Addressing Appropriate Use of Barrier Methods to Prevent HIV Infection

Addressing Appropriate Use of Barrier Methods to Prevent HIV Infection
Condom
Although use of condoms is known to reduce the risk of HIV infection, physicians perform poorly at assessing whether patients use condoms. One study showed that 94% of physicians asked patients about tobacco use, yet only 31% asked about condom use.(57) Whereas assessing condom use is a critical component for developing any prevention strategy, this assessment also should include education in proper condom use techniques to reduce the risk of condom failure. Condom failure rates are approximately 2%, with 15% of MSM in cohort studies reporting at least 1 condom failure in the prior 6 months.(58) Lack of lubricant use, use of amphetamines, and heavy alcohol use are associated with condom failure. Providers also should discuss alternatives to conventional condoms. The "female" condom, used by the vaginal or anal receptive partner, may be a reasonable alternative barrier method. Acceptability of female condoms varies, with women generally reporting a higher acceptability rating for heterosexual intercourse compared with MSM engaging in anal intercourse.(59,60) Female condoms have not been approved by the U.S. Food and Drug Administration (FDA) for anal intercourse, and their cost (as much as $2 each) will limit their use by some individuals.
Nonoxynol-9 and Other Microbicides
Nonoxynol-9 (N-9) is a spermicide added to many lubricants intended for use during anal and vaginal sex. Based on information disseminated early in the AIDS epidemic, many people actively seek out products containing N-9 in the belief that they protect against HIV infection; in one study, 54% reported actively seeking out such products.(61) However, results from recent efficacy studies in heterosexuals indicate that N-9-containing products actually may increase risk of HIV infection.(62) As a result, the San Francisco Department of Public Health no longer recommends that persons use N-9-containing products. Trials are under way to assess the safety and efficacy of other microbicides for vaginal and penile use,(63) but no products currently are FDA approved.

Does Counseling HIV-Infected Persons Lead to Lower-Risk Behavior?

Does Counseling HIV-Infected Persons Lead to Lower-Risk Behavior?
Counseling interventions have been shown effective in reducing self-reported risk behavior of HIV-infected persons, with studies indicating that interventions lead to significant reductions in both unprotected anal intercourse and numbers of sexual partners.(27,39,40) Clinician-based counseling to encourage behavior change has been highly effective in reducing tobacco and alcohol use.(41) Studies examining the efficacy of medical provider counseling have shown reductions in sexual risk behavior among specific groups of HIV-infected patients, although limitations in study design prevent definitive conclusions about the effect of such interventions.(42-45) Richardson et al found that brief prevention counseling delivered by a physician was effective in reducing unprotected anal or vaginal sex among HIV-infected individuals who reported 2 or more partners.(45) In addition, the degree of behavior change necessary to reduce HIV infection rates remains to be determined. In the EXPLORE study, for instance, despite a 20% reduction in serodiscordant unprotected intercourse in the intervention arm, HIV seroincidence was not significantly different among persons in the intensive behavioral intervention arm compared with persons in the standard counseling and testing arm.(10) Research in this area is ongoing and will provide further evidence and direction to clinicians on the most effective approaches to use with patients engaging in high-risk behavior. In particular, the acceptability and feasibility of conducting prevention intervention among HIV-positive patients in a nonresearch context has yet to undergo careful evaluation.
When engaging patients in discussions about reducing behaviors with the potential to transmit HIV, clinicians should consider adapting the conceptual framework from the general theory of behavior change used in the above trials, asking patients:
How important is it to you to reduce your risk behavior?
How confident are you that you can change your behavior?
How ready are you to change your behavior?
In contrast to counseling that promotes behaviors to improve a patient's own health, counseling HIV-positive patients about the risk of sexual transmission emphasizes changing behavior to protect others from infection. This may present a conflict for the clinician, yet HIV-positive patients themselves may derive health benefits from changes in transmission risk behaviors associated with sex or drug use. These potential health benefits include reduced likelihood of contracting other STDs and, possibly, reduced potential for superinfection with drug-resistant HIV. By engaging patients in frank discussions about the risks of HIV transmission, their current risk behavior, and factors associated with increased risk, providers can begin to tailor risk-reduction strategies based on patients' needs and desires. The following sections address issues that should be discussed with patients, over a series of visits, to assess risk fully and to help patients develop strategies for behavioral change. After the initial assessment, the provider should reassess frequently to determine if behaviors have changed or if there are new factors influencing risk.
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Many HIV-Positive Persons Continue to Engage in High-Risk Behaviors

