Until vaccination is a reality, prevention of HIV infection will depend on HIV testing and counseling, including precautions regarding sexual practices and injection drug use, initiation of antiretroviral treatment as a prevention tool for transmission to others, preexposure and postexposure use of antiretroviral treatment, perinatal management including antiretroviral treatment of the mother, screening of blood products, and infection control practices in the health care setting.
1. HIV testing and counseling
Primary care clinicians should routinely obtain a sexual history and provide risk factor assessment of their patients. Because approximately 15% of the HIV-infected persons in the United States do not know they are infected, the US Preventive Services Task Force recommends that clinicians screen for HIV infection in adolescents and adults ages 15 to 65 years. Younger adolescents and older adults who are at increased risk should also be screened. Clinicians should review the risk factors for HIV infection with the patient and discuss safer sex and safer needle use as well as the meaning of a positive test. Although the CDC recommends “opt-out” testing in medical settings, some states require specific written consent. For persons whose test results are positive, it is critically important that they be connected to ongoing medical care. Many public health systems advocate for initiating care and treatment the same day that someone tests positive if appropriate resources are available (see C. Antiviral Treatment, below). Referrals for partner-notification services, social services, mental health services, and HIV-prevention services should also be provided. Prevention interventions focused on the importance of HIV-infected persons not putting others at risk have been successful.
For patients whose test results are negative, clinicians should review safer sex and needle use practices, including counseling not to exchange bodily fluids unless they are in a long-term mutually monogamous relationship with someone who has tested HIV antibody-negative and has not engaged in unsafe sex, injection drug use, or other HIV risk behaviors for at least 6 months prior to or at any time since the negative test.
To prevent sexual transmission of HIV, only latex or polyurethane condoms should be used, along with a water-soluble lubricant. Although nonoxynol-9, a spermicide, kills HIV, it is contraindicated because in some patients it may cause genital ulcers that could facilitate HIV transmission. Patients should be counseled that condoms are not 100% effective. They should be made familiar with the use of condoms, including, specifically, the advice that condoms must be used every time, that space should be left at the tip of the condom as a receptacle for semen, that intercourse with a condom should not be attempted if the penis is only partially erect, that men should hold on to the base of the condom when withdrawing the penis to prevent slippage, and that condoms should not be reused. Although anal intercourse remains the sexual practice at highest risk for transmitting HIV, seroconversions have been documented with vaginal and oral intercourse as well. Therefore, condoms should be used when engaging in these activities. Women as well as men having sex with men should understand how to use condoms to be sure that their partners are using them correctly. Partners of HIV-infected women should use latex or polyurethane barriers such as dental dams (available at dental supply stores) to prevent direct oral contact with vaginal secretions. Several randomized trials in Africa demonstrated that male circumcision significantly reduced HIV incidence in men, but there are a number of barriers to performing widespread circumcisions among men in Africa.
Persons using injection drugs should be cautioned never to share needles or other drug paraphernalia. When sterile needles are not available, bleach does appear to inactivate HIV and should be used to clean needles.
2. Antiretroviral treatment for decreasing transmission of HIV to others (treatment as prevention)
Besides preventing progression of HIV disease, effective antiretroviral treatment decreases the risk of HIV transmission between sexual partners. Among serodiscordant couples, stably suppressing HIV with antiretroviral treatment almost completely eliminates the risk of HIV transmission to the uninfected partner. Although HIV-negative persons in stable long-term partnerships with HIV-infected persons represent only one group of at-risk persons, increasing the use of antiretroviral treatment among the population of HIV-infected persons appears to decrease community-wide transmission of HIV. Despite major improvements in effectiveness and tolerability of antiretroviral treatment, only about 60% of HIV-infected persons in the United States are virally suppressed. Persons in whom the HIV virus has been “undetectable” for a prolonged period have virtually no chance of sexually transmitting HIV. Still, because of the possibility of variations in measured viral load, and not knowing whether their partners are virally suppressed, and the possibility of transmission through blood, all HIV-infected persons should practice safer sex and not share needles so as to avoid the possibility of transmitting HIV.
et al. Antiretroviral therapy for prevention of human immunodeficiency virus infection. Med Clin North Am. 2016 Jul;100(4):927–50.
