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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.

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).

Examples of Case Situations for Prevention Counseling

1. A patient with newly diagnosed HIV infection comes to your office for initial evaluation. Of the many things that must be addressed during this initial visit (e.g., any emergent medical or psychiatric problems, education about HIV, history, physical, initial laboratory work [if not already done]), how does one address prevention? What is the minimum that should be done, and how can it be incorporated into this visit?

Assuming no emergent issues preclude a complete history and physical examination during this visit, the following should be done:

  • During the history, question how the patient might have acquired HIV, current risk behaviors, current partners and whether they have been notified and tested for HIV, and current or past STDs.
  • During the physical examination, include genital and rectal examinations, evaluation and treatment of any current STD, or, if asymptomatic, appropriate screening for STDs.
  • Discuss current risk behavior, at least briefly. Emphasize the importance of using condoms; address active injection-drug use.
  • Discuss the need for disclosure of HIV serostatus to sex and needle-sharing partners, and discuss potential barriers to disclosure.
  • Note issues that will require follow-up; e.g., risk behavior that will require continuing counseling and referral and partners who will need to be notified by either the patient or a health department.

2. A patient with chronic, stable HIV comes to you with a new STD. What prevention considerations should be covered in this visit?

For the patient who has had a stable course of disease, a new STD can be a sign of emerging social, emotional, or substance abuse problems. These potential problems should be addressed in addition to the STD.

  • During the history, cover topics related to acquisition of the new STD---number of new partners, number of episodes of unsafe sex, and types of unsafe sex.
  • Address the personal risks associated with high-risk behavior, e.g., viral superinfection and HIV/STD interactions.
  • Address personal or social problems (including substance abuse and domestic violence) that might have led to a change in behavior resulting in the acquisition of the new STD; refer to social services, if necessary.
  • Address other issues (e.g., adherence to HAART) that may be affected by personal or social problems. Check viral load if nonadherence is evident or is suspected.
  • During the physical examination, include a careful genital and rectal examination and screen for additional STDs, such as syphilis, trichomoniasis, (for women), chlamydial infection (for sexually active women aged <25 years and selected populations of men and women), and gonorrhea (for selected populations of men and women).
  • Discuss the need for partner notification and referral for counseling and testing.
  • Note in the chart that risk behavior should be addressed in future visits and that tailored counseling may be needed for the patient.

3. A patient with chronic, stable HIV has been seen regularly in a health care setting. What should be included in this patient's routine clinical care?

Discussion of sexual and needle-sharing practices should be integrated into a routine part of clinical care.

  • Periodically (e.g., annually) screen for STDs. STDs to be included in screening should be determined by patient's sex, history of high-risk behavior, and local epidemiology of selected STDs.
  • Reiterate general prevention messages and patient education regarding partner notification, high-risk behaviors associated with transmission, prevention of transmission, or condom use, as deemed appropriate by the clinician.

4. A patient who has been treated with HAART for 2 years comes to you. At the time of treatment initiation, CD4+count was 200 cells/µL and the viral load was 50,000 copies/ml. The response to therapy was prompt; CD4+ count increased to 500 cells/µL, and the viral load has been undetectable since soon after treatment began. The patient now has mildly elevated cholesterol, some mild lipodystrophy, and facial wasting. He states that he would like to stop HAART because of the side effects. What should you tell this patient?

  • Inform the patient that upon stopping HAART, CD4+ count and viral load will likely return to pretreatment levels with risk for opportunistic infections and progression of immune deficiency.
  • Inform the patient that increase in viral load to pretreatment levels will likely result in increased infectiousness and risk for transmission of HIV to sex or needle-sharing partners.
  • Counsel the patient regarding the option of changing the HAART regimen to limit progression of metabolic side effects.
Partner Counseling and Referral Services, Including Partner Notification

HIV-infected persons are often not yet aware of their infection; thus, they cannot benefit from early medical evaluation and treatment and do not know that they may be transmitting HIV to others. Reaching such persons as early after infection as possible is important for their own health and is a critical strategy for reducing HIV transmission in the community. Furthermore, interviews of HIV-infected persons in various settings suggest that >70% are sexually active after receiving their diagnosis, and many have not told their partners about their infection (188). Partner counseling and referral services (PCRS), including partner notification, are intended to address these problems by 1) providing services to HIV-infected persons and their sex and needle-sharing partners so the partners can take steps to avoid becoming infected or, if already infected, to avoid infecting others and 2) helping infected partners gain earlier access to medical evaluation, treatment, and other services. A key element of PCRS involves informing current partners (and past partners who may have been exposed) that a person who is HIV infected has identified them as a sex or needle-sharing partner and advising them to have HIV counseling and testing (235--238).

Informing partners of their exposure to HIV is confidential; i.e., partners are not told who reported their name or when the reported exposure occurred. It is voluntary in that the infected person decides which names to reveal to the interviewer. Studies have indicated that infected persons are more likely to name their close partners than their more casual partners. Limited reports of partner violence after notification suggest a need for caution, but such violence seems to be rare. When asked, 92% of notified partners reported that they believe the health department should continue partner notification services. No studies have directly shown that PCRS prevents disease in a community. However, studies have demonstrated that quality HIV prevention counseling can reduce the risk of acquiring a new STD and that persons who become aware of their HIV infection can take steps to protect their health and prevent further transmission; in addition, before--after studies have suggested that partners change their behavior after they are notified. Finally, compelling arguments have been offered regarding partners' rights to know this information that is important to their health.

Laws and Regulations Related to Informing Partners

The majority of states and some cities or localities have laws and regulations related to informing partners that they have been exposed to HIV. Certain health departments require that, even if a patient refuses to report a partner, the clinician report to the health department any partner of whom he or she is aware. Many states also have laws regarding disclosure by clinicians to third parties known to be at high risk for future HIV transmission from patients known to be infected (i.e., duty to warn). Clinicians should know and comply with any such requirements in the areas in which they practice. With regard to PCRS, clinicians should also be aware of and adhere to all laws and regulations related to providing services to minors.

