setting, messages delivered to patients by clinicians or other qualified staff on-site, or referral to other persons or organizations providing prevention services. Because behavior change often occurs in incremental steps, a brief behavioral intervention conducted at each clinic visit could result in patients, over time, adopting and maintaining safer practices. Behavioral interventions should be appropriate for the patient's culture, language, sex, sexual orientation, age, and developmental level). In settings where care is delivered to HIV-infected adolescents, for example, approaches need to be specifically tailored for this age group. Also, clinicians should be aware of and adhere to all laws and regulations related to providing services to minors.

Structural Approaches To Support and Enhance Prevention

Clinic or office environments can be structured to support and enhance prevention. All patients, especially new patients, should be provided printed information about HIV transmission risks, preventing transmission of HIV to others, and preventing acquisition of other STDs. Information can be disseminated at various locations in the clinic; for example, posters and other visual cues containing prevention messages can be displayed in examination rooms and waiting rooms. These materials usually can be obtained through local or state health department HIV/AIDS and STD programs or from the National Prevention Information Network (NPIN) (1-800-458-5231;). Additionally, condoms should be readily accessible at the clinic. Repeating prevention messages throughout the patient's clinic visit reinforces their importance, increasing the likelihood that they will be remembered.

Interventions Delivered On-Site

Prevention Messages for All Patients

All HIV-infected patients can benefit from brief prevention messages emphasizing the need for safer behaviors to protect both their own health and the health of their sex or needle-sharing partners. These messages can be delivered by clinicians, nurses, social workers, case managers, or health educators. They include discussion of the patient's responsibility for appropriate disclosure of HIV serostatus to sex and needle-sharing partners. Brief clinician-delivered approaches have been effective with a variety of health issues, including depression, smoking, alcohol abuse, weight and diet, and physical inactivity. This diverse experience with other health behaviors suggests that similar approaches may be effective in reducing HIV-infected patients' transmission risk behaviors. For patients already taking steps to reduce their risk of transmitting HIV, hearing the messages can reinforce continued risk-reduction behaviors. These patients should be commended and encouraged to continue these behaviors.

General HIV Prevention Messages

Patients frequently have inadequate information regarding factors that influence HIV transmission and methods for preventing transmission. The clinician should ensure that patients understand that the most effective methods for preventing HIV transmission remain those that protect noninfected persons against exposure to HIV. For sexual transmission, the only certain means for HIV-infected persons to prevent sexual transmission to noninfected persons are sexual abstinence or sex with only a partner known to be already infected with HIV. However, restricting sex to partners of the same serostatus does not protect against transmission of other STDs or the possibility of HIV superinfection unless condoms of latex, polyurethane, or other synthetic materials are consistently and correctly used. Superinfection with HIV has been reported and appears to be rare, but its clinical consequences are not known. For injection-related transmission, the only certain means for HIV-infected persons to prevent transmission to noninfected persons are abstaining from injection drug use or, for IDUs who are unable or unwilling to stop injecting drugs, refraining from sharing injection equipment (e.g., syringes, needles, cookers, cottons, water) with other persons. Neither antiretroviral therapy for HIV-infected persons nor postexposure prophylaxis for partners is a reliable substitute for adopting and maintaining behaviors that guard against HIV exposure).

Identifying and Correcting Misconceptions

Patients might have misconceptions about HIV transmission (98), particularly with regard to the risk for HIV transmission associated with specific behaviors, the effect of antiretroviral therapy on HIV transmission, or the effectiveness of postexposure prophylaxis for nonoccupational exposure to HIV.