JM. HIV prevention: opportunities and challenges. Top Antivir Med. 2017 Dec/Jan;24(4):123–6.
et al. Antiretroviral drugs for treatment and prevention of HIV infection in adults: 2018 recommendations of the International Antiviral Society—USA Panel. JAMA. 2018 Jul 24;320(4):379–96.
3. Preexposure antiretroviral treatment prophylaxis
Several large randomized double-blind placebo-controlled trials demonstrated that administering emtricitabine/TDF (Truvada) can reduce the risk of sexual transmission of HIV among uninfected individuals at high risk for infection; one study was of HIV-negative men and transgender women who have sex with men, and two studies were of heterosexual HIV-discordant couples. Preexposure tenofovir has also been shown to reduce HIV infection among injection drug users from Thailand. In addition, real-world studies of men who have sex with men, where adherence with emtricitabine/TDF has been high, have found preexposure prophylaxis (PrEP) to be highly effective in preventing HIV infection. Emtricitabine/TAF (Descovy) has also been approved for PrEP among men. It has not been studied among women.
Who should be prescribed PrEP is not a simple question. PrEP is best thought of as one “option” for HIV prevention, rather than as the only option. Whether it is the “best” option depends on three things: (1) the likelihood that a person will have HIV-infected partners or use the needles of infected persons, (2) whether there is a better option available to prevent HIV, and (3) the patient’s ability to take a daily medication. CDC guidelines recommend offering PrEP to persons at “substantial risk” for HIV. Risk for HIV is a combination of the likelihood of having a partner who is HIV-infected and the likelihood that the behavior (eg, type of intercourse, shared needles) transmits HIV. Men who have sex with men, and transgender male-to-females are the groups with the highest HIV seroprevalence in the United States, and they are likely to have partners who are known to be or at risk for being HIV-infected. Those who have receptive anal intercourse have the highest risk of HIV because the behavior is much more efficient at transmitting HIV than other sexual practices. Heterosexual drug users are also at high risk for HIV-infection if they do not consistently use clean needles or if they trade drugs for sex. It can be hardest to assess the risk of heterosexual non-drug users because it requires assessing the likelihood that their partners have HIV risks such as being bisexual men or using injection drugs. Factors known to increase the risk of HIV transmission and therefore make PrEP a good choice for particular groups of patients are shown in Table 31–4.
Table 31–4.Recommendations for preexposure prophylaxis (PrEP) of HIV infection. ||Download (.pdf) Table 31–4. Recommendations for preexposure prophylaxis (PrEP) of HIV infection.
Patients for whom PrEP should be considered as an option for HIV prevention
Sexually active homosexual and bisexual men, male-to-female transgender persons, and heterosexuals and bisexual women who are likely to have partners with HIV risks
Injection drug users
Factors that increase the likelihood that PrEP is a good option
Patient has receptive anal intercourse
Patient has a known HIV-infected partner
Patient has a history of sexually transmitted diseases
Patient has a high number of sex partners
Patient is a commercial sex worker
Patient with inconsistent or no condom use
Patient who is sharing needles or related paraphernalia (“works”)
Initial assessment before prescribing PrEP
HIV antibody test to confirm HIV negative
Symptom review to exclude primary HIV infection (eg, no history of acute illness with fever and rash in prior month)
STD tests: syphilis; gonorrhea (at risk site-specific); and chlamydia (at risk site-specific)
Serum creatinine and eGFR1
Confirm immunity to HBV or vaccinate if nonimmune2
Discuss risks, including that PrEP is not 100% effective, does not protect against other STDs, and may have side effects
Counsel patients to use latex or polyurethane condoms and clean needles, in addition to PrEP
Assess substance use and offer treatment, if needed
Discuss importance of daily medication adherence
Emtricitabine/TDF (Truvada) 1 tablet orally daily, initially for 90 days
Emtricitabine/TAF (Descovy) 1 tablet orally daily, initially for 90 days (men only; not tested in women)
HIV antibody test every 3 months
Serum creatinine every 6 months
Pregnancy test every 3 months
STD tests: syphilis, gonorrhea (at risk site-specific); and chlamydia (at risk site-specific)
Assess and support daily medication adherence
Reinforce benefits of using latex or polyurethane condoms and clean needles with PrEP
Assess substance use and offer treatment, if needed
How does PrEP compare to other options for preventing HIV? Latex or polyurethane condoms are an excellent choice for preventing sexual transmission of HIV because they are inexpensive, have no side effects, and prevent other sexually transmitted diseases and pregnancy. However, for a variety of reasons, people do not always use condoms even when taught to do so. In addition, condoms break or slip on occasion, so even persons who always use condoms may want the extra protection of PrEP if they have a known HIV-infected partner. History of sexually transmitted diseases is proof of unprotected sex and increases the likelihood that PrEP is a good option for a patient.
