This article by Roger Pebody first appeared on aidsmap.com here.
The American public health agency, the Centers for Disease Control and Prevention (CDC) has published new recommendations on the HIV prevention interventions and advice that should be offered to people who are HIV positive.
The CDC last issued guidelines on what is sometimes called ‘prevention with positives’ in 2003. Those guidelines ran to 24 pages and emphasised screening for behavioural risk factors and sexually transmitted infections, one-to-one prevention counselling and advice delivered by clinicians, other behavioural interventions, and partner notification.
All those elements remain but the scope of the new guidelines is much broader, with the recommendations now running to 240 pages. Whereas previous guidelines were clearly focused on the individual’s knowledge and behaviour, the new recommendations take greater account of social and structural factors as well as the profound impact that antiretrovirals have on HIV transmission. For example, an individual may need support with poverty, mental illness, substance use or unstable housing in order to be able to fully engage with medical care and adhere to HIV treatment.
Moreover, the document reaffirms the central role of people living with HIV in prevention. “A prevention strategy that aims to increase access to effective biomedical, behavioral, and structural interventions for the more than one million persons with HIV is more likely to decrease HIV transmission than a strategy that attempts to change sexual and drug-injection behaviors of the many millions of persons at risk for infection,” it states.
The recommendations have been developed in partnership with the Health Resources and Services Administration, the National Institutes of Health, the American Academy of HIV Medicine, the Association of Nurses in AIDS Care, the International Association of Providers of AIDS Care, the National Minority AIDS Council and the Urban Coalition for HIV/AIDS Prevention Services.
On many issues, the guidelines bring together and repeat guidelines that have already been developed by those and other organisations. The recommendations have also been made in light of the 2010 National HIV/AIDS Strategy, notable for its concern with improving health equity and with a better targeting of HIV prevention.
Setting out the context for the guidelines, the weaknesses of the United States’ treatment cascade are described straightaway. Far too many individuals who are diagnosed with HIV are not linked to care and are unable to remain in care, with the result that only a quarter of those living with HIV have an undetectable viral load. Furthermore, less than half of those in care receive HIV prevention counselling and many do not have sexual health check ups.
Interventions to improve linkage to and retention in medical care are seen as central to HIV prevention. Rather than simply offering appointments or making referrals, services are expected to take a proactive approach and to track outcomes (such as whether an appointment was attended). For example, services providing HIV testing should assess barriers and facilitators to starting medical care, make referrals to medical and social services that could deal with underlying problems, and provide practical help with making and attending appointments.
Health professionals are asked to help people living with HIV enrol in private health insurance or programmes such as Medicare, Medicaid, the AIDS Drug Assistance Program and the Department of Veterans Affairs. Several recommendations tackle problems with obtaining healthcare; for example, recommending that the programmes mentioned should be promoted as a population-level strategy, or that information should be provided on options for obtaining medication during a break in coverage.
Many of the recommendations on behavioural risk-reduction interventions are broadly similar to those in the guidelines a decade ago. However, providers are now expected to recommend biomedical as well as behavioural strategies.
Healthcare workers should inform all people with HIV about the role of effective antiretroviral treatment in reducing HIV transmission, as well as in improving their own health and lifespan. While some limitations of antiretroviral treatment should be described (the need for adherence and lifelong treatment, possible side-effects, the transmission risk not being entirely eliminated), providers are urged to encourage patients to start antiretroviral therapy within three months of diagnosis, regardless of CD4 cell count.
People with HIV must also be informed about the availability – for their HIV-negative partners – of pre-exposure prophylaxis (PrEP) and post-exposure prophylaxis (PEP).
A large part of the recommendations concern advice around conception for men or women living with HIV who wish to have a child and specific recommendations for women who are pregnant. Both men and women living with HIV should receive reproductive health counselling. People in a relationship with an HIV-negative partner should be informed of ways to reduce the risk of transmission while conceiving, including antiretroviral therapy, timed unprotected intercourse and PrEP.
The recommendations are notable for recommending that health departments use routinely collected surveillance data in order to identify individuals and social groups who are falling through the cracks. For example, a person who has been diagnosed with HIV but has not had a CD4 cell count may be sent an outreach worker who will attempt to help with linkage to care. Similarly, a person taking antiretroviral treatment who has a rising viral load may be identified as needing more effective treatment or adherence support. However, the document notes that this approach must be handled with respect to patient confidentiality, data security and local legislation (which differs from state to state).
However, when it comes to the 33 American states which use the criminal law to prosecute people for behaviours thought to run a risk of HIV transmission (even including spitting and biting), the guidance sits on the fence. It notes that the laws are controversial and have been subject to public debate, but rather than suggesting steps to limit their application, asks health professionals to make people with HIV aware of their legal obligations.
Detailed recommendations which are largely consistent with existing guidelines are provided on topics including adherence support, partner notification and other partner services, and the screening and treatment of sexually transmitted infections.