Step 1: Screen Patients for Risk Behaviors   TOP

• Behaviors and clinical factors associated with HIV, other STDs, and
  IV drug use (every visit)
• STD symptoms: most are asymptomatic (every visit)
• Pregnancy
• Screening tests

* Repeat RPR or VDRL annually. Consider repeating screening tests for N. gonorrhea and C. trachomatis annually or more frequently if sexually active, if screening previous test positive, or other high risk

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Step 2: Behavioral Interventions   TOP

• Prevention messages should be provided with each visit
• Communicate factors that influence transmission and risk reduction; i.e. abstinence, sex with condoms, sex exclusively with HIV-infected person(s). If sex with persons with unknown or negative serologic status, stress proper condom use.
• IDU
  • Stop using drugs
  • Enter substance abuse treatment
  • If patient continues to use drugs:
    • Never reuse or share needles, water, or drug preparation
      equipment
    • Use only syringes from reliable sources (pharmacies)
    • Use new syringe; if not possible-boil or disinfect with bleach
      (http://www.cdcnpin.org)
    • Use sterile water to prepare drugs; otherwise use tap water
    • Use new or disinfected cooker and new cotton
    • Clean injection site with new alcohol swab
    • Safely dispose of needle
• Per act relative risks of HIV transmission
  • Condom vs no condom: 1:20
  • Compared to insertive vaginal sex: receptive vaginal sex 2:1,
    receptive anal sex 10:1, insertive fellatio 1:10, insertive anal sex
    1.3:1, receptive fellatio 1:5 (STD 2002;29:38)
    Note: Risks for condom use and acts are multiplicative; e.g, for
    the ratio for anal sex without a condom vs vaginal insertive sex
    with a condom is 100:1
• Viral load: each log₁₀ reduction in viral load reduces probability of transmission 2.5 fold
• Non-occupational postexposure prophylaxis: not endorsed by CDC due to “uncertain effectiveness”
• HAART recipients: decreases in VL probably reduces but risk transgression in behavior eliminates this benefit; with structured treatment interruption, warn patient that viral load increases as does risk of transmission

Step 3: Partner Counseling and Notification   TOP

• Laws: Follow local and state laws for reporting sex and needlesharing partners
• Initial Visit: Ask if all sex and needlesharing partners have been notified
• Follow-ups: Ask about new sex or needlesharing partners who have not been notified
• Referrals: All contacts should be referred to the Health Department; arrange for notification and testing without identifying source; patients who elect not to notify partners should be referred to the Health Department to conduct these activities