which vary among states, for HIV and other STDs

Local and state health departments have reporting requirements, which vary among states, for HIV and other STDs. Clinicians need to be aware of and comply with requirements for the areas in which they practice; information on reporting requirements can be obtained from health departmentsshould be tested for pregnancy. Early pregnancy diagnosis would benefit even women not receiving antiretroviral treatment because they could be offered treatment to decrease the risk for perinatal HIV transmission.Behavioral interventions are strategies designed to change persons’ knowledge, attitudes, behaviors, or practices in order to reduce their personal health risks or their risk of transmitting HIV to others (Table 4). Behavioral change can be facilitated by environmental cues in the clinic or office setting, messages delivered to patients by clinicians or other qualified staff on-site, or referral to other persons or organizations providing prevention services. Because behavior change often occurs in incremental steps, a brief behavioral intervention conducted at each clinic visit could result in patients, over time, adopting and maintaining safer practices. Behavioral interventions should be appropriate for the patient’s culture, language, sex, sexual orientation, age, and developmental level (44). In settings where care is delivered to HIV-infected adolescents, for example, approaches need to be specifically tailored for this age group (83). Also, clinicians should be aware of and adhere to all laws and regulations related to providing services to minors.These materials usually can be obtained through local or state health department HIV/AIDS and STD programs or from the National Prevention Information Network (NPIN) (1-800-458-5231; http://www.cdcnpin.org). Additionally, condoms should be readily accessible at the clinic. Repeating prevention messages throughout the patient’s clinic visit reinforces their importance, increasing the likelihood that they will be remembered (68).
Interventions Delivered On-Site Prevention Messages for All Patients
All HIV-infected patients can benefit from brief prevention messages emphasizing the need for safer behaviors to protect both their own health and the health of their sex or needle-sharing partners। These messages can be delivered by clinicians, nurses, social workers, case managers, or health educators. They include discussion of the patient’s responsibility for appropriate disclosure of HIV serostatus to sex and needle-sharing partners. Brief clinician-delivered approaches have been effective with a variety of health issues, including depression (84), smoking (85–90), alcohol abuse (91,92), weight and diet (93), and physical inactivity (94). This diverse experience with other health behaviors suggests that similar approaches may be effective in reducing HIV-infected patients’ transmission risk behaviors. For patients already taking steps to reduce their risk of transmitting HIV, hearing the messages can reinforce continued risk-reduction behaviors. These patients should be commended and encouraged to continue these behaviors.
General HIV Prevention Messages
Patients frequently have inadequate information regarding factors that influence HIV transmission and methods for
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preventing transmission. The clinician should ensure that patients understand that the most effective methods for preventing HIV transmission remain those that protect noninfected persons against exposure to HIV. For sexual transmission, the only certain means for HIV-infected persons to prevent sexual transmission to noninfected persons are sexual abstinence or sex with only a partner known to be already infected with HIV. However, restricting sex to partners of the same serostatus does not protect against transmission of other STDs or the possibility of HIV superinfection unless condoms of latex, polyurethane, or other synthetic materials are consistently and correctly used. Superinfection with HIV has been reported and appears to be rare, but its clinical consequences are not known (95,96). For injection-related transmission, the only certain means for HIV-infected persons to prevent transmission to noninfected persons are abstaining from injection drug use or, for IDUs who are unable or unwilling to stop injecting drugs, refraining from sharing injection equipment (e.g., syringes, needles, cookers, cottons, water) with other persons. Neither antiretroviral therapy for HIV-infected persons nor postexposure prophylaxis for partners is a reliable substitute for adopting and maintaining behaviors that guard against HIV exposure (97).
Identifying and Correcting Misconceptions
Patients might have misconceptions about HIV transmission (98), particularly with regard to the risk for HIV transmission associated with specific behaviors, the effect of antiretroviral therapy on HIV transmission, or the effectiveness of postexposure prophylaxis for nonoccupational exposure to HIV.
Risk for HIV Transmission Associated with Specific Sexual Behaviors. Patients often ask their clinicians about the degree of HIV transmission risk associated with specific sexual activities. Numerous studies have examined the risk for HIV transmission associated with various sex acts (99–113). These studies indicate that some sexual behaviors do have a lower average per-act risk for transmission than others and that replacing a higher-risk behavior with a relatively lower-risk behavior might reduce the likelihood that HIV transmission will occur. However, risk for HIV transmission is affected by numerous biological factors (e.g., host genetics, stage of infection, viral load, coexisting STDs) and behavioral factors (e.g., patterns of sexual and drug-injection partnering) (105,114), and per-act risk estimates based on models that assume a constant per-contact infectivity could be inaccurate (110,113). Thus, estimates of the absolute per-episode risk for transmission associated with different activities could be highly misleading when applied to a specific patient or situation. Further the relative risks of becoming infected with HIV, from the perspective of a person not infected with HIV, might vary greatly according to the various choices related to sexual behavior (Table 5) (115,116).
Effect of Antiretroviral Therapy on HIV Transmission. High viral load is a major risk factor for HIV transmission (117–125). Among untreated patients, the risk for HIV transmission through heterosexual contact has been shown to increase approximately 2.5-fold for each 10-fold increase in plasma viral load (126) (Table 6). By lowering viral load, antiretroviral therapy might reduce risk for HIV transmission, as has been demonstrated with perinatal transmission (127,128) and indirectly suggested for transmission via genital secretions (semen and cervicovaginal fluid) (2,129–133). However, because HIV can be detected in the semen, rectal secretions, female genital secretions, and pharynx of HIV-infected patients with undetectable plasma viral loads (16,134–137) and because consistent reduction of viral load depends on high