Many HIV-Positive Persons Continue to Engage in High-Risk Behaviors

Although a desire to protect sexual partners is a major reason for condom use among all HIV-infected risk groups, research has consistently demonstrated that many HIV-infected persons continue to engage in high-risk sexual behaviors that may transmit HIV, despite knowledge of their HIV infection. Across studies of HIV-positive MSM, women, and IDUs, between 17% and 38% report unprotected vaginal or anal intercourse (many as recently as their last sexual encounter) with partners who are HIV negative or of unknown HIV status.(22-27)

High-risk sexual behavior among HIV-infected persons is not limited to interactions with casual or anonymous partners. Multiple studies have found that safer sex precautions are less likely to be adopted in relationships characterized by affection and in ongoing sexual relationships than in casual or transient partnerships.(28-31) This pattern has been found not only in the case of monogamous serodiscordant male couples, but also among affectionate relationships that are not mutually exclusive and in which partners do not know each other's serostatus.(32,33) In one analysis of couples in serodiscordant relationships, 31% reported unprotected anal sex with their primary partner at least once in the past 12 months. This behavior may put heterosexual women especially at risk, as they are more likely than other groups to have a single high-risk partner rather than multiple partners.(34)

Patterns of risk behavior also may vary by the stage of HIV infection and knowledge of infection status. A metaanalysis of high-risk sexual behavior among persons infected with HIV found that prevalence of high-risk behavior was 68% lower in HIV-positive persons aware of their status than in persons unaware of their status.(35) Several studies have suggested that HIV-positive persons go through a period of sexual abstinence as they adjust to their infection status, but later resume their sexual activity.(36,37) However, one study of newly infected persons found that 11% reported unprotected insertive anal sex and 26% reported unprotected receptive anal sex with unknown-serostatus or HIV-negative partners within a 6-month period after infection, suggesting a need to address behavior change early following the diagnosis of HIV infection.(38)

The origin of AIDS and HIV

In the United States, HIV Incidence Rates Remain High among Men Who Have Sex with Men, and within Some Communities of Heterosexual Women

HIV infections rates among men who have sex with men (MSM) remain high, and MSM continue to account for the largest proportion of new HIV infections in the United States. In San Francisco, estimates of infection rates among MSM increased from 1.1/100 person-years in 1997 to 2.2/100 person-years in 2000. HIV incidence was 5.3% among MSM seeking sexually transmitted disease (STD) services.(7) These high rates are reported despite other evidence that HIV infectivity declined by as much as 60% among MSM in San Francisco following the introduction of highly active antiretroviral therapy (ART).(8) The CDC Behavioral Surveillance Survey, a probability-based survey of MSM in urban venues, reported HIV incidence rates ranging from 1.2% to 8% in urban settings in the United States.(9) The EXPLORE study of high-risk HIV-uninfected MSM in 6 U.S. urban centers enrolled between 1999 and 2001 and followed for up to 4 years reported an HIV incidence of 2.1%.(10) Young men of color may be at especially high risk for infection: a large urban study of MSM <22 years of age found that HIV infection rates among Latino and black participants were 2.3 times and 6.3 times higher, respectively, than those of white MSM.(11,12) The study by Valleroy et al also found that 82% of the HIV-positive young men were unaware that they were HIV infected, suggesting a need to emphasize frequent testing among this population.(11)

Among women, blacks and Latinas are at continued high risk for HIV infection.(13) It is estimated that 3 out of 10 new HIV cases in the United States will occur in women. Among new HIV cases reported in 2001, women accounted for 56% of cases among those 13-19 years of age, 36% of the cases in those 20-24 years of age, and 37% of all cases.(14) It appears that young women are at least as likely as young men to become HIV infected. Most striking in these statistics is the fact that two thirds of women becoming infected with HIV in the United States are black, and nearly 20% are Latina. Among 33 states with HIV reporting, 50% of newly diagnosed HIV infections occurred in blacks.(15)

Among populations of injection drug users (IDUs), HIV incidence appears to be in decline in some U.S. cities.(16,17) The availability of needle exchange programs, clean injection equipment, and community outreach to IDUs has contributed to this decline.(18) Recent analyses of HIV transmission behavior among IDUs suggest sexual risk behavior as the main contributor driving new infections, and that HIV seroconversion among IDUs is now being fueled by men having sex with men, and by women trading sex for money or drugs.(19,20) Demographic trends of HIV incidence among IDUs are similar to those among non-IDU MSM and women, with HIV becoming overrepresented among black and Latino IDU populations.(21) Among women, 70% of those who reported their risk as heterosexual contact identified their male partners as IDUs, and among male IDUs, 54% were black.(15)