HIV Prevention

HIV prevention and protection against HIV is important for everyone. Here are some HIV prevention strategies.

by Robert Garofalo MD, MPH

Introduction

The Human Immunodeficiency Virus (HIV) continues to pose a significant threat to worldwide public health. Recent statistics from the United Nations show that there are approximately 34 million people in the world infected with HIV and that there are 5.6 million new infections each year. The human tragedy associated with HIV is unparalleled.

Most cases of HIV transmission can be linked to human behavior in some way—e.g., drug use and sexual activity. While these behaviors may seem entrenched in some populations, most can be changed or modified by appropriate education and counseling. Several countries, including Thailand and Uganda, have successfully decreased the spread of HIV by aggressive efforts in this regard.

In the United States, although high-risk behavior has declined remarkably in some groups, especially gay males; recent data is showing a resurgence of infection. This resurgence is certainly multi-factorial, due in part to wavering political and public support. Large-scale campaigns, such as the “safer sex” educational efforts, condom promotion, and needle-exchange programs, have had variable and inconsistent results in modifying behaviors over time. Further, physicians’ (or clinicians’) potential to influence patients’ attitudes and behaviors have, unfortunately, gone largely unrealized. In contrast to cigarette smoking, for which we play a recognized role in public health prevention efforts, counseling and advice about HIV prevention is offered in fewer than one percent of patient visits to their primary care physician. Finally, new therapies, which prolong and preserve life for many of those infected, may also decrease the fear of contracting HIV. Unfortunately, they do not work for everyone, are difficult to take, and are associated with significant potential toxicities and long-term complications.

Since a cure or vaccine is unlikely in the near future, efforts to curtail the HIV epidemic must focus on HIV prevention as a primary goal. Physicians and other healthcare providers must play a significant role in counseling and other preventive efforts. It is important for physicians to recognize that HIV prevention does not require extensive counseling skills and psychological interventions. I view prevention as part of routine health education, assessing risk and providing information, which will help to modify high-risk behaviors.

Who is at Risk?

In the United States alone, more than one million Americans are believed to be infected with the HIV virus and there are 40 to 80,000 new infections each year. Once considered largely an urban disease of gay men and intravenous (IV) drug users, as the HIV epidemic has grown, the groups at-risk have changed. Women, adolescents/young adults, and racial minorities are the fastest growing populations being infected with HIV. Where they used to represent only a handful of cases, adolescent and young-adult women now account for more than 20 percent of AIDS cases nationwide, and the most rapidly increasing way in which people are becoming infected with HIV is heterosexual sex. While traditionally concentrated in urban centers, HIV cases have gradually shifted more to suburban locations.

So, to answer my own question, “Who is at risk?” In a word—EVERYONE! I assume all my patients—adolescent and adult—to be at-risk for HIV. Therefore, I ask everyone specific questions about sexual and other high-risk behaviors, and tailor my education and counseling accordingly. In my opinion, assuming anyone to be not at-risk of HIV is a dangerous and misguided practice.

HIV Prevention and Sexual Behavior

In order to offer effective counseling and education about HIV, a physician must first feel comfortable taking a sensitive and comprehensive sexual history. This involves being comfortable discussing sexuality, respecting individual differences, using “real-world” language that patients understand, and asking pointed questions about specific behaviors—not just, “Are you sexually active?”

Abstinence
With each patient, I discuss a range of sexual options in relation to HIV transmission and risk—including abstinence. All people (particularly adolescents) should be supported in their decision to abstain from sexual activity. Yet, I remain aware that many young people are choosing to have sex. In my experience, an HIV prevention strategy based on abstinence alone is a misguided and unrealistic option. Therefore, I address all patients with nonjudgmental messages, which emphasize taking personal responsibility for protection against HIV. Specifically, while safer sex guidelines have historically emphasized limiting your number of sexual partners and avoiding partners who may be at-risk of HIV, I believe more important messages are:

• protect yourself with consistent, appropriate latex condom or dental dam use
• limit yourself to lower risk sexual activities

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For people who are allergic to latex, I advise using polyurethane condoms. I provide everyone with specific instructions about correct condom use such as using adequate lubrication with a water-based lubricant. Improper usage can make condoms break and lead to unnecessary HIV exposure, not to mention pregnancy risk.

HIV basics
When it comes time for specific HIV education, I always make sure to cover the basics— i.e., that HIV is transmitted sexually by exposure of the mucous membranes of the penis, mouth, vagina, and rectum to infected semen, pre-ejaculate (pre-cum), vaginal secretions, or blood. I explain that sexual transmission of HIV is unpredictable. In other words, one person may be infected from a single sexual encounter, yet another may have multiple encounters and never become infected. Furthermore, while patients frequently ask me to assign some numeric risk to specific sexual behaviors (5 percent, 10 percent risk, etc.), I explain that these risks are difficult, if not impossible, to quantify. I prefer to describe sexual risk as occurring along a continuum from low-to-high risk behaviors.

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Dr. Robert Garofalo is an adolescent medicine specialist at Children's Memorial Hospital in Chicago. In addition to his clinical work, Dr. Garofalo has published research articles on the health risks facing gay, lesbian, bisexual, and transgender youth.

Last reviewed: 10/05

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