Risk for HIV Transmission Associated with Specific Sexual Behaviors. Patients often ask their clinicians about the degree of HIV transmission risk associated with specific sexual activities. Numerous studies have examined the risk for HIV transmission associated with various sex acts. These studies indicate that some sexual behaviors do have a lower average per-act risk for transmission than others and that replacing a higher-risk behavior with a relatively lower-risk behavior might reduce the likelihood that HIV transmission will occur. However, risk for HIV transmission is affected by numerous biological factors (e.g., host genetics, stage of infection, viral load, coexisting STDs) and behavioral factors (e.g., patterns of sexual and drug-injection partnering), and per-act risk estimates based on models that assume a constant per-contact infectivity could be inaccurate. Thus, estimates of the absolute per-episode risk for transmission associated with different activities could be highly misleading when applied to a specific patient or situation. Further the relative risks of becoming infected with HIV, from the perspective of a person not infected with HIV, might vary greatly according to the various choices related to sexual behavior.

Effect of Antiretroviral Therapy on HIV Transmission. High viral load is a major risk factor for HIV transmission. Among untreated patients, the risk for HIV transmission through heterosexual contact has been shown to increase approximately 2.5-fold for each 10-fold increase in plasma viral load. By lowering viral load, antiretroviral therapy might reduce risk for HIV transmission, as has been demonstrated with perinatal transmission and indirectly suggested for transmission via genital secretions (semen and cervicovaginal fluid). However, because HIV can be detected in the semen, rectal secretions, female genital secretions, and pharynx of HIV-infected patients with undetectable plasma viral loads and because consistent reduction of viral load depends on high adherence to antiretroviral regimens, the clinician should assume that all patients who are receiving therapy, even those with undetectable plasma HIV levels, can still transmit HIV. Patients who have treatment interruptions, whether scheduled or not, should be advised that this will likely lead to a rise in plasma viral load and increased risk for transmission. Another concern related to adherence to antiretroviral therapy is the development of drug-resistant mutations with subsequent transmission of drug-resistant viral strains. Several reports suggest that transmission of drug-resistant HIV occurs in the United States. Recent reports suggest that drug-resistant HIV strains might be less easily transmitted than wild-type virus, but these data are limited and their significance is unclear.

Effectiveness of Postexposure Prophylaxis for Non occupational Exposure to HIV. Although the U.S. Public Health Service recommends using antiretroviral drugs to reduce the likelihood of acquiring HIV infection from occupational exposure (e.g., accidental needle sticks received by health care workers), limited data are available on efficacy of prophylaxis for nonoccupational exposure. Observational data suggesting effectiveness have been reported; however, postexposure prophylaxis might not protect against infection in all cases, and effectiveness of these regimens might be further hindered by lack of tolerability, potential toxicity, or viral resistance. Thus, avoiding exposure remains the best approach to preventing transmission, and the potential availability of postexposure prophylaxis should not be used as justification for engaging in risky behavior.

Tailored Interventions for Patients at High Risk for Transmitting HIV

Interventions tailored to the individual patient's risks can be delivered to patients at highest risk for transmitting HIV infection and for acquiring new STDs. This includes patients whose risk screening indicates current sex or drug-injection practices that may lead to transmission, who have a current or recent STD, or who have mentioned items of concern in discussions with the clinician. Any positive results of screening for behavioral risks or STDs should be addressed in more detail with the patient so a more thorough risk assessment can be done and an appropriate risk-reduction plan can be discussed and agreed upon.

Although the efficacy of brief clinician-delivered interventions with HIV-infected patients has not been studied extensively, substantial evidence exists for the efficacy of provider-delivered, tailored messages for other health concerns (151--155). An attempt should be made to determine which of the patient's risk behaviors and underlying concerns can be addressed during clinic visits and which might require referral.

