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Primary care physicians hold a key strategic position within the healthcare system that allows them to identify patients at high risk for HIV infection and institute appropriate interventional strategies. As a result, they must be knowledgeable of major risk factors for infection, effective counseling strategies, and recommended prevention interventions.
The CDC recommend that behavioral risk assessment for HIV identify the following risk factors:
Counseling individuals identified to be at high risk for HIV infection who are interested in PrEP is a critical feature of optimal management, which should include assisting in deciding if they would likely benefit from PrEP, determining if they are candidates for PrEP (ie, HIV negative), screening and treatment of other sexually transmitted infections, and discussions of correct daily dosing and administration of PrEP drugs, the importance of adherence, not increasing high-risk behaviors if PrEP is initiated, and monitoring required during PrEP, including for potential adverse events, HIV infection, and ARV drug resistance. Additional prevention interventions should also be used for at-risk individuals, including CDC-defined evidence-based behavioral interventions.
Once the decision to initiate PrEP has been made, primary care physicians must follow CDC guidance on optimal management before, during, and after PrEP for heterosexuals, MSM, and people who inject drugs.
For individuals already infected with HIV, primary care physicians should follow the DHHS recommendation that ART be offered to all persons with HIV but particularly those at risk of transmitting HIV to their sexual partners, including heterosexuals and other risk groups. Primary care physicians should also counsel individuals with HIV infection on the concept of HIV treatment-as-prevention, in which full suppression of virus in a person with HIV renders their infection unable to be sexually transmitted to others, with U = U or Undetectable = Untransmittable messaging and guidance.
Another area in which primary care physicians play an important role is in counseling and referral of serodiscordant couples who are wishing to conceive. The DHHS provides the following management recommendations for serodiscordant couples who wish to conceive: