HIV prevention is
more than basic HIV education (e.g. infectious fluids, transmission routes,
risky behaviors, condom use, etc.), it includes Risk Reduction and, the
controversial strategy of, Harm Reduction. What does HIV prevention mean, and
what is the difference between risk and harm reduction.
***
HIV
Prevention focuses on the prevention of new HIV infections with
education and risk/harm reduction strategies. HIV transmission occurs through
sexual and non-sexual behaviors with varying levels of risk. Sexually, HIV is
transmitted through unsafe/unprotected oral, vaginal, anal, or any form of
sexual play that involves exposure to HIV infected fluids (blood, semen,
vaginal fluids, breast milk, or any bodily fluid that contains HIV-infected
blood). Non-sexually, HIV is transmitted through blood-to-blood contact (shared
needles used by an HIV-infected individual and, extremely rare, contaminated
blood products) and mother-to-child transmission (during pregnancy, delivery,
or breastfeeding).
Preventing sexual transmission of HIV involves a number of
strategies including safer sex practices, testing, treating STIs, and treatment
as prevention. Safer sex practices include limiting the number of sexual
partners and unprotected sexual
encounters; knowing the risk-level involved in oral, vaginal, and anal sex;
and, correct use of condoms from erection to ejaculation. Condom use includes
both external (male) and internal (female) condoms (never to be used together),
and it is important to note that internal condoms can be used for vaginal sex
by women and for anal sex by both women and men.
Regular HIV and STI testing is key in preventing new HIV
infections. It was not too long ago that we were advised to get an HIV test
once a year. Now, frequency of HIV testing depends upon the quantity of sexual
encounters & partners an individual has had; thus, a sexually-active individual
not in an honest, monogamous relationship (regardless of age, gender, or sexual
identity) should test once every 3 to 6 months.
Treatment as prevention consists of two strategies using
antiretroviral therapy (ART) to prevent HIV transmission: PEP and PrEP. PEP, or
Post-Exposure Prophylactics, is utilized after an individual has potentially
been exposed to HIV in an exposure situation (sexual or non-sexual). PEP is a
4-week daily dose of ART that potentially stops HIV infection and should be
started within 72 hours after HIV exposure. PrEP, or Pre-Exposure
Prophylactics, is utilized before an individual is potentially exposed to HIV.
PrEP is being targeted to at-risk HIV-negative men who have sex with men (MSM).
More about this controversial topic shall be addressed in a later blog.
Preventing HIV transmission through blood focuses on
screening blood products; reducing the instances of accidental needle sticks in
medical settings; and, most importantly, decreasing the sharing of used needles
in injection drug use (IDU).
***
Risk
Reduction is concerned with reducing the actual risk an individual
has of acquiring HIV through sexual and non-sexual behaviors. For example,
knowing that receptive (bottoming) anal sex (regardless of sexual identity)
carries the greatest risk for sexual transmission of HIV, whereas, oral sex
(regardless of sexual identity) carries the least risk for sexual transmission
of HIV emphasizes risk reduction.
Risk reduction among People living with HIV/AIDS (PLWHA)
focuses on treatment and adherence to HART. The goal of HART for PLWHA is to
decrease an individual’s viral load (how many copies of HIV replications per ml
of blood) as low as possible, hopefully, until it becomes undetectable (also
known as viral suppression). This is an example of using Treatment as
prevention and risk reduction.
Although having an undetectable viral load does not mean
that HIV is no longer transmittable, it does mean that it is less likely to
transmit HIV than an individual without viral suppression. In 2014, the
Conference on Retroviruses and Opportunistic Infections stated that researchers
“calculated that the average real-world risk reduction as a result of an
undetectable viral load would be 95 percent."
***
Harm
Reduction, historically, is concerned with reducing the harms
associated with injection drug users (IDU). The number one non-sexual behavior that
carries the most risk for HIV transmission is sharing needles, most commonly,
for injection drug use. However, other forms of drug use (smoking, snorting,
drinking, etc.) also contribute to the transmission and spread of HIV. Alcohol,
marijuana, methamphetamines, and other recreational drugs often impair one’s
decision-making skills, decreases inhibitions, and increase the opportunity to
engage in sexual or non-sexual risky behaviors that put the individual at risk
for HIV transmission and other STIs.
Harm reduction, in terms of reducing non-sexual HIV
transmission, should include availability to clean needles and works for IDU.
It is more likely that an IDU would use clean needles/works if they are
available than an IDU would simply quit injecting drugs.
Harm reduction strategies need to be applied to sexual risks
as well. Harm reduction, in terms of sexual HIV transmission, may include
getting an individual to move from never using condoms to using condoms for the
most risky sexual behaviors (anal and vaginal sex).
***
Today we, the diligent community of HIV professional in all
areas of the fight, have a myriad of HIV prevention strategies of which we
should not take advantage. It is equally important to acknowledge that many of
these prevention strategies were not available in the beginning of the aids era
more than thirty years ago. Finally, regardless of the prevention, risk
reduction, or harm reduction strategy used, one must implement said strategy
without judgment, prejudice, or blame.
-Bryan Heitz
Risk Reduction Specialist
CCCofSN