At a minimum, an appropriate referral should be made and the patient should be informed of the risks involved in continuing the behavior. HIV-infected persons who remain sexually active should be reminded that the only certain means for preventing transmission to noninfected persons is to restrict sex to partners known to be already infected with HIV and that they have a responsibility for disclosure of HIV serostatus to prospective sex partners. For mutually consensual sex with a person of unknown or discordant HIV serostatus, consistent and correct use of condoms made of latex, polyurethane, or other synthetic materials can substantially reduce the risk for HIV transmission. Also, some sex acts have relatively less risk for HIV transmission than others). For HIV-infected patients who continue injection drug use, the provider should emphasize the risks associated with sharing needles and should provide information regarding substance abuse treatment and access to clean needles. Examples of targeted motivational messages on condom use and needle sharing are provided), and providers can individualize their own messages using these as a guide.

Clinician Training

Clinicians can prepare themselves to deliver HIV prevention messages and brief behavioral interventions to their patients by 1) developing strategies for incorporating HIV risk-reduction interventions into patients' clinic visits; 2) obtaining training on speaking with patients about sex and drug-use behaviors and on giving explanations in simple, everyday language 3) becoming familiar with interventions that have demonstrated effectiveness ; 4) becoming familiar with the underlying causes of and concerns related to risk behaviors among HIV-infected persons (e.g., domestic violence; and 5) becoming familiar with community resources that address risk reduction. Free training on risk screening and prevention can be obtained at CDC-funded STD/HIV Prevention Training Centers and HRSA-funded AIDS Education and Training Centers, which also offer continuing medical education credit for this training. Ongoing training will help clinicians refine their counseling skills as well as keep current with prevention concerns at the community level, thus increasing their ability to appropriately counsel and provide support to patients.

Ongoing Delivery of Prevention Messages

Prevention messages can be reinforced by subsequent longer or more intensive interventions in clinic or office environments by nurses, social workers, or health educators. Advantages of a multidisciplinary approach are that skill sets vary among staff members from various disciplines and that a patient may be more receptive to discussing prevention-related issues with one team member than with another. For HIV-negative persons or persons of unknown HIV serostatus, randomized controlled trials provide strong evidence for the efficacy of short, one- or two-session interventions and for longer or multisession interventions in clinics for individuals and groups. For example, for persons who continue to engage in risky behaviors, CDC recommends client-centered counseling, a specific model of HIV prevention counseling, Evidence for the efficacy of multisession interventions for HIV-infected patients, individually or in groups, in clinical settings is limited to a few randomized, controlled trials and other studies that might not have assessed behavioral outcomes. The studies of single-session interventions for individual HIV-infected patients in clinical settings have not been randomized controlled trial.

Referrals for Additional Prevention Interventions and Other Services

Types of Referrals

Certain patients need more intensive or ongoing behavioral interventions than can feasibly be provided in medical care settings). Many have underlying problems that impede adoption of safer behaviors (e.g., homelessness, substance abuse, mental illness), and achieving behavioral change is often dependent on addressing these concerns. Clinicians will usually not have time or resources to fully address these issues, many of which can best be addressed through referrals for services such as intensive HIV prevention interventions (e.g., multisession risk-reduction counseling, support groups), medical services (e.g., family planning and contraceptive counseling, substance abuse treatment), mental health services (e.g., treatment of depression, counseling for sexual compulsivity), and social services (e.g., housing, child care and custody, protection from domestic violence). For example, all patients should be made aware of their responsibility for appropriate disclosure of HIV serostatus to sex and needle-sharing partners; however, full consideration of the complexities of disclosure, including benefits and potential risks, may not be possible in the time available during medical visits. Patients who are having, or are likely to have, difficulty initiating or sustaining behaviors that reduce or prevent HIV transmission might benefit from prevention case management. Prevention case management provides ongoing, intensive, one-on-one, client-centered risk assessment and prevention counseling, and assistance accessing other services to address concerns that affect patients' health and ability to change HIV-related risk-taking behavior. For HIV-seronegative persons, randomized controlled trials provide evidence for the efficacy of HIV prevention interventions delivered by health departments and community-based organizations. For HIV-infected persons, efficacy studies of such interventions are limited to a few randomized controlled trials, only one of which documented change in risk-related behavior, and to other studies, the majority of which did not assess behavioral outcomes.

