hiv prevention guidelines

The International AIDS Society-USA just published guidelines regarding hiv prevention (see hiv prevention 

guidelines 2014 jama in dropbox, or doi:10.1001/jama.2014.7999). recommendations:

Testing:

    --all adults and adolescents should be offered HIV screening at least once [of note, we have found an HIV-

positive Cape Verdean couple >70yo in our clinic...]

    --evaluate risk periodically to determine if more frequent testing is warranted

    --testing with informed consent, according to individual patient's needs (ie tailored, not

 formulaic approach...). should (obviously) honor patient's right-to-refuse testing, but this should be 

documented

    --use rapid testing, esp in patients less likely to return for their results

    --consider home testing for those with recurrent risks, difficulty in testing in clinical site

Prevention, for HIV-positive people:

    --educate patient about personal benefits of ART (anti-retroviral therapy), as well as public health benefits (treatment as prevention) in decreasing spread of virus

    --offer ART to all people at time of detection of virus regardless of CD4 count (see next blog on HIV therapy)

    --important to have structures in place to improve med adherence, give support/appropriate services to patient to help with med adherence, case management, health care system navigation, peer outreach.... as indicated

    --counsel on risk reduction: regular assessment of sexual/substance use practices, with risk-reduction counseling (and testing for sexually-transmitted infecions --STI's, etc). needle-exchange program referrals if appropriate

    --offer partner notification [which may be done through the state or local public health commission]

Prevention, for HIV-negative people:

    --regular risk assessment, with risk-reduction counseling for those at high risk

    ​--daily pre-exposure prophylaxis with FTC/TDF (equivalent of Truvada) shold be offered to those:

            --at high risk (where background incidence of hiv >2%, or recent STI--esp GC, chlamydia, syphilis)

            --persons who have used post-exposure prophylaxis >2x in past year

            --people who inject drugs and share equipment, inject >1x/day, or inject cocaine or methamphetamines

    ​--the issue with pre-exposure prophylaxis in the studies is medication adherence, which is not great even in the studies (and likely to be less so in the community). [makes sense to me that these people should be counseled about med adherence and followed closely. one concern is inadequate treatment, low medication

 levels and developing resistance if they get HIV. notably, oral tenofivir alone seems to work well and 

saves developing resistance from FTC/3TC.  studies ongoing. also vaginal tenofivir may be useful.]

    --continue to assess risk if on pre-exposure prophylaxis. if, perhaps because of ongoing risk reduction counseling, the patient's risk changes, may be able to stop the prophylaxis

    --consider in HIV-negative partner in HIV-discordant couples, considering whether the viral load is suppressed (though i think people should be aware of the small but existent transmission rate in those virally suppressed, at least in a couple of studies)

    --HIV testing/symptom check for acute HIV should be done prior to starting pre-exposure prophylaxis (to avoid undertreating a real infection and developing resistance). also check creatinine before given med [they do not give further medication recommendation, since inadequate studies on other meds. tenofivir has significant renal toxicity. both it and FTC or 3TC need renal dosing]. should also check hepatitis B status, since tenofivir has significant efficacy against hep B [and stopping the tenofivir can lead to hep B flares]

Post-exposure prophylaxis:

    --offered to all who have sustained mucosal or parenteral exposure to HIV from known source, as soon as possible and preferably within 72 hours

    --give meds suggested by US Public Health Service (at this time, TNF/FTC/raltegravir)

    --women should be offered emergency contraception if needed to prevent pregnancy

    --do HIV testing 3 months after completing the meds

Voluntary male circumcision:

    --"should be recommended to sexually active heterosexual males for the purpose of HIV prevention, especially in areas with high background HIV prevalence" [all of these recommendations are in parentheses, since all the studies were done in 

Africa and their generalizability​ is unclear to me.             ​though in Africa circumcision reduces heterosexual hiv acquisition by 50-60%, and this is durable on a population-basis at least for a couple of years]

    --"should be discussed with men who have sex with men and who engage in primarily insertive anal sex, particularly in settings of high HIV prevalence"

    --"parents and guardians should be informed of the preventive benefits of male infant circumcision"

Prevention relevant to all persons at risk for HIV infection:

    --routine and periodic screening for STIs at appropriate anatomical sites

    --test HIV-positive people for hep C at entry to care and regular intervals [they include those with high risk sexual practices, though the risk of hep C transmission through sex is low]

    ​--offer HPV vaccine to all HIV-infected people [this is a bit misleading. though the say "should be offered routinely", they reference the new ACIP guidelines, which target both males and females only up to 26 years old]

    --check for hep B status and immunize if appropriate

    --"routine screening for HSV-2 should be considered for HIV-infected persons who do not know their HSV-2 serostatus and wish to consider suppressive antiviral therapy to prevent transmission of HSV-2"

so, pretty reasonable. have included a few comments above.