Prevention with Positives:
Theory into Practice
Joseph McGowan, MD
Sanjiv Shah, MD
North Shore University Hospital
May 2007
Please do not reproduce without permission
of authors: sshah2@nshs.edu
Other Resources
 Prevention
in Positives: A Case Based
Workshop for Providers (Shah, McGowan
and Young, 2005)
 New York/New Jersey AIDS Education
and Training Center
(http://www.nynjaetc.org/)
Case Presentation
• 43 year old female, diagnosed with HIV and
HCV in 2004.
• CD4 count is > 500 and VL 45,000, ART naïve.
• Married last year to her partner of 3 years who
tested HIV negative 4 months ago. Partner is
aware of patient’s HIV positive status.
• They are sexually active and do not use
condoms.
Case Presentation (2)
• Patient’s partner believes that since they have been
sexually active for 3 years and he has not contracted
HIV by now, there is little chance of him getting HIV
at this point.
• Both partners have expressed the concept that
women can’t spread HIV readily to men
• What type/frequency of sexual activity do the couple
engage in?
• Should the patient start treatment now to lower her
risk of transmission in spite of her high CD4 count?
• How can HIV risk behavior be reduced in a
monogamous relationship?
Background
• Persons with HIV infection are the source of
HIV transmission in the community
• Transmission occurs from both those who
know their serostatus and those who are
unaware
• Risk of transmission may increase as
prevalence of HIV rises due to stable infection
rate and decreased mortality
Background: HIV Transmission
among Known Seropostives
• Potentially greater risk of transmission of multidrug
resistant HIV from individuals who know their status,
and have virologic failure on antiretroviral therapy
• Length of time of seropositivity and perceived health
of the individual increases opportunity for
transmission (McGowan, et al, CID, 2004)
• Research indicates that approximately one third of
HIV+ persons engage in behavior that place
uninfected individuals at risk for infection (Fisher, J,
et al, JAIDS, 2006)
HIV Transmission Risk Behavior
among Seropositives
• Among 3,723 HIV+ individuals (1918 MSM, 978
women, 827 heterosexual men) interviewed in 4 US
cities about HIV risk activity within the preceding 3
months:
• 44.7% of MSM engaged in unprotected sex (15.6% with
HIV-/unknown partner)
• 36.5% of women engaged in unprotected sex (19% with
HIV-/unknown partner)
• 34% of heterosexual men engaged in unprotected sex
(13.1% with HIV-/unknown partner)
• Estimated 30.4 new infections would be expected
among these sex partners in this 3 month period
Weinhardt, et al, JAIDS, 2004
Sexual Behaviors of HIV+ Men and Women
Following Release from Prison
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Study conducted within North Carolina State prison system
64 HIV+ (59% F), scheduled for release within 3 months, agreed to
interview within 30-45 days of release
47% reported having sex after release
56% with regular partners believed their partners to be HIVseronegative
33% with a regular partner reported UPS with HIV-seronegative
partners
44% of the pre-releases were first diagnosed in prison
Secondary risk reduction strategies including lectures given by
correctional nurses and health care providers
Stephenson BL, et al. Int J of STD/AIDS, Feb 2006
Some Factors Affecting
HIV Risk Behavior
• Rise in STDs among MSMs, linked, in part, to
crystal meth use
• Decreased concern about HIV transmission risk
due to HAART use among HIV+ MSM
associated with increased sexual risk taking
(Ostrow et al, AIDS, 2002)
• HIV transmission behavior among MSM may be
linked to spread of HIV to women by “straight”
males who engage in undisclosed sex with men
(“down low”).
Some Factors Affecting
HIV Risk Behavior- cont.
• High prevalence (41%) of unprotected sex
among HIV+ urban patients (mostly
heterosexual), especially women (associated with
trade of sex for money/drugs) [McGowan, Shah
et al, CID, 2004]
• History of sexual trauma, drug and alcohol
abuse, and homelessness associated with
increased high-risk sexual behavior among
women (HIV+/HIV-) in Los Angeles. (Paxton et al,
AIDS Behav, 2004)
HAART Use and HIV
Transmission Risk

HAART use has been associated with reduced fear of
HIV mortality and increased sexual risk behavior among
MSM and urban men and women [Miller AIDS 2000, Stolte AIDS
2004, Van de Ven AIDS 2005, McGowan, CID 2004].

