In the 1980s, Oncologists across the nation were noticing a perplexing phenomena: hundreds and hundreds of young gay men with Kaposki’s sarcoma, a rare cancer. This was the beginning of the HIV epidemic in the United States.[1]
Since then, HIV care has come a long way.[2] An HIV diagnosis is no longer a death sentence.[3] But the virus is still endemic, and can still pose serious risks to those infected. The number of new HIV diagnoses is not currently spiking, as it was in the 1980s. Yet this number is no longer declining, either.[4]
Furthermore, in some populations, HIV is actually on the rise. If current projections are correct, one in two black men and one in four Latino men who have sex with men will become HIV-positive in their lifetimes.[5] For these communities, the HIV epidemic is far from over. But anyone can get HIV—heterosexual people account for almost a quarter of new HIV diagnoses.[6]
The HIV virus is spread when body fluids from an infected person crosses the mucus membrane (such as those in the vagina or anus) of an uninfected person. Six body fluids transmit HIV: Blood, semen, pre-seminal fluids, rectal fluids, vaginal fluids, and breast milk. Hugging, sneezing, coughing, or sharing utensils do not transmit HIV. There is no cure for HIV, and up until 2012, there was no pharmaceutical way to prevent HIV.
This is why pre-exposure prophylaxis (PrEP) is so exciting. PrEP is a daily pill that reduces a person’s risk of getting HIV by over 90%![7] Some researchers estimate that PrEP could be up to 99% effective, when used correctly.[8] No other HIV prevention method comes close.[9]
People at high risk for HIV include:[10]
● Men who have sex with other men
● Injection drug users
● Transgender women who have sex with men
● Anyone whose partner is HIV-positive
● Sex workers
● Heterosexual people with higher-risk sexual behavior
These groups of people should consider taking PrEP.
For those who use injection drugs, quitting should be a top priority. Besides HIV, injection drug users have a high risk of hepatitis and overdose. These patients urgently need substance use disorder treatment.[11] In 2015, the number of HIV infections attributed to injection drug use rose for the first time in decades.[12] The town of Austin, in Indiana, has borne witness to this. In Austin, a poverty-stricken rural town with a population of 4,000,190 people were diagnosed with HIV in 2015.[13] This HIV epidemic was sparked by injection drug use.[14]
So discuss PrEP with your patients! When a patient of yours is at a high risk of HIV, have a talk about PrEP. Have they heard of PrEP? Are they open to it? Can they commit to taking a daily pill, and to getting tested for STIs every three months while on PrEP?[15] If they want to take PrEP, the next step is medical screening.
Remember, PrEP does prevent pregnancy or other STIs. Patients on PrEP must still practice safer sex. Talk to your patients about condom use, safer sexual behaviors, and pregnancy prevention.
If someone not on PrEP is exposed to HIV, post-exposure prophylaxis (PEP) is an option. If a patient may have been exposed to HIV, they should immediately see a health care provider or go to the emergency room to begin taking PEP.[16] PEP is a 28-day course of antiretroviral drugs that must be started within 72 hours of an HIV exposure.
To learn more about HIV care and PrEP, visit the Centers for Disease Control’s clinical practice guideline.
References:
[1] https://ari.ucsf.edu/about-us/history-aids-ucsf
[2] https://www.hiv.gov/hiv-basics/overview/history/hiv-and-aids-timeline
[3] http://time.com/4585537/world-aids-day-hiv/https://www.nytimes.com/2014/07/17/upshot/is-truvada-the-pill-to-prevent-hiv-99-percent-effective-dont-be-so-sure.html
[4] https://www.cdc.gov/hiv/statistics/overview/ataglance.html
[5] https://www.cdc.gov/nchhstp/newsroom/2016/croi-press-release-risk.html
[6] https://www.cdc.gov/hiv/statistics/overview/ataglance.html
[7] https://www.cdc.gov/hiv/basics/prep.html
[8] https://www.nytimes.com/2014/07/17/upshot/is-truvada-the-pill-to-prevent-hiv-99-percent-effective-dont-be-so-sure.html
[9] https://www.cdc.gov/nchhstp/newsroom/docs/factsheets/hiv-proven-prevention-methods-508.pdf
[10] https://www.hiv.gov/hiv-basics/overview/about-hiv-and-aids/who-is-at-risk-for-hiv
[11] https://www.cdc.gov/hiv/risk/idu.html
[12] https://www.kff.org/hivaids/issue-brief/hiv-and-the-opioid-epidemic-5-key-points/
[13] https://www.indystar.com/story/news/2016/04/08/year-after-hiv-outbreak-austin-still-community-recovery/82133598/
[14] https://www.npr.org/sections/health-shots/2018/01/14/577713525/mapping-how-the-opioid-epidemic-sparked-an-hiv-outbreak
[15] https://www.cdc.gov/hiv/pdf/risk/prep/cdc-hiv-prep-guidelines-2017.pdf
[16] https://www.plannedparenthood.org/learn/stds-hiv-safer-sex/hiv-aids/pep