Prevention efforts to halt the spread of HIV traditionally focused on HIV-negative individuals.
But according to the Centers for Disease Control and Prevention, a strategy centered solely on HIV-negative persons is not enough to stop HIV transmissions. The Atlanta-based CDC says it is crucial to include HIV-positive persons in efforts to reduce the risks of transmitting HIV.
POZ Magazine (Jan. 2015) reported the CDC accented the “centrality” of HIV-positive people to prevention efforts because targeting them is more probable in reducing HIV incidence than working to change the behaviors of millions who are at risk for infection.
The AIDS Education and Training Center (AETC) Program, the training arm of the Ryan White HIV/AIDS Program, informs the rate of new HIV infections in the United States has remained in the stable range of 50,000 per year. Antiretroviral therapy (ART) – sometimes referred to as highly active antiretroviral therapy (HAART) – improves the health of HIV-positive individuals who are in appropriate medical care and lowers the risks of HIV transmission.ART reduces the HIV viral load, which can prevent new infections, an outcome termed “treatment as prevention.”
It is important to understand that maximal suppression of the HIV viral load does not mean one is cured of HIV. The CDC defines viral load suppression as less than 200 copies per milliliter of blood; an HIV-positive person is considered “undetectable” when the HIV viral load is less than about 40 copies per milliliter of blood. Current medical literature indicates there has never been a recorded case involving an undetectable HIV-positive person transmitting HIV.
Unfortunately, not all HIV-positive Americans are taking antiretroviral therapy, which means many people have yet to achieve maximal suppression of their viral load. Clearly, other risk reduction and behavioral modification methods are needed in the fight to prevent new HIV infections.
The clinical interaction with HIV-positive persons about transmission risk behaviors with the goal of reducing HIV transmission is referred to as “prevention with positives” (PWP).
While many people with HIV infection have a real desire to prevent others from being infected with HIV, it can be challenging for some people to disclose their HIV+ status when engaging in high-risk behaviors that could place others at risk for infection. HIV-positive individuals who repeatedly present with sexually transmitted infections may be placing themselves and others at additional health risks, as STIs are often accompanied by increased risk for HIV transmission. In these cases, information alone may not be enough to change risky behaviors in sexual practices or drug use. Personal conversations involving a harm-reduction approach may provide clear concepts of the risks of certain behaviors and strategies on how to reduce those risks or avoid them completely.
Some HIV-positive persons may have trouble sticking with their safer goal behaviors; a referral to a mental health clinician or to prevention case management could be beneficial. A mental health assessment can reveal disorders that can increase the chances of risky sexual and drug use behaviors. Health care providers can counsel an HIV-positive person to understand risk and to work to modify harmful behaviors to self and to others.
What is involved in “prevention with positives?”
The CDC now counsels health care providers to encourage their HIV-positive patients to begin ART within three months of diagnosis, regardless of CD4 count. The chance of an HIV-positive individual transmitting the HIV virus is virtually eliminated when ART treatment is successful and an undetectable viral load has been achieved.
There can sometimes be interruptions in a person’s medical care. These gaps may be created by personal patient circumstances such as mental health issues, substance abuse, or lack of financial resources. Maintaining consistent contact with a healthcare provider is key when a person is trying to suppress their viral load. Many HIV services now have a component designed to helping clients with multiple barriers stay active in care. (Having not referenced the cascade until now, it might be better not to bring it up, as it is rather an in-depth topic.)
Partner notification may be one of the most difficult issues for the HIV-positive individual. HIV service professionals (that is a big word for people not in the field) can help patients who are newly diagnosed by offering confidential partner notification – helping disclose to partners who might have been exposed with or without the patient present. Generally, HIV Testing counselors help clients identify which option works best for them.
Health professionals are advised by the CDC to assist people with HIV in finding insurance. Providers are also urged to counsel HIV-negative patients about pre-exposure prophylaxis (PrEP) and post-exposure prophylaxis. When someone tests positive at an AIDS Service Organization here, they are immediately linked to case managers that will assist them in securing the necessary resources they will need to initiate and remain engaged in care.
If you have questions about PWP, I encourage you to contact your health care provider.