Approaches to Notifying Partners

Partners can be reached and informed of their exposure by health department staff, clinicians in the private sector, or the infected person. In the only randomized controlled trial that has been conducted to date, 35 HIV-infected persons were asked to notify their partners themselves, and 10 partners were notified. Another 39 HIV-infected persons were assigned to health department referral; and for these, 78 partners were notified. Thus, notification by the health department appears to be substantially more effective than notification by the infected person. Other studies, with less rigorous designs, have demonstrated similar results. Some persons, when asked, prefer to inform their partners themselves. This could have a benefit if partners provide support to the infected person. However, patients frequently find that informing their partners is more difficult than they anticipated. Certain health departments offer contract referral, in which the infected person has a few days to notify his or her partners. If by the contract date the partners have not had a visit for counseling and testing, they are then contacted by the health department. In practice, patients' difficulties in informing their partners usually means notification is done by the health department.

Although clinicians might wish to take on the responsibility for informing partners, one observational study has indicated that health department specialists were more successful than physicians in interviewing patients and locating partners. Health departments have staff who are trained to do partner notification and skilled at providing this free, confidential service. These disease intervention specialists can work closely with public and private sector clinicians who treat persons with other STDs. With regard to partner notification, the clinician should be sensitive to concerns of domestic violence or abuse by the informed partner.

All partners should be notified at least once. Persons who continue to have sex with an HIV-infected person despite an earlier notification may have erroneously concluded that someone else was the infected partner. Thus, renotification might be important, although no research is available on renotification.

Counseling Sessions

To establish initial rapport with the patient, the counselor will need to convey positive regard, genuine concern, and an empathic response toward the patient. This connection will help build trust and will set the tone for the rest of the session. The counselor must be professional and respectful toward the patient and recognize that issues of sex and drug use behaviors may be sensitive and difficult for the patient to discuss. The patient should be helped to feel comfortable with the clinic procedures, understand the role of the counselor, and be clear about the content and purpose of the session. If the patient is clear about the expectations and the process, the counselor has reduced the patient’s anxiety and increased the patient’s ability to focus on the session. This clear delineation of the session serves to model for the patient a rational and responsible approach to addressing the challenging issues of behavior change. It is important that the counselor conducts the session, to the extent possible, as described to the patient. Ifthe counselor must deviate from what he/she has indicated will occur in the session, this change should beexplained to the patient.

The counselor should convey confidence in being able to understand the patient’s risk behavior and in the patient’sability to initiate a risk reduction process. Also, the counselor should communicate an appropriate sense ofurgency and concern relative to the patient’s HIV/STD risks. In this component of the session, the counselorshould establish the collaborative nature of the session and the mutual commitment of both counselor and patient to earnestly address risk reduction issues.

The counselor is attempting to focus the patient’s attention on his/her behavior and the corresponding risk ofacquiring HIV. The counselor’s approach to this component of the session will shift based on the patient’sparticular issues in addressing HIV risk: 1. Enhance self-perception of risk;2. Address dissonance (examples whenbeliefs and behavior are at odds) and ambivalence (mixed feelings) about risk reduction; 3. Increase self-efficac (belief in one’s power or ability to do something);4. Invoke peer and community norms. The patient’s presence in the clinic and request for STD services is the starting point from which the counselor addresses these issues. Inthis section, the counselor is attempting to use the patient’s STD concerns to encourage him/her to examine HIVissues. The link between STD and HIV risk should be emphasized. The process is intended to help the patientbecome motivated and invested in addressing HIV issues and concerns with the counselor. At the completion ofthis component of the session, the counselor’s aim is to have the patient fully engaged in the session and invested in reducing HIV/STD risk.

The counselor should have an open and inquisitive approach to this portion of the session. This approach willstimulate the patient’s curiosity and encourage him/her to self-reflect and examine his/her own behaviors. Theexploration of the risk behavior should be specific. A thorough discussion of the most recent risk behavior helpsthe patient clarify how the risk behavior occurred. What may have initially seemed like an accident or an unusualincident begins to have concrete circumstances that contributed to the patient’s decision to engage in high-riskbehavior. This process can demystify the risk behavior for the patient. The questions asked by the counselor aredirected at eliciting the entire range of factors that may have contributed to the risk behavior. The counselor shouldbe aware that emotions, recent life events, substance use, self-esteem, and other patient characteristics and issuesmay influence a particular risk incident or pattern of risk behavior. The counselor and patient should be workingtogether to understand the context of the risk behavior. If the patient’s risk behavior is episodic or chronic, thecounselor is trying to discover and clarify the characteristic patterns that contribute to the patient’s risk behavior.

The counselor should explore any changes initiated by the patient to reduce his/her HIV risk(s). This provides thecounselor with an essential opportunity to support and reinforce the patient. The counselor should note all of thepatient’s intentions, communication, and actions concerning HIV risk reduction. The counselor should elicitobstacles encountered by the patient in considering or attempting behavior change. The counselor should gentlyand sensitively discuss the challenges the patient has encountered or perceived. It is important to acknowledge thatbehavior change is a complex and challenging process. It is helpful, particularly if the patient has difficultyarticulating his experiences with risk reduction, to explore his/her perception of community and peer normsconcerning HIV prevention. Further, encouraging the patient to articulate his/her attitudes and beliefs about HIVrisk behavior may provide additional insight. This process allows the patient to verbalize the extent to which he/shehas addressed HIV issues and provides the counselor with insight into the patient’s strengths and difficulties in

initiating and sustaining behavior change. During this portion of the session the counselor may educate and clarifymisinformation for the patient, as needed.

The purpose of this component of the session is to enable the patient to gain an understanding of the complexity offactors that influence his/her risk behavior. The counselor summarizes to the patient the inter-related factorsinfluencing risk. This summary provides the patient with an organized perspective of his/her narrative. Thecounselor’s approach to this should be empathic and non-judgmental, which will help the patient understand his/herown behavior with compassion. This process enhances the counselor and patient’s collaboration in reducing thepatient’s risk of acquiring HIV/STD. It may seem paradoxical, but the counselor must simultaneously convey asense of urgency in understanding this behavior and be clear about the consequences should the patient fail toprioritize and respond to this situation. This component of the session provides the foundation on which the riskreduction plan will be developed. The counselor should use this summary of the session to transition to the riskreduction component of the session.

