The quality of evidence (I-III) and strength of recommendation (A-C) are defined at the end of the "Major Recommendations" field.
Prevention of Sexual Transmission
Key Point:
Prevention should be viewed as a lifelong activity that changes as patients progress through their lives. Effective risk-reduction counseling requires ongoing discussion and flexibility to adapt to patients' evolving needs and lifestyles. |
Obtaining a Sexual Risk Assessment and History
Clinicians should obtain a baseline sexual risk assessment for all human immunodeficiency virus (HIV)-infected patients (see the table below). (AII)
Ongoing sexual risk assessments should occur at least every 3 to 4 months. The content and intensity of prevention interventions should be tailored as the clinician learns more about the patient's behaviors and health beliefs. (AIII)
Clinicians should stress the confidential nature of discussions and maintain a nonjudgmental attitude regarding sexual activities to encourage patients to be open and honest. (AIII)
Components of Sexual Risk Assessment
Clinicians should include the components listed in the table below when obtaining a baseline risk assessment. (AII)
Clinicians should assess whether HIV-infected women of childbearing potential might be pregnant or wish to become pregnant. Clinicians should discuss the importance of barrier protection in addition to contraception with women of childbearing potential who are not specifically considering pregnancy but are sexually active. (AI) (See the National Guideline Clearinghouse [NGC] summary of the New York State Department of Health [NYSDoH] guideline Preconception Care for HIV-Infected Women).
Clinicians should screen for alcohol and substance use at baseline and at least annually and should assess whether patients are more likely to engage in high-risk sexual activity while using. (AII)
Table: Elements of an Initial Sexual Risk Behavior Assessment |
- Satisfaction with sex life (Are you happy with your sex life? Do you find your sex life satisfying?)
- History of sexually transmitted infections (STIs)
- Current STI symptoms
- Sexual practices, including vaginal, anal, digital, and oral sex
- Methods currently used to reduce risk, such as condom use
- Drug or alcohol use and sexual activity during use
- Exchanging sex for money, drugs, or a place to sleep
- Use of erectile dysfunction agents
- Methods of contraception and interest in conceiving
- Information about partners
- Number of partners in the last 3 months
- Age of partners*
- Gender of partners
- Where partners are met
- Disclosure of HIV status to partners, discussion of safer sex with partners
- HIV and STI status of partners
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*Inquiring about the age of partners may be useful when obtaining a sexual risk assessment in younger men and women because it is often harder for them to negotiate safer sex with older partners. |
Risk-Reduction Counseling for Sexual Transmission
Clinicians should:
- Routinely encourage HIV-infected individuals and their partners to adopt safer sexual practices. (AII)
- Educate HIV-infected patients about the risks associated with the patient's specific sexual behaviors. (AII) (See Table 4 in the original guideline document).
- Tailor messages according to the patient's relationship status and ongoing transmission risk behaviors. (AII) (See Appendix A in the original guideline document for examples of scripted dialogue that could be used for risk-reduction counseling).
Table: Elements of Risk-Reduction Counseling for Sexually Active HIV-Infected Patients |
For patients who are sexually active, risk-reduction counseling should include the following:
- Review of safer sexual practices to prevent transmission of HIV and other STIs (see Table 4 in the original guideline document):
- Instructions about consistent, correct male and female condom use
- Importance of avoiding use of lambskin condoms and nonoxynol-9
- Strategies to avoid intoxicating substances that can lead to unsafe sex, or if the patient is unwilling or unable to avoid these substances, discuss pre-planning when using drugs that lower inhibitions (e.g., have condoms available)
- Avoidance of activities that irritate the mucosal surfaces before sex occurs, such as douching and use of sex toys or hyperosmolar lubricants
- Avoidance of exposure to pre-ejaculatory fluid, because it may contain HIV
- Reducing number of sexual partners, particularly those who are at-risk, such as those who are HIV-negative or of unknown status
- Clarification that an undetectable plasma viral load does not guarantee elimination of the risk of HIV transmission, even though it greatly reduces the likelihood that HIV will be transmitted
- Reassurance that behaviors that do not involve exchange of or exposure to potentially infectious bodily fluids cannot transmit HIV
- How to communicate about HIV status with prospective sexual partners
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Viral Load and Transmission Risk
Clinicians should educate HIV-infected patients about the following:
- Antiretroviral therapy (ART) is an important prevention strategy because it reduces viral burden, thereby reducing the risk of HIV transmission to sexual partners (AI)
- Adherence to ART is an achievable and important strategy because strict adherence enables ART to reduce transmission risk (AI)