Finally, for PrEP to be effective, patients have to be willing to take it. Taking one pill right before sex would not be expected to offer protection because the medicine would not have adequate drug levels in the body. Maximum concentrations are achieved in various locations in the body at different treatment intervals: in blood, maximum levels are achieved after 20 days of daily dosing; in rectal tissue, after 7 days; in cervicovaginal tissue, after 20 days. Study participants who took at least 4 daily doses in a week were protected almost as well as those who took the drug every day, indicating that missed doses do not render the treatment ineffective; however, adherence to daily dosing is the safest method.
Recommendations on initial and follow-up assessments are shown in Table 31–4. Emtricitabine/TDF is contraindicated for persons with kidney disease (creatinine clearance less than 60 mL) because of the small risk of kidney toxicity with TDF. Decreases in bone mineral density have been documented in persons taking emtricitabine/TDF for PrEP at 24 weeks; whether this decrease will have clinical significance is unknown. In someone with osteoporosis or at high risk for osteoporosis, clinical judgement would be needed to assess whether the benefits of emtricitabine/TDF justified the risks of worsening bone density. If emtricitabine/TAF is found to be effective as PrEP, it would be a good alternative to emtricitabine/TDF for patients with kidney disease or osteoporosis since TAF appears to have less effect on the kidney and bone than TDF.
Substantial increases in sexually transmitted diseases have also been seen in persons taking PrEP, indicating the importance of regular follow-up in patients using PrEP. Some patients are reluctant to use insurance to cover the cost of the medication for fear of revealing that they are at risk for HIV; without insurance, the cost is high. Compassionate use programs are available from the medication manufacturer for low-income uninsured persons.
et al. Optimizing delivery of HIV preexposure prophylaxis for women in the United States. AIDS Patient Care STDS. 2018 Jan;32(1):16–23.
SP. Maximizing the benefits of HIV preexposure prophylaxis. Top Antivir Med. 2018 Apr;25(4):138–42.
et al. Pre-exposure prophylaxis 2.0: new drugs and technologies in the pipeline. Lancet HIV. 2019 Nov;6(11):e788–99.
et al. Pre-exposure prophylaxis for HIV infection in the older patient: what can be recommended? Drugs Aging. 2018 Jun;35(6):485–91.
et al. Does pre-exposure prophylaxis for HIV prevention in men who have sex with men change risk behaviour? A systematic review. J Clin Nurs. 2018 Sep;27(17–18):3254–65.
et al. Drug resistance during HIV pre-exposure prophylaxis. Drugs. 2019 Apr;79(6):609–19.
et al. Antiretroviral medications for the prevention of HIV infection: a clinical approach to preexposure prophylaxis, postexposure prophylaxis, and treatment as prevention. Infect Dis Clin North Am. 2019 Sep;33(3):629–46.
et al. Pre-exposure prophylaxis for HIV prevention in women: current status and future directions. Drugs. 2019 Aug;79(12):1263–76.
et al. Pre-exposure prophylaxis for HIV prevention during pregnancy and lactation: forget not the women and children. Med J Aust. 2019 Apr;210(6):281–4.
DL; PrEP in Pregnancy Working Group. Emerging evidence from a systematic review of safety of pre-exposure prophylaxis for pregnant and postpartum women: where are we now and where are we heading? J Int AIDS Soc. 2020 Jan;23(1):e25426.
et al. Expanding knowledge about implementation of pre-exposure prophylaxis (PrEP): a methodological review. AIDS Behav. 2019 Oct;23(10):2761–78.
et al. HIV preexposure prophylaxis: a review. JAMA. 2018 Mar 27;319(12):1261–8.