Meta-analysis of 25 studies on HAART and high risk
behavior for HIV transmission found that while there was
no association of increased UPS with HAART use or
with having an undetectable viral load, there was an
increase in UPS among subjects who believed that
HAART was protective against HIV transmission [Crepaz,
JAMA 2004]
HAART Use and HIV
Transmission Risk
Attitudes toward health risks and perceived
susceptibility to disease may affect both
adherence to HAART and HIV transmission
risk behavior [Wilson, CID 2002]
 HIV prevention interventions should be
implemented to educate patients initiating
HAART on their potential to transmit HIV,
including drug resistant virus [CDC, NYSDOHAI].

High Risk Behavior Among HIV
Seropositives- Lessons Learned
• Complacency regarding safe sex practices- patient and
medical provider- “Prevention Fatigue”. Prevention efforts
should be ongoing- not just at the initial/annual visit
• Misconception of risk, especially if viral load is low.
Acknowledge that although risk of transmission is less with
low VL, it is not eliminated
• Untreated STD can lead to increased local shedding of HIV in
genital tract. Vigilant STD screening should be part of our
prevention efforts
• Substance use, socioeconomic factors, and mental illness
underlie HIV transmission behavior. Providers should know
their patients and address the issues that may contribute to
ongoing risky behavior (e.g. drug rehab, psychiatric care,
entitlements, supportive services).
Lessons Learned- IDU
• Significant decline in HIV infection prevalence among
IDUs entering BIMC detox program.
• Decline observed in males and females, and long- and
short-term drug users.
• Potential reasons:
• Access to clean needles
• “Informed altruism”: knowledge of serostatus may
impact behavior
• “Partner restriction”: sharing of “works” confined to a
small network of contacts
• Risk elimination may not be necessary to curtail the
epidemic within a population
Des Jarlais, et al, JAIDS, 2004
Can High Risk Sexual Behavior
Among HIV+ be Reduced?
• HIV Testing of all “at risk” persons and engagement of all
seropostives into care
• Rapid HIV Testing
• Opt out testing in certain STD clinics in TX.
• Routine screening for STDs
• Heightened awareness for medical providers of risk
behavior rates
• Education about impact of high risk behavior for HIV+
individuals themselves and their contacts
• Counseling intervention to impact on high risk behaviorrole of “Motivational Interviewing Techniques”
CDC Revised Recommendations for
HIV Testing in Health-Care Settings

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HIV screening is recommended for patients in all health-care
settings after the patient is notified that testing will be performed
unless the patient declines (opt-out screening).
Persons at high risk for HIV infection should be screened for HIV
at least annually.
Separate written consent for HIV testing should not be required;
general consent for medical care should be considered sufficient to
encompass consent for HIV testing.
Prevention counseling should not be required with HIV diagnostic
testing or as part of HIV screening programs in health-care settings.
HIV screening should be included in the routine panel of prenatal
screening tests for all pregnant women. Repeat screening in the
third trimester is recommended in high-prevalence areas.
MMWR: September 22, 2006 / 55(RR14);1-17
Role of Universal HIV Testing
and Prevention

In a meta-analysis of findings from eight studies, the
prevalence of unprotected anal or vaginal intercourse
with uninfected partners was on average 68% lower
for HIV-infected persons who were aware of their
status than it was for HIV-infected persons who were
unaware of their status.

HIV testing must be accompanied by linkage to HIV
specialty care.
Marks, J Acquir Immune Defic Syndr 2005;39:446--53.
HIV Super-infection
• Now well described based on dual infections with
different clade virus and presence of circulating
recombinant forms.
• Intra-subtype super-infection is not readily apparent
but may occur in up to 15% of patients (Taylor and
Korber, Infect Genet Evol, 2005)
• “Serosorting” may not lead to new HIV infections, but
may increase the risk of HIV superinfection, STDs
and spread of drug-resistant virus
• Risk of HIV super-infection may be a potent stimulus
for behavior change (“Loss Frame” safer sex
message).
HIV Serosorting

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Partner selection and condom use
Many studies among MSM have shown increased
odds for UAI among HIV concordant vs discordant
partners
Imperfect prevention strategy: 15- 30% of new HIV
cases occurring among MSM who report having UAI
only with HIV – sex partners (i.e. partners who said
they were negative) [Golden, M, CROI, 2006]
Serosorting does not prevent new bacterial STDs
Case Presentation
• 26 year old male, HIV+, CD4 50, VL 300,000, he has
MDR HIV and has been on multiple ART regimens
and is now on “salvage” treatment.
• He is sexually active with men but feels that it is the
responsibility of his partners to initiate condom use.
He will use condoms only if asked. Does not disclose
HIV status to his partners.
Case Discussion
• What is your reaction to the patient’s attitude toward
safer sex?
• At a recent PIP workshop, a physician stated that
what this patient was doing was bordering on
“criminal behavior”. What do you think? Would this
effect your approach to the patient?
• Gains in reducing HIV transmission due to ARV use
can be offset by behavioral changes that increase
HIV transmission risk
What Does Not Work
• Ignoring the problem (missed opportunities to
address unsafe sex practices- Viagra Rx,
testosterone replacement, pregnancy, STDs, etc)
• Being judgmental or condescending (“Blame and
Shame”)
• Passing the Buck (“It’s not my job, the social worker
will deal with it”)
• Prudishness- If we are not comfortable discussing
or knowledgeable about sexual risk (especially
across straight/gay perspectives) and drug use
practices, how can we engage our patients to
change?
Percent of Patients
Counseling Received at That Day’s Visit:
CAPS HRSA Study
50%
45%
40%
35%
30%
25%
20%
15%
10%
5%
0%
42%
37%
33%
25%
HIV
Prevention
ART
Adherence
Emotional
Issues
Diet &
Nutrition
Physicians and the
Safer Sex Message