The risk reduction plan is a fundamental component of the prevention counseling session. The counselor shouldassist the patient in identifying a behavior that corresponds to his/her risk and that he/she is invested in changing. Itis essential that the plan match the patient’s skills and abilities with his/her motivation to change a specificbehavior. The counselor should challenge the patient to go beyond what he/she has previously attempted in termsof risk reduction. The plan must be specific in that it describes the who, what, where, when and how of the riskreduction process. It must be concrete in that it details the successive actions required of the patient to implementand complete the risk reduction plan. Finally, it must be incremental in that it is directed at a single aspect of therisk behavior or one particular factor/issue that contributes to that risk behavior. The counselor should avoidsupporting risk reduction plans that involve unreasonable or radical changes in the patient’s life. The patient mayexperience a “flight to health” as a result of the STD clinic experience, the anxiety from the testing process, or thequality of the counseling interaction. Global risk reduction messages such as “always wear condoms,” “remainmonogamous,” or “abstain from sex” do not meet the criteria for an appropriate risk reduction plan. The counselorshould ensure that the patient agrees with the plan and is committed to its implementation. The patient should beasked to critique the plan and identify problems with the plan. The counselor may even quiz the patient on the planor provide plausible examples of obstacles the patient may encounter in initiating the plan. These obstacles shouldbe problem-solved with the patient and may require revising the plan. The process of developing a plan representsthe patient’s movement toward risk reduction. In fact, it is the second step in reducing risk (the first being thepatient’s participation in the study), for which he/she should be provided encouragement and considerable support.

The counselor should acknowledge that the plan is a challenge and assure the patient that you will review withhim/her the outcome of the plan at the next session. Explain to him/her that together you can renegotiate the plan,if necessary, in the posttest session.

This component of the session is intended to identify or develop for the patient, peer and community support forHIV risk reduction, as well as to provide referral to professional services to address specific issues the patientmay have identified. If during the course of the session the counselor or patient has identified a need for referralsto professional services (e. g. , drug treatment, support group, mental health counseling, etc. ), then the counselorshould be prepared to provide specific provider names and phone numbers to the patient. Referrals in this contextare particularly important because the referral services may enhance the risk reduction process. The counselorshould confirm that the referral is something the patient is willing to consider. To the extent possible, thecounselor should try to provide referrals consistent with that patient’s readiness to receive the services, comfortwith the setting in which the service is provided, and interest in accessing the services. The counselor should becautious not to overwhelm the patient with numerous referrals. A single appropriate referral is often better thanseveral referrals to generic types of support services. The referral may augment the risk reduction plan, but unlessit is the only alternative, completion of the referral by the patient should not be the primary objective of the riskreduction plan.

Second Session

In preparation for the test results and prevention counseling session, the counselor should review the notes fromthe previous session. The counselor should remind him/herself of the specific details of the risk reduction planand the patient’s particular issues and vulnerabilities in attempting behavior change related to HIV/STD risks. Thecounselor should also review the patient’s STD clinic chart and know whether the patient was diagnosed or treatedfor an STD. The HIV test results should be available in the counseling room.

The counselor should be aware that the patient may be very anxious to receive his/her results upon returning to theclinic. The counselor should greet the patient warmly and then proceed with the session. Based on the counselor’ssense of the patient, he/she should determine whether to ask if the patient has concerns or questions prior toproviding the test results. Generally, providing the results expediently and directly is advised. The counselorshould review the patient’s experience of and reactions to the previous STD assessment, clinical exam/diagnosisand, as appropriate, incorporate this information into the counseling session. This second session should build onwork started in the first session.

If the patient’s HIV test results are positive, the counselor should follow their clinic’s standard protocol forproviding HIV positive test results. The guidance in this section pertains to providing results to HIV negative

RESPECT-2 patients.

The counselor should provide the initial test result in simple terms, avoiding technical jargon. The patient may bevery relieved at receiving the negative test result. The counselor should allow the patient to experience his/herpleasure at not being infected while underscoring the need for behavior change in order for him/her to remainnegative. The counselor should cautiously explore the patient’s feelings and beliefs about his/her negative testresult, specifically in the context of the risk behavior described by the patient in the previous session. Thecounselor should be alert to the possibility that the patient may experience disinhibition (i. e. , feel more inclinedto engage in risky behavior) in response to the results. The patient may believe the test result is an indication thathe/she has, thus far, made the “right choices. ”It is often helpful for the counselor to underscore the fact that thenegative test result does not mean that the patient’s sex/needle-share partner(s) are not infected. Nor does it meanthat the patient is immune to HIV, or that his/her behavior is less risky than addressed in the initial session.

There is a slight possibility that a recent risk behavior (especially in the last 6 to 12 weeks) may have resulted inthe patient becoming infected without the infection being indicated in this test result. However, both counselor andpatient should be reminded that the current result represents all other, sometimes years’, previous risk behavior.

Counselors must be very careful with their “retest message. ”If there is not a significant risk in the previous 3months, then no additional test is indicated unless the patient has a later exposure to HIV. If there is a very recentand significant risk exposure, there is a small chance that the patient could have been infected by that exposure.

The counselor should remember that the risk of infection from a single exposure, when the partner is known to beinfected, is relatively small (<1 – 8%). The counselor should avoid technical discussions of this information andrecommend, when necessary, a specific time for possible retest linked to a specific previous date of exposure. Insummary, a brief explanation of the possible need for retesting is sometimes, with some patients, important, butthis should not be over-emphasized. Too much attention to retesting takes away attention from the risk reductionprocess and often inaccurately diminishes the meaning of the HIV negative result.

The counselor may briefly inquire about how the week went for the patient and his/her thoughts and reactions fromthe previous session. However, the focus of this session will be to discuss the step(s) taken by the client to reducehis/her HIV risk behavior as negotiated in session one. Regardless of whether the patient is resolved to changehis/her behavior or is struggling to find the resolve, a sense of urgency concerning addressing risk behavior shouldbe conveyed by the counselor. It is important to review with the patient both the successes and challenges inimplementing the plan. The counselor should listen for an opportunity to provide support and reinforcement to thepatient. The counselor should have a copy of the plan available and, if necessary, provide reminders to the patientabout specific details of the plan.

