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Position paper: HIV prevention

An estimated 40,000 new individuals are infected with HIV annually in the United States.¹ While the overall number has remained stable since the early to mid 1990s, racial and ethnic minorities, women, and youth have been disproportionately affected.^2,3 With major vaccine and universally available treatment breakthroughs possibly years away, health care providers and policymakers still view prevention as the most effective weapon against the virus. Education also is the only weapon available to fight the discrimination suffered by individuals infected with the virus.^4-6

The AAPA believes that physician assistants should take an active role in preventing HIV transmission by counseling their patients about behaviors that could expose them to HIV and about ways to reduce or eliminate the risk of exposure. In particular, sexually active adolescents and patients being treated for other sexually transmitted diseases should be counseled about risk reduction. The counseling should include information on abstinence and the availability of condoms and their appropriate use for HIV prevention. The AAPA encourages PAs to support community programs that provide easy access to condoms and urges PAs to consider distributing condoms in their practices. If PAs or their practices choose not to make condoms available to minors without parental consent, they should at least inform their patients about where condoms are available.

PAs should strongly encourage patients who abuse drugs or alcohol to enter treatment programs. The AAPA encourages PAs to counsel and educate drug-injecting patients who are unwilling to enter or unable to gain access to treatment programs about where to obtain clean needles and syringes. Clean injection equipment is available either through established exchange programs or over-the-counter in states where such sales are legal. PAs also should teach patients who inject illegal drugs the proper disinfection methods for the successful sterilization and use of injection equipment, and about safer sexual practices to help them avoid contracting or spreading the AIDS virus. Related AAPA policy, “Needle/Syringe Access for the Prevention of HIV Transmission,” supports needle/syringe exchange and access programs as among the effective measure for stemming the spread of the epidemic.⁷

Routine screening for HIV can also play an important role in preventing the spread of the virus. In September 2006 the Centers for Disease Control and Prevention (CDC) released Revised Recommendations for HIV Testing of Adults, Adolescents, and Pregnant Women in Health-Care Settings. These recommendations call for routine screening of patients age 13-64. They recommend that screening be voluntary, with consent being done as part of the general consent given for medical care. Patients may opt not to have the test after notification that it will be performed. The recommendations state that prevention counseling should not be required as part of testing. Additional recommendations are given for testing of high risk individuals and pregnant women.⁸

According to the CDC, evidence suggests that as many as two-thirds of new HIV infections diagnosed each year are the result of exposure to HIV infected individuals who were not aware that they have the virus. The CDC says that new infections could be reduced by better detection programs.

In 2004, 39 percent of individuals diagnosed with AIDS first tested positive for HIV within one year of diagnosis. This suggests that these individuals were HIV positive for a number of years prior to diagnosis. During that time, they were at risk for unknowingly transmitting the virus to others. In addition, the lack of knowledge of their positive HIV status prevented them from receiving early access to medical therapy. Survival rates from HIV infection have improved dramatically with the availability of HAART, but early treatment is essential to optimizing care.

Specialized counseling and consent requirements have become barriers to health care providers recommending HIV screening. Testing programs that rely on screening for risk factors miss a large number of HIV positive patients. Making HIV screening routine will reduce the stigma associated with testing.

Routine screening of pregnant women has shown that patients will accept screening when recommended by their health care providers. The combination of widespread prenatal screening and use of preventive interventions reduced the incidence of perinatal transmission of HIV by 95 percent between 1992 and 2004.⁹

The CDC has stated that routine screening for HIV is as cost effective as screening for other diseases such as hypertension, or breast and colon cancer. Because of the benefits attributed to early treatment, screening is cost effective even without taking into account the public health benefit of reducing transmission.

It will take time for federal and state laws and regulations to change. Physician assistants are encouraged to follow the CDC recommendations for routine testing. PAs must still adhere to current laws regarding counseling and testing. It is important to remember that moving away from specialized counseling and explicit written consent for HIV testing does not eliminate the need for talking with patients. Informed consent is part of any medical treatment or testing. Counseling patients on risk reduction and a healthy lifestyle remains an important part of preventive healthcare.

Because of the benefit both to the individual patient and to public health, AAPA supports routine HIV testing for all adolescents, adults, and pregnant women in health care settings as recommended by the Centers for Disease Control and Prevention (CDC). All physician assistants should be familiar with the CDC recommendations and incorporate them into their clinical practice.

In summary, the American Academy of Physician Assistants believes that

• Routine screening, education, and behavioral change are the best tools currently available to prevent the spread of HIV.

• Physician assistants should counsel their patients about behaviors that could expose them to HIV and about ways to reduce or eliminate their risk of exposure.

• The AAPA encourages PAs to support community programs that provide easy access to condoms and urges PAs to consider distributing condoms in their practices.

• The AAPA supports routine HIV testing for all adolescents, adults, and pregnant women in health care settings as recommended by the Centers for Disease Control and Prevention.

• All physician assistants should be familiar with the CDC recommendations for HIV testing of adults, adolescents and pregnant women and incorporate them into their clinical practice. JAAPA

REFERENCES

	1.	Centers for Disease Control and Prevention. CDC HIV/AIDS Fact Sheet: A Glance at the HIV/AIDS Epidemic. June 2007. http://www.cdc.gov/hiv/resources/factsheets/PDF/At-A-Glance.pdf.
	2.	CDC. Office of Minority Health and Health Disparities. Eliminate Disparities in HIV and AIDS. June 5, 2007. http://www.cdc.gov/omhd/AMH/factsheets/hiv.htm.
	3.	CDC. CDC HIV/AIDS Fact Sheet: HIV/AIDS among Youth. June 2006. http://www.cdc.gov/hiv/resources/factsheets/youth.htm.
	4.	Institute of Medicine. No Time to Lose: Getting more from HIV Prevention. Washington, DC: National Academy Press; 2001. http://books.nap.edu/html/no_time_to_lose/reportbrief.pdf and http://www.nap.edu/catalog.php?record_id=9964.
	5.	Kaiser Family Foundation. Spotlight: Attitudes about Stigma and Discrimination Related to HIV/AIDS. August 2006. http:// www.kff.org/spotlight/hivstigma/upload/Spotlight_Aug06_Stigma-pdf.pdf.
	6.	KFF. Spotlight: The Public’s Knowledge and Perceptions about HIV/AIDS. August 2006. http://www.kff.org/spotlight/hiv/upload/Spotlight_Aug06_Knowledge.pdf.
	7.	Needle/Syringe Access for the Prevention of HIV Transmission. Alexandria, Virginia: American Academy of Physician Assistants; 2003.
	8.	CDC. Revised Recommendations for HIV Testing of Adults, Adolescents, and Pregnant Women in Health-Care Settings. MMWR Recomm Rep. 2006;55(RR14):1-17.
	9.	CDC. Reduction in Perinatal Transmission of HIV Infection – United States, 1985-2005. MMWR Morb Mortal Wkly Rep. 2006;55(21):592-597.