Physicians were more likely to provide HIV risk
reduction counseling to newly diagnosed HIV +
patients than established patients (60% vs
14%) [Richardson J, CROI, 2006]
Plan for Success
• Engagement in care (SAFE)- increased HIV testing of all
at risk and engagement of positives in care (and counsel
the negatives in how to remain negative)
• Incorporation of HIV transmission risk reduction into
primary HIV care (Site specific)
• Use of a multidisciplinary team approach to reinforce the
message and funnel feedback from all sources
• Establishment of an open, non-judgmental environment
that fosters discussion and disclosure (start in the waiting
room with leaflets, condoms in exam rooms)
• Continuous re-engagement, reinforcement to avoid
fatigue
Techniques to Encourage
Behavior Change
• Recognize behavior change as a continuous,
evolving process moving toward a desired goal
• Utilize Motivational Interviewing Techniques to
stimulate the patient to change behavior
• The desire for change must come from the
patient. The provider can marshal the
discussion, but the patient must feel in charge.
• In the end the patients should feel they have
done it themselves.
Techniques to Encourage
Behavior Change
• Be careful not to validate unsafe behavior, the
goal should always be to reduce risky practices.
• Negotiate and escalate: Essence of harm
reduction
• Don’t be discouraged by relapses
• Open ended questions: “Tell me about the
people you’ve had sex with recently” vs. “Are
you having sex?”
Essentials of Motivational
Interviewing
 Express
Empathy
 Develop Discrepancy
 Roll with Resistance
 Support Self-Efficacy
Case Presentation
• 46 year old male, uses methamphetamines, has
had multiple male casual sexual contacts that he
met at various clubs, recently diagnosed HIV+. He
states he had a negative HIV test approximately 1 ½
years prior.
• Initial VL was 250,000 and CD4 count was 80.
• How would you address partner notification in this
case?
• What other prevention issues may be relevant?
Screening for STDs. HIV drug resistance testing.
Sexual risk taking in the context of
methamphetamine use (especially if boosted by
ART use).
Challenges
• Behavior change is difficult. Sexual practices
are difficult to modify
• How do we confront our own attitudes toward
behavior which we find objectionable
• How do we address risk behavior in HIVserodiscordant relationships?
• How do we train, motivate and sustain the
prevention effort…among patients AND
PROVIDERS
Clinician-Delivered
Prevention Message
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Fisher JD et al (JAIDS, 2006): Significant reductions
in UP events (vaginal and anal intercourse, insertive
oral sex) over 18 month period
2 HIV clinics: Intervention in one clinic, SOC in the
other
CASI: to assess sexual and IDU behaviors. Baseline
and 3 more times at 6 month intervals
5-10 minutes at each clinical encounter using
motivational interviewing techniques
“Prevention prescription”
Clinician-Delivered
Prevention Message
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497 patients participated in the study
Baseline: 23% reported unprotected vaginal, anal or
insertive oral sex during preceding 3 months
Estimated mean unprotected sexual events:
intervention arm: 7.15 (BL) vs. 1.53 (18 mos)
SOC: 2.06 vs. 9.61
Caution: provider fatigue (“boosting”), staff turnover
(attendings, residents, ID fellows)
Clinician-Delivered
Prevention Message
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Loss frame safer sex message may be more
effective than gain frame prevention message
(Richardson J, CROI, 2006)
Loss frame: “if you smoke you may get lung
cancer”
Gain frame: using condoms will keep your
partner free of getting HIV or other STDs.
Loss frame: negative consequences of UPS, for
example: STDs, HIV superinfection.
Prevention Workshop
 http://www.nynjaetc.org/
curriculum/Preventionbook.pdf
Please do not reproduce without permission
of authors: sshah2@nshs.edu