Hot Topics in Sexually Transmitted Infections and Associated Conditions – HIV

(Published November 2013)

• Key facts about infection
  • Prevalence
    • Over the past 30 years, more than 25 million people in the world have died from HIV/AIDS.²⁹
    • As of 2011, about 34 million people were living with HIV worldwide.²⁹
    • In the United States, more than one million individuals ages 13 and older have HIV infection; approximately one fifth are unaware they have been infected.³⁰
    • The number of new infections in the United States has remained stable over the past decade, although the rate of new infection has increased substantially among certain populations and the total number of people living with HIV in the United States has increased.³⁰
  • Risk
    • • By risk group
        • MSM of all racial/ethnic groups remain the population at highest risk for HIV infection.³⁰ MSM comprise approximately 4 percent of the male population in the United States but account for 63 percent of all new infections and 52 percent of people living with HIV.^31,32,33
        • New infections in women are primarily related to heterosexual contact (84 percent); the remainder is related to injection drug use (16 percent).³⁰
      • By race/ethnicity
        • Blacks/African Americans have experienced the greatest burden of disease from HIV. Although approximately 12 percent of the US population, Blacks/African Americans represent 44 percent of people with HIV infection.^31,32
        • An even smaller proportion of the US population, Native American/Alaska Native women are almost three times as likely to be diagnosed with HIV infection than Caucasian women.³⁴
        • Recent research shows that the risk of acquiring HIV and other STIs for a specified level of risky behaviors varies across social-sexual networks. Using data from a national survey of 18- to 26-year-olds, researchers divided individuals into 16 risk categories based on degree of risk of sexual behaviors and substance use. For Blacks, the prevalence of HIV and other STIs was higher than the average prevalence for the population in every one of the 16 categories, even those with the least risky behaviors. For Whites, the prevalence was lower than the average for all except the 4 highest risk categories.³⁵

        Figure 2: Estimated Rate of New HIV Infections, 2009, by Gender and Race/Ethnicity³⁶

         

        
        Source: Adapted from Prejean 2011

    • By age
      • Individuals ages 50 and older account for 15 percent of new HIV/AIDS diagnoses.³7 Many do not perceive themselves to be at risk and are less likely to use condoms and obtain HIV testing.^38,39
      • Older women may be at greater risk because of age-related thinning of the vaginal wall, which may increase the chance of viral acquisition through tears in the mucosa. ⁴⁰
      • Young people ages 15 to 29 account for about 39 percent of new HIV infections in the country, although they constitute only 21 percent of the population.41 Of the high school youth reporting sexual intercourse in the previous three months, almost 40 percent did not use a condom the last time they had sex.⁴² Youth with older sex partners and those who have experienced sexual abuse are at higher risk.⁴¹
    • With comorbid STIs
      • Both non-ulcerative STIs (such as chlamydia) and ulcerative STIs (such as genital herpes and chancroid) increase the risk of HIV infection through mechanisms that appear to increase both infectiousness and susceptibility.⁴³ When individuals are exposed to HIV, those with other existing STIs are two to five times more likely to acquire HIV infection than individuals without STIs. In addition, an individual with HIV infection and another coexisting STI is more likely to transmit HIV than an individual with HIV but without an additional STI.⁴⁴
      • Ulcerative STIs create breaks in the skin than can serve as portals for entry of HIV. Both ulcerative and non-ulcerative STIs cause local inflammation, which can increase the number of cells in genital secretions that can be targeted by HIV.⁴⁵
• Screening and diagnosis

• • • • Some populations are known to be at greater risk; however, clinicians should consider the possibility of HIV infection in patients who fall outside these high-risk groups rather than assume that a patient is HIV free because of history or demographics (e.g., young woman who reports a monogamous relationship, 80-year-old woman).
      • Clinicians should avoid “siloed” thinking regarding HIV and other STIs; they should consider HIV when seeing patients with other STIs and associated infections (both the common infections, such as BV and multiple bouts of candidiasis, and the less common infections, such as chancroid).
      • USPSTF now recommends that all adolescents and adults ages 15 to 65 years be screened for HIV; in addition, younger and older individuals who are at increased risk should be  screened.⁴⁶ USPSTF recommends that all pregnant women be screened for HIV, even if they present in labor without prior screening.⁴⁶
      • CDC recommends opt-out HIV testing, meaning that unless a patient who meets the criteria for screening specifically declines, he or she should be informed about and undergo testing.⁴⁷
      • For specific information about screening and diagnosis, see www.cdc.gov/hiv/testing/clinical.
• Treatment and management
  • • • Guidelines for the treatment of HIV change rapidly. For current recommendations see http://aidsinfo.nih.gov/guidelines/html/1/adult-and-adolescent-arv-guidelines/0.
      • Refer individuals newly diagnosed with HIV infection to an experienced facility or provider for comprehensive HIV care, and assist them in navigating access issues.
      • Educate and counsel patients about the infection and how to reduce the risk of transmitting the infection. For downloadable patient education materials available in a number of languages, see http://aids.gov/hiv-aids-basics.
      • Obtain initial lab studies. The National Institutes of Health recommends the following tests for individuals newly diagnosed with HIV infection:⁴⁸
        • HIV antibody testing (if prior documentation is not available or if HIV RNA is below the assay’s limit of detection)
        • CD4 T-cell count (CD4 count)
        • Plasma HIV RNA (viral load)
        • Complete blood count, chemistry profile, transaminase levels, blood urea nitrogen, and creatinine
        • Urinalysis
        • Serologies for hepatitis A, B, and C viruses
        • Fasting blood glucose and serum lipids
        • Genotypic resistance testing at entry into care, regardless of whether antiretroviral therapy will be initiated immediately
      • Use screening questions to assess for risk of domestic or partner abuse. For example,⁴⁹
        • “Do you ever feel unsafe at home?”
        • “Are you in a relationship in which you have been physically hurt or felt threatened?”
        • “Have you ever been or are you currently concerned about harming your partner or someone close to you?”
      • If a patient reveals a concern about domestic violence, express support and concern and help him or her access support services. Express concern with statements such as the following:
        • “I believe you.”
        • “I am concerned about your safety and well-being.”
        • “I imagine this situation must be very difficult for you.”
        • “You are not alone.”
        • “There are options and resources available.”
      • Take steps to engage the patient and increase the chance of retention in treatment.
        • Be aware of the patient’s emotional state—he or she is likely to be upset, frightened, and aware of the stigma associated with HIV infection.
        • Ensure cultural sensitivity of care providers and staff to increase the patient’s comfort with accessing care services.
        • Ensure that all care providers and staff treat the patient with dignity and respect, respond to questions with language he or she can understand, demonstrate interest in the patient as a person, and take time to listen to his or her concerns.