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Overview of HIV Prevention

Joseph J. Eron, Jr., MD
Program Director
Daniel R. Kuritzkes, MD
Program Director
Sharon L. Hillier, PhD
Released: September 17, 2020

Primary Care Essentials

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.[136]

The CDC recommend that behavioral risk assessment for HIV identify the following risk factors[73]:

  • Frequent partner changes 
  • Sex partner with HIV
  • Recent bacterial sexually transmitted infection
  • Condoms not used or used inconsistently
  • Commercial sex work

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.[136] Additional prevention interventions should also be used for at-risk individuals, including CDC-defined evidence-based behavioral interventions.[26]

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.[73]

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.[114] 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[126]:

  • Expert consultation
  • For serodiscordant couples who want to conceive, initiation of ART for the partner with HIV is recommended, and achievement of maximal viral suppression is recommended before conception is attempted.
  • For women with HIV who have male partners without HIV, artificial insemination eliminates the risk of HIV transmission to the uninfected partner
  • For men with HIV who have female partners without HIV, artificial insemination with donor sperm from a male without HIV eliminates the risk of HIV transmission to the uninfected partner. In addition, it is recommended that males with HIV undergo semen analysis before attempting conception to prevent unnecessary HIV exposure if the likelihood of conception is low because of semen abnormalities.
  • The utility of PrEP for the uninfected partner when the infected partner is receiving fully suppressive ART is unknown

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