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2015, October 7-11
San Diego
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New US HIV Prevention Guidelines Underline Antiretroviral Use
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IDSA/IDWeek 2015, October 7-11, San Diego
Mark Mascolini
Updating 2003 US recommendations on HIV prevention, new guidelines from governmental and nongovernmental groups place new emphasis on antiretrovirals for treatment and prevention, partner services, and reproductive health and pregnancy services [1]. The 2014 update, available online [2], encourages clinical providers to offer antiretroviral therapy (ART) to everyone with HIV, regardless of CD4 count.
The revised guidelines emerged from a Centers for Disease Control and Prevention (CDC) and Health Resources and Services Administration (HRSA) Workgroup on HIV prevention, collaborating with the National Institutes of Health and five nongovernmental groups. The evidence-based guidelines target not only healthcare providers but also health departments, AIDS service organizations, and HIV planning groups. They push well beyond the scope of 2003 HIV prevention guidelines.
Much of the new advice focuses on use of antiretrovirals--as therapy, preexposure prophylaxis (PrEP), or postexposure prophylaxis (PEP)--to prevent HIV transmission between partners. Specific recommendations include:
-- Inform all persons with HIV about the benefits of early ART to improve health, increase longevity, and reduce transmission -- Offer ART to all patients regardless of CD4 count, according to latest DHHS recommendations -- If a patient declines or stops ART, periodically reoffer ART -- Support care retention and long-term ART adherence -- Strategies to support retention and adherence include simplified regimens and advice on managing ART dosing and costs -- Encourage adherence by informing patients about pill boxes, reminder systems, and support from family or friends -- Encourage adherence by managing side effects, drug supply, missed doses, and interactions with other drugs or substances -- Engage services that can improve adherence, such as mental health and housing services -- Consider more intensive interventions for patients with low adherence -- Inform patients about PrEP and PEP for their HIV-negative partners -- Explain where HIV-negative partners can be evaluated for clinical indications for PrEP and PEP -- Note that PrEP and PEP may not eliminate all risk of HIV infection
The new guidelines also break new ground in encouraging clinical providers to collaborate with AIDS service organizations and health departments "to promptly initiate HIV care with expedited appointments, welcoming intake, and help enrolling in insurance or assistance programs." The guidelines advise clinicians to track linkage and retention outcomes and to provide follow-up assistance when possible, for example, through appointment reminders and transport assistance.
The new recommendations expand advice on HIV partner services, emphasizing key points including:
-- Identify HIV-positive patients who need expedited services, such as those with acute infection and the newly diagnosed
-- Explain voluntary, confidential health department partner notification services
-- Promptly refer for health department assistance to supplement partner services
-- If a patient is exposed to a partner with a sexually transmitted disease (STD), immediately provide presumptive STD therapy
-- Screen partners for HIV, STDs, and viral hepatitis
Corollary advice on STD preventive services includes (1) informing patients that some STDs can increase HIV load or shedding, (2) assessing sexual risk behaviors, (3) regularly screening genital and extragenital sites for STDs, and (4) screening sexually active patients at least annually, including gonorrhea, chlamydia, syphilis, and HSV-2 for men, and those STDs plus trichomonas for women. The new recommendations also cover reproductive health counseling, family planning, special conception methods, and "pregnancy services that reduce sexual and perinatal HIV transmission."
The guideline writers stress that providers who review and implement recommendations in the 2014 guidelines "can advance goals of the National HIV/AIDS Strategy," which are to "prevent new HIV infections and reduce HIV-related illness and health disparities."
1. Irwin K, Robilotto S, Erbelding E. 2014 Federal recommendations for HIV prevention with persons with HIV: a new road map for high impact prevention. IDWeek 2015, October 7-11, San Diego. Abstract 117.
2. Centers for Disease Control and Prevention. Recommendations for HIV prevention with adults and adolescents with HIV in the United States, 2014. http://stacks.cdc.gov/view/cdc/26062