- The use of condoms is still recommended for all patients, including those with undetectable viral load levels because an undetectable viral load does not completely eliminate the risk of HIV transmission (AI)
Safer Sexual Practices
Use of Barrier Methods
Clinicians or members of the healthcare team should educate HIV-infected patients about both male and female condoms and dental dams and should:
- Reinforce condom use for all sexually active patients, regardless of relationship status (AI)
- Provide patients with access to condoms (AI)
- Recommend polyurethane condoms for patients with latex allergy (AI)
- Advise patients to avoid using lambskin condoms or condoms that are lubricated with nonoxynol-9 (AI)
- Instruct patients about the effectiveness of different kinds of condoms and how to use condoms properly (AI)
- Advise patients to avoid oil-based lubricants with latex condoms (only water-based lubricants should be used); water- or oil-based lubricants can be used with polyurethane condoms (AI)
- Instruct patients about the use of dental dams during oral sex (BII)
Sexual Disinhibition Related to Alcohol and Substance Use
Clinicians should:
- Screen for alcohol and substance use at baseline and at least annually (AIII)
- Discuss how alcohol and substance use may affect decision-making regarding engagement in high-risk sexual behaviors (AIII)
- Help patients identify methods to either avoid substance use or to reduce HIV transmission risks while using substances (AII)
- Refer patients in need of treatment to substance use treatment services (AII) (See AIDS Institute Resource Directory for programs that provide substance use treatment services and harm-reduction counseling).
Partner Selection: Serosorting
Clinicians should discuss partner selection as a component of safer-sex education. For patients who choose to engage in serosorting and do not use condoms, clinicians should discuss the possible risks of acquiring or transmitting resistant HIV strains or other STIs. (BIII)
Clinicians should obtain more frequent STI screening for patients who report serosorting without the use of condoms. (AI)
Superinfection
Clinicians should educate HIV-infected individuals about the risk of acquiring a different strain of HIV from HIV-infected sexual and drug-using partners. (BIII)
The Role of STI Screening and Treatment
Clinicians should screen HIV-infected patients for STIs at baseline and at least annually (see Table 5 in the original guideline document). Clinicians should re-screen patients for STIs if they have had any new sex partners since the last screening, or if they report that their partner has had any new sex partners. (AI)
Clinicians should inquire about the following STI symptoms at baseline, annually, and when clinically indicated: (AI)
- Penile and vaginal/cervical discharges
- Ulcerative lesions
- Anorectal or pharyngeal pain
- Difficulty or pain during sex, urination, defecation, or menstruation
- Pruritus, burning, or bleeding in the anogenital area
- Rash
- For women, abdominal pain with or without fever
When an HIV-infected patient presents with symptoms or a diagnosis of an STI, clinicians should:
- Perform a risk assessment and provide appropriate risk-reduction counseling (AII)
- Consider both HIV exposure and STI exposure to partners
- Offer assistance with partner notification if needed, or refer patient to other sources for partner notification assistance (Contact Notification Assistance Program [CNAP], Partner Notification Assistance Program [PNAP]) (AI)
Key Point:
Early identification and treatment of STIs is a crucial prevention strategy. The risk of HIV transmission in patients co-infected with genital ulcer disease is increased by 2 to 6 times because of increased levels of HIV virus in semen and vaginal secretions. |
Partner Notification
Clinicians should discuss the importance of partner notification with HIV-infected patients on a routine and ongoing basis for both new partners and previous partners who have not yet been notified. (AI)
Clinicians must discuss with HIV-infected patients their options for informing sexual and needle-sharing partners that they may have been exposed to HIV (New York State Public Health Law, Article 21, Chapter 163 of the Laws of 1998). Clinicians and/or patients should contact the New York State Department of Health Partner Services Program (1-800-542-AIDS) or the New York City Department of Health and Mental Hygiene Contact Notification Assistance Program (CNAP) (212-693-1419) for assistance with partner notification. (AI)
If a risk for domestic violence is identified, partner notification should be deferred and the patient referred to a domestic violence agency (see Section II. D. 3. Domestic Violence Screening below and in the original guideline document). (AI)
Key Point:
Based on recent evidence-based reviews, it is strongly recommended that all persons with newly diagnosed or reported HIV infection receive partner services with active health department involvement. Medical providers play a key role in actively linking patients to health department partner services throughout the continuum of care. |
See the original guideline document for information on New York State HIV Reporting and Partner Notification (HIVRPN) Law.
