HIV prevention: Entering mainstream medicine

A new CDC initiative seeks to launch a broader attack against the spread of this deadly disease.

Editorial. Sept. 22/29, 2003.

The AIDS virus is not going away. After more than two decades of prevention messages, about 40,000 people are still infected with HIV each year. An estimated 900,000 people in the United States live with the virus, and of those, 180,000 to 280,000 are unaware of their serostatus.

That's why the Centers for Disease Control and Prevention this year launched a new initiative to make greater strides against the disease's spread. The objective is to look beyond those groups traditionally considered most at risk, to make HIV testing a part of mainstream medical practice, and to step up prevention messages aimed at those already infected. Ultimately, physicians will play a critical role in making the initiative a success, and the AMA is committed to helping medical professionals achieve these purposes.

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The CDC effort relies on the idea that people tend to take action in response to advice from their physicians. Whether it be a gentle suggestion to be tested or a reminder to an HIV-positive patient to take precautions against transmitting the virus to others, physicians have the power to influence patients' behavior, and the CDC would like them to exercise it at every appropriate opportunity.

The agency's blueprint for action, "Advancing HIV Prevention: New Strategies for a Changing Epidemic," provides specific details on exactly how to do so. It outlines a broader attack against HIV that combines proven public health approaches -- screening, new case identification, partner notification, and increased availability of treatment and prevention services -- with a greater awareness that not everyone who is HIV-positive fits into a high-risk category.

The initiative involves four key elements:

HIV testing should become a routine part of medical care like any medical test provided by primary care physicians. It should be included, when indicated, on the same voluntary basis as other diagnostic and screening tests. To make this goal more achievable, the CDC will promote adoption of simplified counseling procedures before testing.
New models for diagnosing HIV infections should be implemented. In 2003, the CDC will fund demonstration projects using OraQuick to increase access to early diagnosis and referral for treatment and prevention services in high-HIV prevalence settings, including correctional facilities. OraQuick is a fingerstick test for HIV-1 that provides results in 20 minutes.
Prevention efforts should be expanded to include people already diagnosed with HIV. Guidelines were published July 18 to help physicians who care for people infected by the AIDS virus to initiate conversations about sexual habits and intravenous drug use. On Nov. 13, the CDC and the Public Health Training Network will present a two-hour satellite broadcast discussing the updated recommendations.
Increased focus should be placed on decreasing the rates of perinatal HIV transmission. The CDC will encourage the routine HIV testing of all pregnant women and, as a safety net, the routine screening of any infant whose mother was not screened. This effort is compatible with AMA policy. The CDC also will work with professional societies such as the American College of Obstetricians and Gynecologists, the American Academy of Pediatrics and the American Academy of Family Physicians to spread the word. Doctors should be aware that some state laws currently interfere with this activity.

Overall, the new CDC marching orders are a timely and important response to the recognition that more must be done to stanch the spread of HIV and improve the morbidity and mortality of those living with the disease.

Doctors can have a significant impact against this ongoing epidemic if they embrace these new prevention efforts. That's why the AMA echoes the CDC's call to action. It is the right thing to do in the face of a deadly virus that otherwise will not disappear.