4. Postexposure prophylaxis for sexual and drug use exposures to HIV
The goal of postexposure prophylaxis is to reduce or prevent local viral replication prior to dissemination such that the infection can be aborted. Although there is no proof that administration of antiretroviral medications following a sexual or parenteral drug use exposure reduces the likelihood of infection, there is suggestive data from animal models, perinatal experience, and a case-control study of health care workers who experienced a needle stick.
Treatment of persons who have been exposed to HIV should be within 72 hours, but sooner is better. All exposed persons should first receive HIV testing to exclude the possibility that they are already infected. If rapid tests are not available, treatment should begin pending the results of a standard HIV test.
The choice of antiretroviral agents and the duration of treatment are the same as those for exposures that occur through the occupational route; the preferred regimen is tenofovir 300 mg with emtricitabine 200 mg daily with raltegravir 400 mg twice a day. In contrast to those with occupational exposures, some individuals may present very late after exposure. Because the likelihood of success declines with length of time from HIV exposure, treatment is not recommended after more than 72 hours after exposure. In addition, because the psychosocial issues involved with postexposure prophylaxis for sexual and drug use exposures are complex, it should be offered with prevention counseling. Counseling should focus on how to prevent future exposures. Individuals with ongoing risk for HIV infection should be considered candidates for PrEP. Clinicians needing more information on postexposure prophylaxis for occupational or nonoccupational exposures should contact the National Clinicians’ Post-Exposure Prophylaxis Hotline (1-888-448-4911; http://nccc.ucsf.edu/clinician-consultation/pep-post-exposure-prophylaxis/).
et al. Antiretroviral medications for the prevention of HIV infection: a clinical approach to preexposure prophylaxis, postexposure prophylaxis, and treatment as prevention. Infect Dis Clin North Am. 2019 Sep;33(3):629–46.
et al; STRIBPEP Study Group. Tenofovir disoproxil fumarate/emtricitabine
plus ritonavir-boosted lopinavir or cobicistat-boosted elvitegravir
as a single-tablet regimen for HIV post-exposure prophylaxis. J Antimicrob Chemother. 2017 Oct 1;72(10):2857–61.
et al. Suspected unexpected and other adverse reactions to antiretroviral drugs used as post-exposure prophylaxis of HIV infection - five-year experience from clinical practice. Arch Med Sci. 2018 Apr;14(3):547–53.
et al. Belgian guidelines for non-occupational HIV post-exposure prophylaxis 2017. Acta Clin Belg. 2018 Aug;73(4):275–80.
et al. Optimal HIV postexposure prophylaxis regimen completion with single tablet daily elvitegravir
/tenofovir disoproxil fumarate/emtricitabine
compared with more frequent dosing regimens. J Acquir Immune Defic Syndr. 2017 Aug 15;75(5):535–9.
et al. To prescribe, or not to prescribe: decision making in HIV-1 post-exposure prophylaxis. HIV Med. 2018 Oct;19(9):645–53.
5. Prevention of perinatal transmission of HIV
Prevention of perinatal transmission of HIV begins by offering HIV counseling and testing to all women who are pregnant or considering pregnancy. HIV-infected women who are pregnant should start antiretroviral treatment with at least three medications. Recommended regimens are zidovudine and lamivudine with either ritonavir-boosted lopinavir or ritonavir-boosted atazanavir. Cesarean delivery should be planned if HIV viral load is greater than 1000 copies/mL near the time of delivery. Zidovudine should be given to the infant after birth for 6 weeks. When possible, breastfeeding should be avoided.
et al. Global and national guidance for the use of pre-exposure prophylaxis during peri-conception, pregnancy and breastfeeding. Sex Health. 2018 Nov;15(6):501–12.
et al. Offering pre-exposure prophylaxis for HIV prevention to pregnant and postpartum women: a clinical approach. J Int AIDS Soc. 2017 Mar 8;20(Suppl 1):24–30.