The counselor will encourage the patient to attempt an additional, perhaps more challenging, step toward reducingrisk. If the patient encountered difficulty with the previous plan, then the counselor should help him/her revise theplan. The counselor and the client should refine the plan as necessary, aiming toward a plan that the patient has ahigh probability of successfully implementing. The counselor should, as necessary, remind the patient that riskreduction and behavior change are incremental processes (see details in Session I, “Negotiate Risk ReductionPlan”). The counselor should help the patient identify persons from whom he/she can get support for his/her riskreduction plan. The counselor should obtain a commitment from the client to attempt the risk reduction step andstick to the risk reduction plan.

This component of the session is intended to identify or develop for the patient peer and community support forthe patient’s HIV risk reduction, as well as provide referral to professional services to address specific issues thepatient may have identified. If during the course of the session the counselor or patient has identified a need forreferrals to professional services (e. g. , drug treatment, support group, mental health counseling, etc. ), thencounselor should be prepared to give specific provider names and phone numbers to the patient. Referrals in thiscontext are particularly important to the extent that the referral services received by the patient may complementor enhance the risk reduction process. The counselor should confirm that the referral is something the patient iswilling to consider. To the extent possible the counselor should try to provide referrals consistent with thatpatient’s readiness to receive the services, comfort with the setting in which the service is provided and interest inaccessing the services. The counselor should be cautious not to overwhelm the patient with numerous referrals. single appropriate referral is often better than several referrals to generic types of support services. The referralmay augment the risk reduction plan, but unless it is the only alternative, completion of the referral by the patientshould not be the primary objective of the risk reduction plan.

Methamphetamine is a stimulant drug that has been around for decades. Its popularity has waxed and waned over the years, but its use seems to be increasing in many parts of the United States and in several population subgroups. Methamphetamine is very addictive, it can be injected, and it can increase sexual arousal while reducing inhibitions. Because of these attributes, public health officials are concerned that users may be putting themselves at increased risk of acquiring or transmitting HIV infection―a valid concern, considering that methamphetamine use has been linked with increased numbers of HIV infections in some populations.

There is a growing body of research on methamphetamine use among men who have sex with men (MSM). Overall, assessments show that MSM who use methamphetamine may increase their sexual risk factors (for example, they may use condoms less often, have more sex partners, and may engage in practices that elevate their risk for HIV infection, such as unprotected receptive anal sex) and perhaps their HIV-related drug-use risk factors (for example, injecting methamphetamine instead of smoking or snorting it) .

MSM are not the only group with risk factors related to methamphetamine use. Evidence shows that heterosexual adults and adolescents under the influence of methamphetamine may also engage in practices that increase their risk for HIV infection and other sexually transmitted diseases (STDs) [2]. However, among MSM, the baseline prevalence of infections (such as HIV) and risk behaviors (such as number of partners and anal sex) tends to be higher, resulting in greater risk for transmission. Methamphetamine users may exchange sex for money or drugs, creating another risk factor for acquiring and transmitting HIV.

What is becoming clear is that the use of methamphetamine can contribute to sexual risk behaviors, regardless of the sexual orientation of the user. Current data indicate a strong link between methamphetamine use and sexual risk among MSM, and perhaps among heterosexual adults and youth.

The following are facts about methamphetamine, its effects on the body, and research showing its role in increasing behaviors that put persons at risk of acquiring or transmitting HIV infection.

Methamphetamine Defined

Methamphetamine is a central nervous system stimulant categorized by the U.S. Food and Drug Administration as a Schedule II amphetamine, which means it has a high potential for abuse and for psychological or physical dependence. There are numerous slang names for methamphetamine, some of which are regional or group-specific. The most common are meth, crystal meth, Tina, ice, and glass. Methamphetamine is smoked, injected, snorted, swallowed, or inserted into the anus .

How Methamphetamine Is Produced

Methamphetamine can be produced through a series of fairly simple chemical steps involving a common decongestant―ephedrine or pseudoephedrine― in combination with products such as iodine crystals, battery acid, red phosphorous, and anhydrous ammonia. It can be formulated as a liquid, a powder, a waxy solid (glass), or a clear rock (ice).

Methamphetamine Use in the United States

According to the Substance Abuse and Mental Health Services Administration (SAMHSA), in 2004,

  • an estimated 12 million persons aged 12 and older (4.9% of US persons aged 12 or older) had used methamphetamine at least once in their lifetime
  • 1.4 million persons aged 12 or older (0.6% of the US population) had used methamphetamine during the past year
  • 600,000 (0.2% of the US population) had used it during the past month.

SAMHSA estimated that from 1993 through 2003, the rate of admissions for the treatment of methamphetamine or amphetamine abuse increased from 13 to 56 admissions per 100,000 for people aged 12 or older.

Studies show a higher prevalence of methamphetamine use among MSM than among the general population. For example, in a study of urban, young MSM (aged 15-22 years), conducted during 1994–1998, 20% of the participants reported having used methamphetamine during the past 6 months.  A 2001 study found that 15% of MSM in San Francisco had used methamphetamine during their most recent anal sex (within the past 3 months)―making methamphetamine use third only to the prevalence of alcohol and marijuana use.

The current increase (since the early 1990s) of methamphetamine use began in the western United States. However by the mid-2000s, its use had become a nationwide concern. The National Clandestine Laboratory Database, which includes the number of clandestine labs seized, showed an increase in the number of lab seizures in almost every state from 2000 through 2005.. As of 2004, the rates of methamphetamine use were particularly high in the western states: 12 states, including California, Nevada, Wyoming, and Montana, ranked in the top third of states in terms of methamphetamine use during the past year.

Lab seizures and restrictions on purchasing ingredients have reduced the production of methamphetamine in the United States.

The Effects of Methamphetamine Use

As a central nervous system stimulant, methamphetamine directly affects the brain and the spinal cord by interfering with the normal release and uptake of neurotransmitters (chemicals that nerve and brain cells produce to communicate with each other). Dopamine is the primary neurotransmitter affected by methamphetamine, but norepinephrine and epinephrine are also affected.

