Doctors providing HIV treatment and care should be actively involved in HIV-prevention, providing their patients with a “prevention prescription” along with a prescription for medication at every consultation, according to American doctors writing in the May 2003 edition of Clinical Infectious Diseases.
The authors suggest that HIV doctors could use their clinic time to provide HIV prevention efforts focused on three areas.
- Counselling - directed at changing the HIV risk behaviour of their patients.
- Treatment - the provision of HAART to reduce HIV viral load; promote adherence; test for resistance; and treat sexually transmitted infections (STIs).
- Public health interventions - including free condom distribution.
Counselling
The auhtors recommend that in consultations with their HIV-positive patients doctors should include a counselling session about HIV risk behaviours such as unprotected sex or injecting drug use, which is supportive and non-judgmental. This should encourage patients to describe their risk behaviour and come up with their own solutions, tailored to the needs of each individual patient.
The counselling should set specific achievable goals, for example a patient might agree to consistently use condoms, or inform each partner of their HIV status. These goals would be specified in a “prevention prescription” which the patient would receive at the end of each consultation along with their prescription for medication.
As many doctors are uncomfortable discussing sex and drug use, a set script could be used to help initiate discussion and ensure that issues are “sensitively” dealt with.
Prevention counselling should be delivered regularly, and the authors suggest that each consultation could include a set of questions which invite a response from patients about their risk behaviour. This could take the form of: “Now that we’ve finished discussing your medications, I’d like to ask you some questions about your sex and drug use behaviours. What behaviours are you involved in now? Would you feel comfortable discussing them? Can you think of anything that you might like to change about these behaviours, and what interest might you have for changing them? How might you be able to reduce the riskiness of your sex and drug use behaviours?”
Alternatively, patients might be asked to say how important reducing their risk behaviour is on a scale of one to ten, and how achievable they think this is.
Medical interventions
The authors note that anti-HIV therapy “has the potential to reduce virus load, infectiousness, and the likelihood of HIV transmission”. The authors also mention the use of post exposure prophylaxis for the prevention of sexual transmission of HIV, but notes that the utility of both HAART and PEP at reducing transmission is unknown and that further study is needed.
Adherence support should be integral to prevention efforts, as “lapses in adherence can lead to an increase in viral load and the subsequent selection and transmission of drug -resistant strains of HIV to sex and drug-use partners.”
Sexually transmitted infections (STIs) should be treated, as it has been shown on both an individual and community levels that treatment of STIs reduces HIV transmission rates.
Public health initiatives
Doctors should collaborate with existing public health initiatives in the provision of free condoms and clean needles, and provide information about HIV transmission and sexual health.
Editorial comment
This is a well intentioned article which includes some sensible recommendations for action, particularly sexual health screening, and the provision of condoms and clean needles (still a sensitive political issue in the USA).
However, its recommendations on counselling may be over-optimistic. It is questionable how practical these recommendations will be in the real world setting of busy HIV clinics where patient appointment times typically last ten mintes or less, and which serve increasingly diverse populations of HIV-infected patients with equally diverse prevention needs.
The authors mention that providing sexual health counselling requires specific skills and training, and then go on to admit that specialist HIV doctors often lack such skills. In addition, the authors mention how uncomfortable doctors can be discussing sex and drug use. Is it therefore reasonable to expect specialist clinicians, who already have a heavy commitment to their continuing medical education, to undertake specialist counselling training?
Taking anti-HIV therapy and receiving treatment for STIs has the potential to reduce the transmission of HIV, as the authors highlight. However, it is probable that many patients would object to questions about HIV risk behaviour, and “prevention prescriptions” without first having established a relationship of trust with their HIV care provider. They might at best refuse to participate in such discussions and at worst cease to access HIV care. This could put their own health at risk and possibly increase the chances of onward transmission of HIV if they cease to take medication to control HIV viral load.
Encouraging HIV testing is a key part of HIV prevention initiatives in both the US and UK, not least because a third of HIV cases in both countries are thought to be undiagnosed. Heavy-handed prevention efforts in a clinical setting, particularly in some American states where it is illegal for a person with HIV to have sex with an HIV-negative person without first informing them of their health status, could have the unwanted effect of deterring people at risk of HIV from testing and receiving care, particularly as medical records can be used in prosecution cases.
Schreibman T et al. Human immunodeficiency virus prevention: strategies for clinicians. Clinical Infectious Diseases, 36: on-line edition, 2003.