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Risk Screening and Risk-Reduction Interventions

Risk screening is a brief assessment of behavioral and clinical factors associated with transmission of HIV and other sexually transmitted diseases (STDs). Risk screening can be used to identify persons with HIV who should receive more in-depth risk assessment and risk-reduction interventions or referral for other services (e.g., substance use treatment). Risk screening identifies persons at greatest risk of transmitting HIV so that prevention services can be focused on them. Many persons with HIV reduce risk behaviors after learning that they are infected.24 Nevertheless, adopting and maintaining healthier and safer behaviors over a lifetime can be challenging, and many persons with HIV report unprotected sex after their diagnoses.25,26 For this reason, providers should do risk screening periodically. The frequency will depend on the providers' role in the individual’s care; whether they provide episodic services, such as HIV testing, or long-term care over months or years; and whether there is evidence of continued transmission risks.

photo of an unopened condomMany interventions can reduce the chances that a person with HIV transmits HIV to someone else. Behavioral risk-reduction interventions aim to reduce risk behavior of persons with HIV by promoting behaviors such as using condoms, not sharing drug injection equipment, and avoiding sexual practices that are most likely to result in transmitting HIV to others (e.g., the person with HIV should avoid unprotected insertive anal sex with a partner who is not infected with HIV). Because behavior changes often occur in incremental steps, brief behavioral risk-reduction messages provided at the time of notifying a person of a positive HIV test result or an initial HIV care visit can be followed by behavioral risk-reduction interventions that are more structured or intensive or involve multiple sessions. Biomedical risk-reduction interventions include antiretroviral medications that persons with HIV can take to prevent transmitting HIV as well as antiretroviral medications that their uninfected partners can take to prevent acquiring HIV.

Many of the forthcoming recommendations are consistent with recommendations from existing federal government guidance for these types of providers:

Clinicians and non-clinical providers serving persons with HIV

  • Establish infrastructure to support routine risk screening and risk-reduction interventions, including
    • directories of local agencies that provide risk-reduction interventions.27-29
    • Clinicians should also establish
      • reminder systems that prompt periodic risk screening and provision of, or referral for, risk-reduction counseling;27
      • record systems that include behavioral information and medical data (e.g., viral load, recent STD diagnoses) to allow more accurate assessment of risk;27,28
  • Attempt to create a supportive, nonjudgmental setting that encourages persons with HIV to ask questions, to be honest, and to disclose sex and drug use behaviors and reproductive plans.28

At encounters in which clients or patients are diagnosed with HIV or provided prevention messages,

  • Screen for
    • sexual behaviors, including those that decrease transmission risk (condom use) and those that increase transmission risk (e.g., unprotected insertive anal sex with uninfected partner);27-31
    • history of past STD diagnoses or treatment;27-31
    • substance use (including alcohol and injected and non-injected drugs) and use of non-sterile drug injection equipment;27-31
    • plans to conceive and pregnancy status (if female);27,28,30
    • current sex and drug injection partners who may be at risk of acquiring HIV infection;27-30
    • Clinicians should also screen for
      • use of antiretroviral treatment (ART) as a means to prevent transmission.31
  • Provide risk-reduction information, as appropriate to person’s characteristics and service setting, including
    • information about factors that influence sexual, blood-borne, and perinatal HIV transmission, including transmission risk behaviors, transmission risks associated with specific types of sexual contact and concurrent STD;4-8
    • information about effective methods to prevent HIV transmission to others, such as
      • safer sexual practices for sexually active persons (condoms, reducing number of sex partners, etc.),27-30
      • use of sterile equipment for injection-drug use (IDU),27,28,30
      • Clinicians should also provide risk reduction information related to
        • use of ART to suppress viral load and reduce infectiousness.31
        • reproductive practices that prevent sexual and perinatal transmission.27-29
  • Provide information on how to obtain and use prevention tools (condoms, legal sources of sterile drug-injection equipment).27,28
  • Identify and correct misconceptions about HIV transmission, acquisition, and prevention methods.27,29
  • Offer brief risk-reduction interventions that are based on a person’s unique behavioral information elicited during risk screening (e.g., sexual and drug-injection activity) and on clinical information (e.g., recent STD diagnoses).27,28,35
    • Clinicians should also offer brief risk-reduction interventions based on a person’s ART use and viral load.
  • Provide persons with HIV information about behavioral and biomedical interventions that HIV uninfected sex and drug-injection partners could use to prevent acquiring HIV, e.g., male or female condoms, avoiding unprotected sex or sharing drug-injection equipment with persons confirmed to be HIV-infected.27,32-34a, 4
    • Clinicians should also provide information on: non-occupational postexposure prophylaxis, and preexposure prophylaxis (see topic page on partner services).
  • Provide or make referrals for intensive risk-reduction interventions for persons who report high levels of risk or continue risk behaviors despite brief risk-reduction interventions.27,28
  • Provide or refer for services that can decrease clients’ or patients’ risk of  HIV transmission, including

4See section on Antiretroviral Treatment for more information on prophylaxis.

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