The use of methamphetamine causes the release of large quantities of neurotransmitters. The neurotransmitters, in turn, cause increased heart rate and blood pressure levels and produce sensations of pleasure, self-confidence, energy, and alertness. They also suppress the appetite and enhance sexual arousal. Users may report sleeplessness, talkativeness, teeth grinding, increased body temperature, and compulsive behavior, such as skin picking.

Long-term use can cause physical symptoms (decayed teeth, weight loss, skin lesions, stroke, and heart attack) as well as mental symptoms (paranoia, hallucinations, anxiety, and irritability) and behavioral symptoms (aggressiveness, violence, and isolation).

The long-term use of methamphetamine can lead to reduced levels of dopamine and other neurotransmitters, making the user crave methamphetamine to raise dopamine levels. Because bingeing on the drug depletes neurotransmitter stores, coming down from the high is often described as a “crash,” which includes a phase of depression. Additional doses of methamphetamine are often used to alleviate these negative feelings. This cycle can lead to addiction, which can be very difficult to overcome.

Because methamphetamine use can cause impotence at the same time that it is increasing libido, some MSM may use erectile dysfunction medications and may then engage in unprotected receptive or insertive anal sex while under the influence of the drugs [7].

How Methamphetamine Compares with Amphetamines or Cocaine

Changes in specific parts of the brain of methamphetamine users are similar to those of cocaine and other substance users; however, methamphetamine, amphetamines, and cocaine differ in some ways.

For example, compared with amphetamines, methamphetamine has longer lasting and more toxic effects. Methamphetamine is also stronger and longer lasting than cocaine. Methamphetamine, compared with cocaine, causes a more than 3-fold release of dopamine in the brain and has a half-life (the amount of time necessary for half of the drug to be metabolized) of 12 hours, compared with cocaine’s half-life of 1 hour. If smoked, it can produce a high for 8–24 hours; smoking cocaine produces a high for approximately 20–30 minutes. Because its effects last longer and it is less expensive than cocaine, methamphetamine is attractive to many populations, including young people, who sometimes refer to it as “poor man’s cocaine.”

The Methamphetamine User

There is no typical methamphetamine user. The drug is used by people of different ages and races, in all parts of the country, and for different reasons. However, some trends have been noted in the United States.

  • Age: Many methamphetamine users are young. Because it is cheaper and longer lasting than cocaine, methamphetamine is becoming popular with persons in their teens and early 20s. The average age at first use was 18.9 years in 2002, 20.4 years in 2003, and 22.1 years in 2004]. The highest rate of methamphetamine use during the past year was that for young adults aged 18 to 25, followed by youth aged 12 to 17, and then adults aged 26 or older  
  • Sex: Among all persons 12 years of age or older, the rate of use during the past year was about the same for males and females (0.7% and 0.5%, respectively) [.
  • Race/ethnicity: The largest numbers methamphetamine users are white. However, the highest rates of methamphetamine use during the past year were those for Native Hawaiians or other Pacific Islanders (2.2%), American Indians or Alaska Natives (1.7%), and person who reported 2 or more races (1.9%). Past-year use among whites (0.7%) and Hispanics (0.5%) was higher than among blacks (including African Americans) (0.2%)..
  • MSM: According to data from the 2004 CDC National HIV Behavioral Surveillance System, overall, a higher percentage of MSM methamphetamine users compared to non-users were white (50.4% vs. 43.5% respectively)].
  • Rural users: Many methamphetamine users in rural areas are white, working class, heterosexual young adults [. Trends in rural areas show that increasing numbers of Latinos, Native Americans and youth are using methamphetamine. Rural users, compared with urban users, are more likely to be heterosexual.

Reasons For Methamphetamine Use

The reasons for using methamphetamine vary.

  • Males and females have reported using methamphetamine for increased energy and productivity, its low cost, self-medication for depression or attention deficits, and the euphoric high
  • Males have reported using methamphetamine for economic reasons, (selling the drug, increased energy to work multiple jobs) and sexual reasons (enhanced libido and endurance)
  • A study of HIV-positive MSM who use methamphetamine found that the most frequently reported motivation for use was to enhance sexual pleasure (reported by nearly 90% of respondents) Other reasons included self-medication of negative feelings associated with HIV-positive serostatus. A similar study of HIV-negative heterosexual adults found that the primary motivations for methamphetamine use were to get high, to get more energy, and to party
  • Females reported using methamphetamine to control weight and to combat fatigue .
  • The culture of methamphetamine use provides a social network―a community―for persons who feel like outsiders  

Methamphetamine Use and HIV Risk Behaviors

A growing body of research supports the relationship between methamphetamine use by MSM and heterosexual populations and an increase in behaviors (sexual and those related to injection drug use) that can put the user at risk for HIV infection.

  • A survey of users of noninjection drugs, conducted in California during the mid-1990s, showed that heterosexual persons and MSM who reported using methamphetamine also had more sex partners, were less likely to use a condom, and were more likely to exchange sex for money or drugs, have sex with an injection drug user, or to have a history of STD―all risk factors for HIV transmission.
  • A qualitative study of gay and bisexual men in Seattle (Washington) and San Jose (California), conducted during 1997–2001, revealed a high prevalence of club drugs (methamphetamine, ecstasy, ketamine, and GHB [gamma hydroxyl butyrate]) in tandem with unsafe sex practices. Many of the respondents reported that they already had HIV infection or AIDS and that they “medicated” their symptoms through their drug use. Respondents reported engaging in unprotected sex as well as trading sex for drugs .
  • A 2001 study conducted among gay and bisexual men in the San Francisco Bay Area showed that of MSM who participated in circuit party weekends, those who used methamphetamine were more than twice as likely to have unprotected anal sex during that weekend with a partner whose HIV status was unknown or different from theirs .
  • According to a 1998 study conducted at publicly funded HIV testing sites in California, HIV-positive MSM may be more likely than HIV-negative MSM to use methamphetamine, and some MSM methamphetamine users may be more likely than other methamphetamine users to use it during sex .
  • An analysis of data of heterosexual men, performed by the California Department of Health Services during 2001–2003 determined that recent methamphetamine use was associated with high-risk sexual behaviors, including anal intercourse, sex with an injection drug user, and sex with a casual or an anonymous female partner .
  • In California, 9.5% of primary and secondary syphilis cases in heterosexual men during 2004 were cases in men with a history of methamphetamine use, continuing a trend of increases in syphilis cases, from 3.1% in 2001, 6.4% in 2002, and 7.3% in 2003 . Syphilis infection is a marker for unprotected sex, a risk factor for HIV infection.
  • During a gonorrhea outbreak in 6 central California counties in 2004, substantial proportions of heterosexual men (38%) and women (28%) reported methamphetamine use, particularly when compared with MSM (8%) . Like syphilis, gonorrhea infection is a marker for unprotected sex, a risk factor for HIV infection.
  • Some evidence suggests that the use of methamphetamine (not injected) by heterosexual men and women is associated with unprotected vaginal sex and with a higher number of sex partners during the past 12 months .

