Despite substantial advances in the treatment of human immunodeficiency virusAIDS/HIV infection, the estimated number of annual new HIV infections in the United States has remained at 40,000 for over 10 years. HIV prevention in this country has largely focused on persons who are not HIV infected, to help them avoid becoming infected. However, further reduction of transmission of HIV will require using some new strategies, including more emphasis on stoping transmission of HIV. HIV-infected persons who are aware of their HIV infection tend to reduce behaviors that might transmit HIV to others. Nonetheless, recent reports suggest that such behavioral changes often are not maintained and that a substantial number of HIV-infected persons continue to engage in behaviors that place others at risk for HIV infection.

Reverting to risky behavior can be as important in the transmission of HIV as the orignal failure to adopt safer sex practices. Unprotected anal sex seems to be happening more often in some urban centers, especially amoung young men who have sex with other men. Bacterial and viral sexually transmitted diseases (STDs) in HIV-infected men and women receiving outpatient care have been increasingly noted, indicating ongoing risky behaviors and opportunities for HIV transmission. Despite the decline in syphilis infection rate in the general U.S. population, continued outbreaks of syphilis in MSM, many of whom are co-infected with HIV, continue to happen in some areas; rates of gonorrhea and chlamydial infection have risen in this population as well. Rising STD rates among MSM indicate increased potential for HIV transmission, both because these rates suggest ongoing risky behavior and because STDs have a synergistic effect on HIV infectivity and susceptibility. Studies suggest that optimism about the effectiveness of highly active antiretroviral therapy (HAART) for HIV may be contributing to relaxed attitudes toward safer sex practices and increased sexual risk-taking by some HIV-infected persons.

Drug use still continues to play a big role in the HIV pandemic; 28% of HIV/AIDS cases in adults and adolescents with known HIV risk category report to the CDC in 2000 were associated with needle drug use. In some drug using communites, HIV seroincidene and seroprevalence in injection drug users has declined recently. This decline has been attributed to several factors, including increased use of sterile injection equipment, declines in needle-sharing, shifts from injection to noninjection methods of using drugs, and cessation of drug use. Injection drug use amoung heroin users has helped to increase HIV infection substantially in some areas, serving as a reminder that avoiding all high risk behavior is important.

Clinicians providing medical care to HIV-infected persons can play a key role in helping their patients reduce risk behaviors and maintain safer practices and can do so with a feasible level of effort, even in constrained practice settings. Clinicians can greatly affect patients' risks for transmission of HIV to others by performing a brief screening for HIV transmission risk behaviors; communicating prevention messages; discussing sexual and drug-use behavior; positively reinforcing changes to safer behavior; referring patients for such services as substance abuse treatment; facilitating partner notification, counseling, and testing; and identifying and treating other STDs. These measures may also decrease patients' risks of acquiring other STDs and bloodborne infections (e.g., hepatitis). Managed care plans can play an important role in HIV prevention by incorporating these recommendations into their practice guidelines, educating their providers and enrollees, and providing condoms and educational materials. In the context of care, prevention services might be delivered in clinic or office environments or through referral to community-based programs. Some clinicians have expressed concern that reimbursement is often not provided for prevention services and note that improving reimbursement for such services might enhance the adoption and implementation of these guidelines.

Tags: HIV Transmission, substantial advances, behavioral changes, sex with other men, Health, HIV prevention, HIV, AIDS