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Initiation of and Adherence to Treatment as Prevention

Antiretroviral Treatment for Prevention of HIV Transmission

image of pillsAntiretroviral treatment (ART) improves the health and prolongs the lives of persons with HIV. Studies that included mostly heterosexual HIV-discordant couples (one partner is HIV-infected and the other is not) have shown that ART use by persons with HIV can reduce the risk of sexually transmitting HIV to others by over 90%.45,46 Current U.S. HIV treatment guidelines support initiation of ART for persons with HIV for their personal health benefit and to prevent transmission of HIV infection. To maximize individual and public health benefits, high levels of adherence to ART are critical.

Antiretroviral medications can also be used to prevent HIV acquisition by selected partners of HIV-infected persons after they have had sex (nonoccupational postexposure prophylaxis, nPEP) or before they have had sex (preexposure prophylaxis, PrEP). Use of antiretroviral medications for both nPEP and PrEP may reduce the risk that a person becomes infected with HIV after having contact with a person with HIV.

The forthcoming recommendations will include guidance for clinicians and community-based HIV prevention providers about early initiation of ART for personal and public health benefits. Nearly all forthcoming recommendations for clinicians are consistent with these recommendations from existingfederal government guidelines for clinicians:

Clinicians serving persons with HIV
  • Counsel all HIV-infected persons about the benefits and risks of ART, including the fact that effective ART substantially reduces but does not eliminate the risk of transmitting HIV.47,48
  • Advise all HIV-infected persons that ART use is voluntary and that they can decline ART without risk of being denied medical or social services.48
  • Initiate ART in HIV-infected persons who understand the expected benefits, risks, and need for long-term follow-up and who are willing, able, and ready to initiate long-term, uninterrupted therapy.47,48
  • Select the ART regimen according to Department of Health and Human Services (DHHS) guidelines.47
  • For HIV-infected persons who choose to postpone treatment, periodically re-offer them ART.48
  • At initiation of ART and periodically thereafter, counsel HIV-infected persons that they should
    • take ART as prescribed,
    • understand that missing doses can increase the risk of transmitting HIV to others and of developing antiretroviral resistance,
    • continue other HIV prevention measures, and
    • commit to long-term monitoring and follow-up visits.47

Clinicians serving HIV-uninfected partners of persons with HIV

  • Inform partners who may have been exposed to HIV within the last 72 hours through sexual contact or by using non-sterile drug injection equipment about the availability of nPEP to reduce the risk of HIV acquisition, and offer nPEP to eligible persons according to DHHS recommendations.49, 3
  •  Inform men who have sex with men (MSM) and heterosexually active adults at high risk of HIV infection infection about the availability of PrEP before possible HIV exposure to reduce risk of acquiring HIV, and offer PrEP to eligible persons according to CDC recommendations and current FDA-approved indications.50a

Adherence to Antiretroviral Treatment

Adherence to treatment regimens is also crucial to improve health, increase survival, and prevent the spread of HIV to partners and offspring. ART lowers the amount of the virus in the body—an estimated 77% of patients in the United States taking ART have suppressed viral loads.51 Still, only half of persons with HIV are in care and only 28% of all persons with HIV have virus levels that are fully suppressed. Because having a lower viral load decreases the risk of transmission to others, it is essential that clinical providers and community-based HIV prevention specialists encourage good ART adherence and help persons with HIV identify practical strategies to maintain good adherence over the long term.

The forthcoming recommendations will provide guidance for clinicians and community-based HIV prevention providers about regularly assessing and supporting ART adherence. Many of the forthcoming recommendations are consistent with these recommendations from existing federal government clinical practice recommendations for:

image of a pill boxClinicians serving persons with HIV 52,53

  • Create a multidisciplinary team to support long-term adherence (e.g., nurse, case manager, social worker, pharmacist, counselor), when feasible.
  • Assess patient readiness to start ART, including possible barriers to adherence.
  • Review the benefits of good adherence and potential problems of poor adherence (e.g., health problems, drug resistance, and risk of transmission).
  • Offer ART regimens that are highly effective but reduce pill burden, dosing frequency, and dietary restrictions as much as possible.
  • Involve patient in decisions about treatment regimens.
  • Ensure that patient understands the treatment plan when starting ART, including drug regimen, dosing schedule, dietary restrictions, potential side effects, and what to do when missing doses or experiencing side effects.
  • Acknowledge the difficulties of maintaining perfect adherence, prepare for situations that could impair good adherence, and encourage disclosure of poor adherence.
  • Provide education and tools to support good adherence.
  • Provide referrals for services that address factors that may impede adherence, such as lack of health insurance or other resources to cover ART costs, drug and alcohol use, and mental illness.
  • Use viral load data to assess adherence and motivate attainment of adherence goals.
  • Prepare for, assess, and manage ART side effects at each clinical visit.

3This recommendation does not reflect current Food and Drug Administration (FDA)-approved labeling for medications that are recommended by DHHS for nPEP.

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