In addition to increasing sexual risk factors, methamphetamine use increases the risk for HIV transmission when the drug is injected. For example, women reported being injected with methamphetamine by sex partners, often with a shared syringe.  According to a Colorado study, people who injected methamphetamine more frequently shared syringes during a methamphetamine binge .

Specific Ways Methamphetamine Use Negatively Affects Thinking and Behavior

  • Methamphetamine use may impair the ability or the desire to be safe, both sexually and when injecting drugs. That impairment, in turn, may lead to experimentation with riskier behaviors in general.
  • Methamphetamine may dry mucosa, which may lead to more chafing and abrasions, which, in turn, could provide an entry for HIV during sexual activity.
  • Methamphetamine use is associated with sexual practices that may increase the likelihood of HIV and other STD transmission (e.g., long duration, leading to chafing or sores; multiple partners; lack of inhibition; low level of condom use).
  • Methamphetamine use may cause mental confusion and impair the ability to take medications that have been prescribed for HIV infection or other conditions.

Public Health Implications

Methamphetamine use is a public health issue. There is a need for a broad approach in addressing methamphetamine use and risk for infection with HIV and other STDs―one that includes heterosexual adults and adolescents as well as MSM. HIV and STD prevention and treatment programs could be enhanced to include assessment for methamphetamine use, with referrals to methamphetamine treatment, primary testing, and sexual health promotion.

Hepatitis C virus (HCV) infection is the most common chronic bloodborne infection in the United States; approximately 2.7 million persons are chronically infected . Although HCV is not efficiently transmitted sexually, persons at risk for infection through injection-drug use might seek care in STD treatment facilities, HIV counseling and testing facilities, correctional facilities, drug treatment facilities, and other public health settings where STD and HIV prevention and control services are available.

Persons newly infected with HCV typically are either asymptomatic or have a mild clinical illness. HCV RNA can be detected in blood within 1–3 weeks after exposure. The average time from exposure to antibody to HCV (anti-HCV) seroconversion is 8–9 weeks, and anti-HCV can be detected in >97% of persons by 6 months after exposure. Chronic HCV infection develops in 60%–85% of HCV-infected persons; 60%–70% of chronically infected persons have evidence of active liver disease. The majority of infected persons might not be aware of their infection because they are not clinically ill. However, infected persons serve as a source of transmission to others and are at risk for CLD or other HCV-related chronic diseases for decades after infection.

HCV is most efficiently transmitted through large or repeated percutaneous exposure to infected blood (e.g., through transfusion of blood from unscreened donors or through use of injecting drugs), although less efficient, occupational, perinatal, and sexual exposures also can result in transmission of HCV.

The role of sexual activity in the transmission of HCV has been controversial. Case-control studies have reported an association between acquiring HCV infection and exposure to a sex contact with HCV infection or exposure to multiple sex partners. Surveillance data also indicate that 15%–20% of persons reported with acute HCV infection have a history of sexual exposure in the absence of other risk factors. Case reports of acute HCV infection among HIV-positive MSM who deny injecting-drug use have indicated that this occurrence is frequently associated with other STDs (e.g., syphilis). In contrast, a low prevalence (average: 1.5%) of HCV infection has been demonstrated in studies of long-term spouses of patients with chronic HCV infection who had no other risk factors for infection, and multiple published studies have demonstrated the prevalence of HCV infection among MSM who have not reported a history of injecting-drug use to be no higher than that of heterosexuals. Because sexual transmission of bloodborne viruses is more efficient among homosexual men compared with heterosexual men and women, the reason that HCV infection rates are not substantially higher among MSM compared with heterosexuals is unclear. Overall, these findings indicate that sexual transmission of HCV is possible but inefficient. Additional data are needed to determine whether sexual transmission of HCV might be increased in the context of HIV infection or other STDs.

Diagnosis and Treatment

Anti-HCV testing is recommended for routine screening of asymptomatic persons based on their risk for infection or based on a recognized exposure). For such persons, testing for HCV infection should include the use of an FDA-cleared test for antibody to HCV (i.e., immunoassay, EIA, or enhanced chemiluminescence assay and, if recommended, a supplemental antibody test).

Persons counseled and tested for HCV infection and determined to be anti-HCV positive should be evaluated (by referral or consultation, if appropriate) for presence of active infection, presence or development of CLD, and for possible treatment. Reverse transcriptase polymerase chain reaction to detect HCV RNA may be used to confirm the diagnosis of current HCV infection, and an elevated alanine aminotrans-ferase (ALT) level is biochemical evidence of CLD. Combination therapy with pegylated interferon and ribavirin is the treatment of choice for patients with chronic hepatitis C. Because of advances in the field of antiviral therapy for acute and chronic hepatitis C, clinicians should consult with specialists knowledgeable about management of hepatitis C infection.

Prevention

No vaccine for hepatitis C is available, and prophylaxis with immune globulin is not effective in preventing HCV infection after exposure. Reducing the burden of HCV infection and disease in the United States requires implementation of both primary and secondary prevention activities. Primary prevention reduces or eliminates HCV transmission; secondary prevention activities reduce liver and other chronic diseases in HCV-infected persons by identifying them and providing appropriate medical management and antiviral therapy, if appropriate.

