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Prevention of HIV Infection
Because a large portion of patients infected with HIV are unaware of their infection, it is important for primary care doctors to screen patients. The UPSTF and CDC recommend screening for HIV in adolescents and adults aged 15 to 65 years and in pregnant women at least once regardless of perceived risk factors. Patients should be tested unless they decline (opt-out testing). Younger adolescents and older adults who are at an increased risk of infection should also be tested for HIV.17,18 Primary care doctors should also incorporate into practice available therapies for prevention primarily through education of safe sex practices, information regarding needle sharing, and, most notably, preexposure prophylaxis.
It is important for primary care physicians to conduct a thorough, nonjudgmental assessment of their patients to determine risk factors for HIV infection. Patients at increased risk for HIV infection include those with a history of intravenous drug abuse, sexually transmitted diseases, and receipt of blood products between 1977 and 1985. Men who have had sex with men, sex workers, and heterosexual persons with more than one partner since their last HIV test are also considered to be at high risk, as are the sexual partners of high-risk or HIV-infected persons. Mental illness and incarceration may serve as markers for high-risk behavior, as does a history of hepatitis B or C infection. Persons who consider themselves at risk should be tested even if their risk behaviors are not disclosed.
Preexposure Prophylaxis
Preexposure prophylaxis is defined as the use of antiretroviral medication to reduce the risk of HIV transmission in sexually active adults who are HIV-negative and at an increased risk of acquiring HIV. Currently, the only FDA-approved therapy for preexposure prophylaxia is the daily oral use of combination of tenofovir 300 mg and emtricitabine 200 mg (Truvada).27
Preexposure prophylaxis is currently recommended in several patient populations including women who have sex with HIV-positive men, men who have sex with men who are at a high risk of contracting HIV, heterosexual sexually active men and women at an increased risk of HIV, and in adult intravenous drug users at high risk of acquiring HIV. High-risk behaviors include high number of sexual partners, HIV-positive partner, inconsistent condom use, commercial sex work, recent STI, and those living in a high-prevalence area or network.27 Those who abuse intravenous drugs are considered at high risk if they share injection materials or have undergone recent treatment for addiction. Preexposure prophylaxis is not currently approved for the adolescent population because of insufficient evidence regarding safety and efficacy. Preexposure prophylaxis can be offered once an HIV test is documented negative and a review of the patient’s medication list, renal function, and hepatitis B status shows no contraindications. In addition, a clinical exam would be assessed for signs of acute HIV infection.
Guidelines recommend screening patients on preexposure prophylaxis for HIV infection every 3 months to prevent inadequate treatment in the event of HIV acquisition particularly because this may result in increased resistance to either or both medications.27 It is also recommended that the patient is counseled every 3 months regarding medication adherence, pregnancy intent, and risk reduction in order for preexposure prophylaxis to be used in combination with other means of HIV prevention.