Key Point:
Medical providers are required by law to report the names of sexual and needle-sharing partners of HIV-infected individuals who are known to the provider. Patients, however, are not required to disclose partner information, and their participation in partner notification programs is voluntary. |
See Table 6 in the original guideline document for information on options for partner notification.
Key Point:
The HIVRPN Law allows physicians to notify known partners of an HIV-infected patient with or without patient consent, but only after informing the patient that notification is imminent. All other healthcare providers must have the patient's consent before proceeding with notification. Clinicians should contact Partner Services/CNAP for guidance and assistance with the partner notification process. |
Domestic Violence Screening
As part of post-test counseling and partner notification, clinicians must screen HIV-infected men and women and their partners/contacts for risk of domestic violence related to partner notification (New York State Public Health Law Article 21 [1983], Public Health Law Article 27-F—HIV and AIDS Information; Public Health Law Article 21, Title III—HIV Reporting and Partner Notification; 1998). (AII)
Clinicians should be familiar with local domestic violence agencies and the mechanisms of referral for patients with identified risk of domestic violence resulting from partner notification. (AIII)
Non-Occupational Post-Exposure Prophylaxis (nPEP)
Clinicians should educate HIV-infected patients and their families at initial visits and annually about nPEP. Such counseling should include the benefits and limitations of nPEP. (BII)
The clinician or a member of the HIV care team should provide risk-reduction counseling and primary prevention counseling whenever someone is assessed for nPEP, regardless of whether PEP is initiated. (AII)
Non-occupational PEP should not be routinely dismissed solely on the basis of repeated risk behavior or repeat presentation for nPEP. Persons who present with repeated high-risk behavior or for repeat courses of nPEP should be the focus of intensified education and prevention interventions and should be considered candidates for pre-exposure prophylaxis (PrEP). (AIII)
Prevention of HIV Transmission Secondary to Substance Use
Obtaining a Substance Use History and Screening for Substance Use
Clinicians should:
- Obtain a baseline substance use history for all HIV-infected patients (see the table below) (AIII)
- Screen all HIV-infected patients for substance use at baseline and at least annually. Screening questions should be phrased to include alcohol and prescription and nonprescription drug use (AIII)
- Stress the confidential nature of discussions regarding substance use to encourage patients to be open and honest (AIII)
- Be familiar with the names and routes of administration of commonly used street drugs (see What Are These Drugs? ) (AIII)
When substance use risk is identified, clinicians should help the patient develop individualized goals to prevent transmission, such as abstinence, reduced use, or safer use, and should address the issue at subsequent routine visits. (AII)
Table: Elements of a Baseline Substance Use History |
Current and Past:
- Types of drugs (past and current use)
- Street drugs (e.g., marijuana, cocaine, heroin, "crystal" methamphetamine, 3,4-Methylenedioxymethamphetamine (MDMA)/ecstasy, ketamine)
- Prescription drugs (illicit use)
- Alcohol
- Injectable hormones
- Frequency of use and usual route of administration
- Sexual risk-taking while under the influence of drugs or alcohol
- Sharing needles or other injection equipment
- Number and HIV status of needle-sharing partners
- Exchanging sex for drugs
- History of treatment and actual or perceived barriers to treatment
- Methods of risk reduction and success of these methods
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Risk-Reduction Counseling for Transmission Related to Substance Use
Clinicians should discuss behavioral risk-reduction measures on a routine and ongoing basis with patients who use substances and/or consume alcohol. These discussions should include use of barrier protection, how to speak with partners about safer sex, and the circumstances under which high-risk sexual behavior might occur. (AII)
Clinicians should discuss avoidance of needle/syringe-sharing activity with all injection drug users, regardless of viral load, to prevent HIV transmission. Clinicians should issue prescriptions for new needles and syringes to patients who inject drugs and should discuss options for accessing new needles and syringes, including use of the Expanded Syringe Access Demonstration Program and Syringe Exchange Programs, New York State's two syringe access initiatives. (AI)
Clinicians should refer patients for substance use treatment and/or mental health services, when the need is identified and readiness established.
Definitions:
Quality of Evidence for Recommendation
- One or more randomized trials with clinical outcomes and/or validated laboratory endpoints
- One or more well-designed, non-randomized trials or observational cohort studies with long-term clinical outcomes
- Expert opinion
Strength of Recommendation
- Strong recommendation for the statement
- Moderate recommendation for the statement
- Optional recommendation