Persons seeking care in STD clinics or other primary-care settings should be screened to identify those who should be offered HCV counseling and testing. In STD clinics and other settings that serve large numbers of persons at high risk for bloodborne infections (e.g., correctional settings), the major risk factor for which to screen for HCV infection is injection of illegal drugs. In addition, for clinical management issues, all persons with HIV infection should also be offered HCV counseling and testing. Other risk factors for which routine HCV testing is recommended include persons

  • who had a blood transfusion or solid organ transplant before July 1992,
  • who received clotting factor concentrates produced before 1987,
  • who have been on long-term dialysis, and
  • those with signs and symptoms of liver disease (e.g., abnormal ALT).

Persons who test positive for anti-HCV should be provided information regarding 1) how to protect their liver from further harm, 2) how to prevent transmission to others, and 3) the need for medical evaluation for CLD and possible treatment.

  • To protect their liver from further harm, HCV-positive persons should be advised to avoid alcohol and taking any new medicines (including OTC and herbals) without checking with their doctor.
  • To reduce the risk for transmission to others, HCV-positive persons should be advised to 1) not donate blood, body organs, other tissue, or semen; 2) not share any personal items that might have blood on them (e.g., toothbrushes and razors); and 3) cover cuts and sores on the skin to keep from spreading infectious blood or secretions. HCV-positive persons with one long-term, steady sex partner do not need to change their sexual practices. They should discuss the low but present risk for transmission with their partner and discuss the need for counseling and testing. HCV-positive women do not need to avoid pregnancy or breastfeeding.
  • HCV-positive persons should be evaluated (by referral or consultation, if appropriate) for presence of development of CLD, including assessment of liver function tests, assessment for severity of liver disease and possible treatment, and determination of the need for hepatitis A and B vaccination.

Persons who test negative for anti-HCV who had an exposure previously should be reassured that they are not infected.

Regardless of test results, persons who use or inject illegal drugs should be counseled to

  • stop using and injecting drugs;
  • enter and complete substance abuse treatment, including relapse prevention;
  • take the following steps to reduce personal and public health risks, if they continue to inject drugs:
    • never reuse or share syringes, water, or drug preparation equipment;
    • use only syringes obtained from a reliable source (e.g., pharmacies);
    • use a new, sterile syringe to prepare and inject drugs;
    • if possible, use sterile water to prepare drugs; otherwise, use clean water from a reliable source (e.g., fresh tap water);
    • use a new or disinfected container (“cooker”) and a new filter (“cotton”) to prepare drugs;
    • clean the injection site before injection with a new alcohol swab;
    • safely dispose of syringes after one use; and
    • get vaccinated for hepatitis A and B.

Postexposure Follow-Up

No PEP has been demonstrated to be effective against HCV. Testing to determine whether HCV infection has developed is recommended for health-care workers after percutaneous or permucosal exposures to HCV-positive blood and for children born to HCV-positive women.

Special Considerations

Pregnancy

Routine testing for HCV infection is not recommended for all pregnant women. Pregnant women with a known risk factor for HCV infection should be offered counseling and testing. Patients should be advised that approximately five of every 100 infants born to HCV-infected woman become infected. This infection occurs predominantly during or near delivery, and no treatment or delivery method is known to decrease this risk. The risk is increased by the presence of maternal HCV viremia at delivery and also is greater (2–3 times) if the woman is coinfected with HIV. Breastfeeding does not appear to transmit HCV, although HCV-positive mothers should consider abstaining from breastfeeding if their nipples are cracked or bleeding. Infants born to HCV-positive mothers should be tested for HCV infection and, if positive, evaluated for the presence of CLD.

HIV Infection

Because of the high prevalence of HIV/HCV coinfection and because of critical clinical management issues for coinfected persons, all HIV-infected persons should be tested for HCV. Because a small percentage of coinfected persons fail to acquire HCV antibodies, HCV RNA should be tested in HIV-positive persons with unexplained liver disease who are anti-HCV negative. The course of liver disease is more rapid in HIV/HCV coinfected persons, and the risk for cirrhosis is nearly twice that in persons with HCV infection alone. Treatment of HCV in coinfected persons might improve tolerance to highly active antiretroviral therapy (HAART) for HIV infection because of the increased risk for hepatotoxicity from HAART with HCV infection. However, anti-HCV treatment in coinfected persons is still investigational, and based on ongoing clinical trials, more data are needed to determine the best regimens.

HIV - 2

In 1984, 3 years after the first reports of a disease that was to become known as AIDS, researchers discovered the primary causative viral agent, the human immunodeficiency virus type 1 (HIV-1). In 1986, a second type of HIV, called HIV-2, was isolated from AIDS patients in West Africa, where it may have been present decades earlier. Studies of the natural history of HIV-2 are limited, but to date comparisons with HIV-1 show some similarities while suggesting differences. Both HIV-1 and HIV-2 have the same modes of transmission and are associated with similar opportunistic infections and AIDS. In persons infected with HIV-2, immunodeficiency seems to develop more slowly and to be milder. Compared with persons infected with HIV-1, those with HIV-2 are less infectious early in the course of infection. As the disease advances, HIV-2 infectiousness seems to increase; however, compared with HIV-1, the duration of this increased infectiousness is shorter. HIV-1 and HIV-2 also differ in geographic patterns of infection; the United States has few reported cases.

Which countries have a high prevalence* of HIV-2 infection?

HIV-2 infections are predominantly found in Africa. West African nations with a prevalence of HIV-2 of more than 1% in the general population are Cape Verde, Côte d'Ivoire (Ivory Coast), Gambia, Guinea-Bissau, Mali, Mauritania, Nigeria, and Sierra Leone. Other West African countries reporting HIV-2 are Benin, Burkina Faso, Ghana, Guinea, Liberia, Niger, São Tomé, Senegal, and Togo. Angola and Mozambique are other African nations where the prevalence of HIV-2 is more than 1%.

*Prevalence is the proportion of cases present in a population at a given point in time.

What is known about HIV-2 in the United States?

