many of whom are HIV infected

transmission. Further, despite declining syphilis prevalence in the general U.S. population, sustained outbreaks of syphilis among MSM, many of whom are HIV infected, continue to occur in some areas; rates of gonorrhea and chlamydial infection have also risen for this population (18–21). Rising STD rates among MSM indicate increased potential for HIV transmission, both because these rates suggest ongoing risky behavior and because STDs have a synergistic effect on HIV infectivity and susceptibility (22). Studies suggest that optimism about the effectiveness of highly active antiretroviral therapy (HAART) for HIV may be contributing to relaxed attitudes toward safer sex practices and increased sexual risk-taking by some HIV-infected persons (12,23–27).
Injection drug use also continues to play a key role in the HIV epidemic; at least 28% of AIDS cases among adults and adolescents with known HIV risk category reported to CDC in 2000 were associated with injection drug use (28). In some large drug-using communities, HIV seroincidence and seroprevalence among injection drug users (IDUs) have declined in recent years (29,30). This decline has been attributed to several factors, including increased use of sterile injection equipment, declines in needle-sharing, shifts from injection to noninjection methods of using drugs, and cessation of drug use (31–33). However, injection-drug use among young adult heroin users has increased substantially in some areas (34,35), a reminder that, as with sexual behaviors, changes to less risky behaviors may be difficult to sustain.
Clinicians providing medical care to HIV-infected persons can play a key role in helping their patients reduce risk behaviors and maintain safer practices and can do so with a feasible level of effort, even in constrained practice settings. Clinicians can greatly affect patients’ risks for transmission of HIV to others by performing a brief screening for HIV transmission risk behaviors; communicating prevention messages; discussing sexual and drug-use behavior; positively reinforcing changes to safer behavior; referring patients for such services as substance abuse treatment; facilitating partner notification, counseling, and testing; and identifying and treating other STDs (36,37). These measures may also decrease patients’ risks of acquiring other STDs and bloodborne infections (e.g., viral hepatitis). Managed care plans can play an important role in HIV prevention by incorporating these recommendations into their practice guidelines, educating their providers and enrollees, and providing condoms and educational materials. In the context of care, prevention services might be delivered in clinic or office environments or through referral to community-based programs. Some clinicians have expressed concern that reimbursement is often not provided for prevention services and note that improving reimbursement for such services might enhance the adoption and implementation of these guidelines.
This report provides general recommendations for incorporating HIV prevention into the medical care of all HIV-infected adolescents and adults, regardless of age, sex, or race/ ethnicity. The recommendations are intended for all persons who provide medical care to HIV-infected persons (e.g., physicians, nurse practitioners, nurses, physician assistants). They may also be useful to those who deliver prevention messages (e.g., case managers, social workers, health educators). Special considerations may be needed for some subgroups (e.g., adolescents, for whom laws and regulations might exist governing providing of services to minors, the need to obtain parental consent, or duty to inform). However, it is beyond the scope of this report to address special considerations of subgroups. Furthermore, the recommendations focus on sexual and drug-injection behaviors, since these behaviors are responsible for nearly all HIV transmission in the United States. Separate guidelines have been published for preventing perinatal transmission