HIV Prevention

Find out about low and high-risk sexual activities that put you at risk for contracting HIV and AIDS. And what HIV prevention techniques are available after sexual exposure to HIV?

continued from

Low- and high-risk activities
Mutual masturbation, fondling, and kissing are exceedingly low-risk activities. Unprotected (without a condom) anal and vaginal intercourse are clearly the highest risk sexual activities. I try to dispel common misperceptions such as—men cannot contract HIV from vaginal intercourse or insertive (“top”) anal intercourse. This clearly is not true. Perhaps the biggest gray area in patients’ minds regarding sexual transmission of HIV is oral sex. Seroconversion, or HIV transmission resulting from oral sex has been documented and new information is showing that oral sex may be more risky than previously thought. Therefore, while in the past there has been some debate concerning the degree of risk associated with oral sex, it is becoming increasingly important that appropriate use of a latex condom or dental dam during oral sex is encouraged.

HIV Prevention and Drug Use

One-third of all cases of HIV are believed to be related to injection drug use. This statistic does not include the large numbers of individuals who contract HIV through high-risk sexual activity while under the influence of drugs (injection or noninjection) or alcohol. For patients who use drugs, my goals are to encourage:

• abstinence from drug use altogether
• referral to drug treatment programs
• use of clean needles and avoidance of sharing needles
• should the patient become infected with HIV, prevention of unsafe sex or other practices that place others at risk

Unfortunately, these goals are not always attainable. Patients frequently are unwilling or unable to change their behavior, accept treatment, or access appropriate substance use services. Frequently faced with this scenario, my strategy for HIV prevention conforms more closely to a harm reduction model. This model accepts that drug use exists and occurs, but attempts to minimize the adverse consequences of that behavior.

HIV basics regarding drug use
The first step is education. For patients who actively use IV drugs, I once again cover the basics—i.e., that HIV is transmitted through drug use when blood or other bodily fluids from an infected individual is transferred to an individual who is not yet HIV infected. Patients are informed that sharing needles and syringes is the most common way IV drug users become infected. I urge all of my IV drug-using patients to avoid these practices. I advise all patients who inject drugs to use sterile needles for each injection. Users who continue to share needles are given detailed instructions as to how to best disinfect their apparatus (“works”).

HIV is most effectively killed by first flushing the drug apparatus with clean water. It must then be soaked or rinsed in full-strength bleach for at least one minute, followed by another thorough clean water rinse. In some areas, such as Massachusetts, clinicians can refer IV drug users to needle-exchange programs. Here, patients can exchange used (nonsterile) drug apparatus for clean (sterile) supplies. Several studies have shown that needle-exchange programs reduce HIV transmission among injection drug users and are a useful addition to any comprehensive HIV prevention effort. Critics, however, fear these programs deter IV drug users from seeking treatment and may, in fact, endorse drug use. No evidence supports these claims. With overwhelming support from the scientific community, debate over needle exchange appears to have more to do with politics, than sound public health practice.

HIV Prevention and Pregnancy

No single HIV-prevention effort has been as successful as efforts with pregnant women. Mother-to-infant transmission of HIV accounts for more than 90 percent of pediatric AIDS cases. In this country, approximately 7,000 infants are born to HIV-infected women each year, but the overwhelming majority of these babies are not HIV infected. In developing countries the numbers are much, much higher. During pregnancy, labor, or delivery, HIV can be transmitted from mother to infant in as many as one-third of cases if no antiretroviral therapy is used. In recent years, drug therapies designed to fight HIV (antiretroviral agents) have been shown to be effective at reducing this rate of transmission. One particular drug, AZT (zidovudine), when given to both a pregnant woman and her newborn infant, can reduce HIV transmission rates to as low as eight percent. Other HIV drug therapies may also be effective but have not yet been adequately studied.

Armed with a tremendous opportunity to reduce HIV transmission, I make sure to offer HIV testing and counseling to all women of childbearing age. For women who are infected with HIV, I provide education about contraception, the risks of mother-to-infant HIV transmission, and the use of antiretroviral drugs to help reduce this risk. It is also important that HIV-infected women, especially those with HIV-negative partners, be counseled regarding safer sex and, if they want to become pregnant, about alternatives to unprotected intercourse. Of course, the final decision regarding antiretroviral therapy is up to each woman individually. In the United States, where drugs such as AZT are readily available, prevention efforts in pregnant women have been quite successful in decreasing the number of HIV-infected newborns. However, certain under-served populations of women—such as the poor and racial/ethnic minorities—need to be increasingly targeted by this prevention effort. The situation is far worse in developing countries, where a lack of resources limits the availability of antiretroviral drugs and a lack of public health infrastructure limits widespread access to HIV testing, health education, and medical care.

HIV Prevention After Exposure

Until recently, people had little reason to seek medical attention after exposure to HIV, e.g., when a condom broke or after a needle-stick exposure. A study of healthcare workers found that treatment with AZT shortly after a needle stick (post-exposure) reduced the odds of subsequent HIV infection by almost 80 percent. Post-exposure prophylaxis (or PEP, as it is commonly called) involves taking antiretroviral medications shortly after exposure to HIV. If PEP is effective for healthcare workers exposed to HIV by needle stick, it seems logical to consider it for people exposed to HIV through sexual contact—a much more common source of HIV transmission.

The theory behind PEP as an HIV prevention strategy is that antiretroviral therapy given shortly after exposure may help prevent infection by either blocking the multiplication of HIV and/or boosting one’s immune system to get rid of the virus.

As of yet, there is no direct evidence supporting PEP following sexual exposure and there are currently no national guidelines or protocols for PEP in this circumstance. Despite this, based largely on theory and from our experience with healthcare workers, many physicians and healthcare centers across the country (including ours) offer PEP following sexual exposure to HIV.

advertisement

Most people (and many clinicians) have never heard of PEP. Increasing public awareness is essential if it is to become part of a comprehensive HIV prevention strategy. Find out if and where PEP is offered in your area. Patients need to understand that PEP is not a first line strategy to prevent HIV. Condom use, safer sexual practices, and avoidance of other high-risk activities remain the “gold standards” of HIV prevention strategies. However, in cases where our primary prevention methods have failed, PEP can be used to try to reduce one’s risk of acquiring HIV. The extent to which PEP reduces HIV risk following sexual exposure is still largely unknown.

Keeping in mind that there are no universally accepted guidelines, I recommend PEP to any patient who has had unprotected anal or vaginal intercourse, or oral sex with ejaculation with a person known to be HIV-infected or at high risk for HIV, such as an IV drug user. PEP needs to be started within three days (72 hours) of exposure. PEP is most appropriate for people exposed through isolated sexual encounters and who seem willing to practice safer behaviors in the future, but there are no hard and fast guidelines for when to use PEP under these circumstances.

Conclusion

With no cure or vaccine on the horizon, our efforts to overcome the HIV epidemic must remain focused upon prevention. Whether it is sexual activity, drug use, or other behavior that puts one at risk of contracting HIV, people need to be given the education and skills to protect themselves.

Next: The Future of Preventing HIV and STDs

Last updated: 1/2000.  Last reviewed: 10/05

top ~ pages 1 2 ~ next ~ send page to friend