The first case of HIV-2 infection in the United States was diagnosed in 1987. Since then, the Centers for Disease Control and Prevention (CDC) has worked with state and local health departments to collect demographic, clinical, and laboratory data on persons with HIV-2 infection.

Of the 79 infected persons, 66 are black and 51 are male. Fifty-two were born in West Africa, 1 in Kenya, 7 in the United States, 2 in India, and 2 in Europe. The region of origin was not known for 15 of the persons, although 4 of them had a malaria-antibody profile consistent with residence in West Africa. AIDS-defining conditions have developed in 17, and 8 have died.

These case counts represent minimal estimates because completeness of reporting has not been assessed. Although AIDS is reported uniformly nationwide, the reporting of HIV infection, including HIV-2 infection, differs from state to state according to state policy.

Who should be tested for HIV-2?

Because epidemiologic data indicate that the prevalence of HIV-2 in the United States is very low, CDC does not recommend routine HIV-2 testing at U.S. HIV counseling and test sites or in settings other than blood centers. However, when HIV testing is to be performed, tests for antibodies to both HIV-1 and HIV-2 should be obtained if demographic or behavioral information suggests that HIV-2 infection might be present.

Persons at risk for HIV-2 infection include

  • Sex partners of a person from a country where HIV-2 is endemic (refer to countries listed earlier)
  • Sex partners of a person known to be infected with HIV-2
  • People who received a blood transfusion or a nonsterile injection in a country where HIV-2 is endemic
  • People who shared needles with a person from a country where HIV-2 is endemic or with a person known to be infected with HIV-2
  • Children of women who have risk factors for HIV-2 infection or are known to be infected with HIV-2

HIV-2 testing also is indicated for

  • People with an illness that suggests HIV infection (such as an HIV-associated opportunisticinfection) but whose HIV-1 test result is not positive
  • People for whom HIV-1 Western blot exhibits the unusual indeterminate test band pattern of gag (p55, p24, or p17) plus pol (p66, p51, or p32) in the absence of env (gp160, gp120, or gp41)

Among all HIV-infected people, the prevalence of HIV-2 is very low compared with HIV-1. However, the potential risk for HIV-2 infection in some populations (such as those listed) may justify routine HIV-2 testing for all people for whom HIV-1 testing is warranted. The decision to implement routine HIV-2 testing requires consideration of the number of HIV-2-infected persons whose infection would remain undiagnosed without routine HIV-2 testing compared with the problems and costs associated with the implementation of HIV-2 testing.

The development of antibodies is similar in HIV-1 and HIV-2. Antibodies generally become detectable within 3 months of infection. Testing for HIV-2 antibodies is available through private physicians or state and local health departments.

Are blood donors tested for HIV-2?

Since 1992, all U.S. blood donations have been tested with a combination HIV-1/HIV-2 enzyme immunoassay test kit that is sensitive to antibodies to both viruses. This testing has demonstrated that HIV-2 infection in blood donors is extremely rare. All donations detected with either HIV-1 or HIV-2 are excluded from any clinical use, and donors are deferred from further donations.

Is the clinical treatment of HIV-2 different from that of HIV-1?

Little is known about the best approach to the clinical treatment and care of patients infected with HIV-2. Given the slower development of immunodeficiency and the limited clinical experience with HIV-2, it is unclear whether antiretroviral therapy significantly slows progression. Not all of the drugs used to treat HIV-1 infection are as effective against HIV-2. In vitro (laboratory) studies suggest that nucleoside analogs are active against HIV-2, though not as active as against HIV-1. Protease inhibitors should be active against HIV-2. However, non-nucleoside reverse transcriptase inhibitors (NNRTIs) are not active against HIV-2. Whether any potential benefits would outweigh the possible adverse effects of treatment is unknown.

Monitoring the treatment response of patients infected with HIV-2 is more difficult than monitoring people infected with HIV-1. No FDA-licensed HIV-2 viral load assay is available yet. Viral load assays used for HIV-1 are not reliable for monitoring HIV-2. Response to treatment for HIV-2 infection may be monitored by following CD4+ T-cell counts and other indicators of immune system deterioration, such as weight loss, oral candidiasis, unexplained fever, and the appearance of a new AIDS-defining illness. More research and clinical experience is needed to determine the most effective treatment for HIV-2.

The optimal timing for antiretroviral therapy (i.e., soon after infection, when symptoms appear, or when CD4+ T cell counts fall below a certain level) remains under review by clinical experts. Guidelines for the Use of Antiretroviral Agents in HIV-Infected Adults and Adolescents, by the Department of Health and Human Services Panel on Clinical Practices for Treatment of HIV Infection, may be helpful to the clinician who is caring for a patient infected with HIV-2; however, the recommendations on viral load monitoring and the use of NNRTIs would not apply to patients with HIV-2 infection. Copies of the guidelines are available from the CDC National Prevention Information Network (1 800 458-5231) and from its Web site (www.cdcnpin.org). The guidelines also are available from the HIV/AIDS Treatment Information Service (1 800 448-0440; Fax 301 519-6616; TTY 1 800 243-7012) and on the ATIS Web site (www.hivatis.org).

What is known about HIV-2 infection in children?

HIV-2 infection in children is rare. Compared with HIV-1, HIV-2 seems to be less transmissible from an infected mother to her child. However, cases of transmission from an infected woman to her fetus or newborn have been reported among women who had primary HIV-2 infection during their pregnancy. Zidovudine therapy has been demonstrated to reduce the risk for perinatal HIV-1 transmission and also might prove effective for reducing perinatal HIV-2 transmission. Zidovudine therapy should be considered for HIV-2-infected expectant mothers and their newborns, especially for women who become infected during pregnancy.

How should physicians and patients decide whether to start treatment for HIV-2?

Physicians caring for patients with HIV-2 infection should decide whether to initiate antiretroviral therapy after discussing with their patients what is known, what is not known, and the possible adverse effects of treatment.

What can be done to control the spread of HIV-2?

Continued surveillance is needed to monitor HIV-2 in the U.S. population because the possibility for further spread of HIV-2 exists, especially among injecting drug users and people with multiple sex partners. Programs aimed at preventing the transmission of HIV-1 also can help to prevent and control the spread of HIV-2.

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