Referrals for IDUs

For IDUs, ceasing injection-drug use is the only reliable way to eliminate the risk of injection-associated HIV transmission; however, most IDUs are unable to sustain long-term abstinence without substance abuse treatment. Several studies have examined the effect of substance abuse treatment, particularly methadone maintenance treatment, on HIV risk behaviors among IDUs (208--210). These include controlled and noncontrolled cohort studies, case-control studies, and observational studies with controls, and collectively they provide evidence that methadone maintenance treatment reduces risky injection and sexual behaviors and HIV seroconversion. Thus, early entry into substance abuse treatment programs, maintenance of treatment, and sustained abstinence from injecting are crucial for reducing the risk for HIV transmission from infected IDUs. For those IDUs not able or willing to stop injecting drugs, once-only use of sterile syringes can greatly reduce the risk for injection-related HIV transmission. Substantial evidence from cohort, case-control, and observational studies indicates that access to sterile syringes through syringe exchange programs reduces HIV risk behavior and HIV seroconversion among IDUs. Physician prescribing and pharmacy programs can also increase access to sterile syringes. Disinfecting syringes and other injection equipment by boiling or flushing with bleach when new, sterile equipment is not available has been suggested to reduce the risk for HIV transmission); however, it is difficult to reliably disinfect syringes, and this practice is not as safe as using a new, sterile syringe. Information on access to sterile syringes and safe syringe disposal can be obtained through local health departments or state HIV/AIDS prevention programs.

Engaging the Patient in the Referral Process

When referrals are made, the patient's willingness and ability to accept and complete a referral should be assessed. Referrals that match the patient's self-identified priorities are more likely to be successful than those that do not; the services need to be responsive to the patient's needs and appropriate for the patient's culture, language, sex, sexual orientation, age, and developmental level. For example, adolescents should be referred to behavioral intervention programs and services that work specifically with this population. Discussion with the patient can identify barriers to the patient's completing the referral (e.g., lack of transportation or child care, work schedule, cost). Accessibility and convenience of services predict whether a referral will be completed. The patient should be given specific information regarding accessing referral services and might need assistance (e.g., scheduling appointments, obtaining transportation) in completing referrals. The likelihood that referrals will be completed successfully could possibly be increased if clinicians or other health-care staff assist patients with making appointments to referral services. When a clinician does not have the capacity to make all appropriate referrals, or when needs are especially complex, a case manager can help make referrals and coordinate care. Outreach workers, peer counselors or educators, treatment advocates, and treatment educators can also help patients identify needs and complete referrals successfully. Health department HIV/AIDS prevention and care programs can provide information on accessing these services. Assessing the success of referrals by documenting referrals made, the status of those referrals, and patient satisfaction with referrals will further assist clinicians in meeting patient needs. Information obtained through follow-up of referrals can identify barriers to completing the referral, responsiveness of referral services to patient needs, and gaps in the referral system, and can be used to develop strategies for removing the barriers.

Referral Guides and Information

Preparation for making patient referrals includes 1) learning about local HIV prevention and supportive social services, including those supported by the Ryan White CARE Act; 2) learning about available resources and having a referral guide listing such resources; and 3) contacting staff in local programs to facilitate subsequent referrals. Referral guides and other information usually can be obtained from local and state health department HIV/AIDS prevention and care programs, which are key sources of information about services available locally. Health departments and some managed care organizations are also a source of educational materials, posters, and other prevention-related material. Health departments can provide or suggest sources of training and technical assistance on behavioral interventions. A complete listing of state AIDS directors and contact information is available from the National Alliance of State and Territorial AIDS Directors (NASTAD) at. In addition, information can be obtained from local health planning councils, consortia, and community planning groups; local, state, and national HIV/AIDS information hotlines and Internet websites; and community-based health and human service providers).


Department of Health and Human Services, Center for Disease Control and Preventions