New Guidelines for HIV Preventive Care

Frank J. Domino, MD

Review

“HIV Prevention in Clinical Care Settings; 2014 Recommendations of the International Anti-Viral Society — USA Panel.” JAMA 2014; 312(4):390-409.

Based upon data from the past 17 years of conferences of the International Anti-Viral Society (formerly AIDS Society), the USA HIV Preventions Recommendations Panel issued new preventive care guidelines.

Study Methods

A systematic literature review was done to determine the best evidence regarding the prevention of HIV transmission. More than 250 papers were included in this study with the focus being on determining best practices for HIV prevention in clinical care settings for non-pregnant adults and adolescents. Evidence ratings were assigned to all of the recommendations to help clinicians understand the importance and certainty of the data.

Results and Outcomes

Recommendations for the prevention of HIV:

1. HIV Testing

All adults and adolescents should be offered HIV testing at least once [A111]. This is a onetime screening recommendation, but regular reassessment of HIV-related risks, including sexual and drug use activities, should be made in all adults and adolescents. Those at increased risk should be tested more frequently at an interval appropriate to the individual’s circumstance.

Regarding testing, informed consent for both pre- and post-test counseling should be made. Ideally testing should be performed on a serum sample, but rapid testing may be considered for those persons less likely to return for results. Self-testing and home-testing should be considered for those who have recurrent risk, difficulty with testing in clinical settings, or a combination of the two.

2. Prevention measures for HIV infected individuals.

The panel suggested anti-retroviral therapy (ART) be offered to all on the initial detection of HIV infection [A1a]. In patients who are HIV positive, discussion should focus on the personal health benefits (disease prevention, life expectancy) of ART as well as the public benefits of the prevention of transmission. The panel also noted clinicians should be alert to the non-specific presentation of HIV infection (mono-like syndrome of fever, adenopathy, pharyngitis, myopathy, rash) and pursue diagnostic testing when suspected.

Regarding HIV infected persons, the recommendation was for regular assessment of sexual and substance abuse practices. Patients should be counseled about risk-reduction methods including screening for sexually transmitted infections, condom use, and harm reduction services for people who inject drugs like needle exchange and cleaning practices. The panel said needle exchange and other harm reduction interventions should be considered and used simultaneously with ART.

3. Individual and structural level interventions to promote involvement of the HIV infected person through the continuum of care.

Newly diagnosed individuals with HIV should be connected to a system for care coordination as soon as possible following the new diagnosis of HIV [A1a].

Other potential patient support services included patient health navigation, community and peer outreach, provision of culturally appropriate print media, verbal messages promoting health care utilization and retention from clinic staff, and youth focused case management and support.

4. Prevention measures aimed at HIV uninfected individuals who are high risk for contracting the disease.

Recurrent risk assessment is recommended for all HIV uninfected individuals focusing on sexual and substance abuse practices. These individuals should be offered risk reduction counseling and appropriate risk reduction services [A1a].

For patients who are at “high risk,” such as sex workers, men who have sex with men, those whose sexual partner is HIV positive, etc., for HIV infections who test negative, risk reduction interventions are highly warranted. This includes offering pre-exposure prophylaxis.

HIV testing should be performed before considering pre-exposure prophylaxis, ideally with a sensitive combination antigen-antibody assay capable of detecting acute or early infection (a 4^th generation assay) and regularly (monthly to quarterly depending upon risk) thereafter. When a case of suspected acute HIV infection presents but tests negative, obtain plasma HIV viral load to determine next steps.

Persons taking a Tenofovir Disoproxil Fumarate (TDF) based pre-exposure prophylaxis should have a creatinine clearance of greater than 60 ml/min.

Hepatitis B immunization should be offered to all patients at risk and immunity status should be determined before initiating TDF based pre-exposure prophylaxis.

Post-exposure prophylaxis should be offered to all persons who have sustained mucosal or parenteral exposure to HIV from a known infected source as urgently as possible and at most within 72 hours after exposure.

This post-exposure regimen should be the US Public Health Service preferred regimen which is currently Emtricitabine (FTC) plus TDF and raltegravir. Women who receive post-exposure prophylaxis should be offered emergency contraception to prevent pregnancy.

Those persons who receive post-exposure prophylaxis should be rescreened with a 4th generation HIV antigen-antibody test 3 months after completion of the regimen.

The panel also strongly recommends voluntary male circumcision be offered to all sexually active heterosexual males for the purpose of HIV prevention, especially in those areas where HIV prevalence is high (>2%). Circumcision should be encouraged to all men who have sex with men and all who engage in primary insertive anal intercourse. Parents and guardians should be informed of the benefits of infant male circumcision for the prevention of HIV infection.

5. Prevention of HIV issues relevant to persons with or at risk for HIV infection.

The panel strongly recommended routine and periodic screening for common sexually transmitted infections based upon sexual history. People with HIV should be tested for hepatitis C at entry to care and regularly thereafter based upon risk assessment and sexual practices.

Quadrivalent human papilloma virus vaccine should be offered to all HIV infected persons (Advisory Committee for Immunization Practices criteria: age 18-26 years of age; other if at risk) for its administration. Immunity to hepatitis B vaccine should be insured for all HIV infected persons who were not previously vaccinated. Screening for herpes simplex virus 2 infections should be considered for all HIV infected persons who do not know their HSV-2 sero-status and wish to consider suppressive anti-viral therapy to prevent the transmission of HSV-2.

The panel strongly recommended aggressive use of contraceptive measures, although data was insufficient to document a benefit. Women were also strongly recommended to use condoms and other HIV preventable measures.

Commentary

In my first 10 years of practice, more patients younger than me died than those older than me. HIV/AIDS was their diagnosis and treatments included AZT and oral TMP/SMX to prevent pneumonia. During this time, most physicians believed only those at high risk for HIV should be screened, and that only really high risk pregnancies should be screened. Now, HIV/AIDS is a chronic condition that can be managed with often greater success than many cancers.

I am so happy those days are past.

The CDC estimates there are 1.1 million people living in the US who are HIV positive, yet about 1 in 3 do not know it. Identification of these patients could be lifesaving, and getting them and their partners under care will have health and cost benefits to all.

Many family physicians leave the “care of HIV patients” to those docs who make this an area of interest, and that might be appropriate. However, all of us must be part of aggressive prevention counseling of teens and adults, including use of condoms, and testing for STI’s and HIV as part of our health maintenance visits.

Compared to testing of lipids and use of statins and/or aspirin for the prevention of cardiovascular disease, or even blood pressure determination, the aggressive use of counseling and screening for HIV-related disease will most certainly add years to life expectancy for those infected and could very well save the life of your patient, and by preventing spread, the lives of those of the community in general.

About the Author

Frank J. Domino, MD, is Professor and Pre-Doctoral Education Director for the Department of Family Medicine and Community Health at the University of Massachusetts Medical School in Worcester, MA. Domino is Editor-in-Chief of the 5-Minute Clinical Consult series (Lippincott Williams & Wilkins). Additionally, he is Co-Author and Editor of the Epocrates LAB database, and author and editor to the MedPearls smartphone app. He presents nationally for the American Academy of Family Medicine and serves as the Family Physician Representative to the Harvard Medical School’s Continuing Education Committee.