By: Dr. Geoffrey Modest
There was a recent update of the CDC’s “recommendations for HIV prevention with adults and adolescents with HIV in the United States” — see here and you too can download the 240 page document…). The overall focus of this update is to develop systems of care/infrastructure to facilitate improved access to and retention in care of HIV-positive patients. The underlying issue is that recent studies have found that the vast majority of people with HIV are aware of their disease (around 85%, thanks to much more aggressive screening programs and, it seems to me, a broader acceptance of HIV in many communities), but only 2/3 are linked to care, 40% are retained in care, 1/3 prescribed antiretrovirals, and only 25% were effectively treated to suppress their HIV viral load (which has the dual benefit of, first, turning HIV infection from pretty much a death sentence into a chronic disease, and, second, vastly reducing transmissability to others — ie treatment as prevention). This update does not cover clinical care of HIV or related infections. Basic issues it covers are:
–Barriers to care and medication adherence, including getting people into care and retention in care.
–Developing systems to provide integrated medical and social services to support HIV-infected individuals
–Systems to implement a widespread HIV outreach, testing and treatment program, including the creation of collaborative teams of clinical and nonclinical providers. there is a general focus in the paper for shared decision-making, communicating in a respectful and culturally-appropriate manner, and developing community-based resources
–Risk screening and reduction interventions for HIV and sexually-transmitted diseases
–HIV partner services, including PrEP (preexposure prophyllaxis) and nPEP (nonoccupational postexposure prophylaxis) to prevent transmission to noninfected partners, in collaboration with local health departments
–HIV prevention, testing, and procedures related to pregnancy
–Quality improvement and program monitoring, focusing on improving the delivery and quality of care, with ongoing monitoring (as with all of the above, the recommendations are replete with references)
We are certainly fortunate in Massachusetts that the Dept of Public Health is very supportive of community initiatives, working with us to provide team-based care, focusing on case management (for nursing and social services) and enrolling people into special insurance programs through which they get free medications.