6. Prevention of HIV transmission in health care settings
In health care settings, universal body fluid precautions should be used, including use of gloves when handling body fluids and the addition of gown, mask, and goggles for procedures that may result in splash or droplet spread, and use of specially designed needles with sheath devices to decrease the risk of needle sticks. Because transmission of tuberculosis and the SARS-CoV-2 virus may occur in health care settings, all patients with cough should be encouraged to wear masks. Hospitalized HIV-infected patients with cough should be placed in respiratory isolation until tuberculosis and COVID-19 can be excluded by chest radiograph, sputum smear examination, and nasopharyngeal swab testing.
Epidemiologic studies show that needle sticks occur commonly among health care professionals, especially among surgeons performing invasive procedures, inexperienced hospital housestaff, and medical students. Efforts to reduce needle sticks should focus on avoiding recapping needles and use of safety needles whenever doing invasive procedures under controlled circumstances. The risk of HIV transmission from a needle stick with blood from an HIV-infected patient is about 1:300. The risk is higher with deep punctures, large inoculum, and source patients with high viral loads. The risk from mucous membrane contact is too low to quantitate.
Health care professionals who sustain needle sticks should be counseled and offered HIV testing as soon as possible. HIV testing is done to establish a negative baseline for worker’s compensation claims in case there is a subsequent conversion. Follow-up testing is usually performed at 6 weeks, 3 months, and 6 months. With the patient’s permission, their blood can be tested for HIV antibody and HIV viral load.
A case-control study by the CDC indicates that administration of zidovudine following a needle stick decreases the rate of HIV seroconversion by 79%. Therefore, providers should be offered antiretroviral treatment as soon as possible after exposure and continued for 4 weeks. The preferred regimen is TDF 300 mg with emtricitabine 200 mg (Truvada) daily with raltegravir 400 mg twice a day. Providers who have exposures to persons who are likely to have antiretroviral medication resistance (eg, persons receiving therapy who have detectable viral loads) should have their therapy individualized, using at least two medications to which the source is unlikely to be resistant. Because reports have noted hepatotoxicity due to nevirapine in this setting, this agent should be avoided. Unfortunately, there have been documented cases of seroconversion following potential parenteral exposure to HIV despite prompt use of zidovudine prophylaxis. Counseling of the provider should include “safer sex” guidelines.
7. Prevention of transmission of HIV through blood or blood products
Current efforts in the United States to screen blood and blood products have lowered the risk of HIV transmission with transfusion of a unit of blood to 1:1,000,000. Use of blood and blood products should be judicious, with patients receiving the least amount necessary, and patients should be encouraged to donate their own blood prior to elective procedures.
Primate model data have suggested that development of a protective vaccine may be possible, but clinical trials in humans have been disappointing. Only one vaccine trial has shown any degree of efficacy. In this randomized, double-blind, placebo-controlled trial, a recombinant canarypox vector vaccine plus two booster injections of a recombinant gp120 vaccine reduced the risk of HIV among a primarily heterosexual population in Thailand, but efficacy was too low (31%) for widespread use. A mosaic HIV vaccine resulted in a strong immune response among adult humans and protection against infection with an HIV-like virus in rhesus monkeys. The vaccine is currently being studied in a phase IIB trial in sub-Saharan Africa.
et al. Evaluation of a mosaic HIV-1 vaccine in a multicentre, randomized, double-blind, placebo-controlled, phase 1/2a clinical trial (APPROACH) and in rhesus monkeys (NHP 13-19). Lancet. 2018 Jul 21;392(10143):232–43.
AS. Viewpoint: An HIV vaccine is essential for ending the HIV/AIDS pandemic. JAMA. 2017 Oct 24;318(16):1535–6.
J. Hunt for an HIV vaccine intensifies. JAMA. 2017 Jun 27; 317(24):2475.
et al. A new step towards an HIV/AIDS vaccine. Lancet. 2018 Jul 21;392(10143):192–4.
et al. Recent advances on HIV DNA vaccines development: stepwise improvements to clinical trials. J Control Release. 2019 Dec 28;316:116–37.
In the era prior to the development of effective antiretroviral treatment, cohort studies of individuals with documented dates of seroconversion demonstrate that AIDS developed within 10 years in approximately 50% of untreated seropositive persons. With currently available treatment, progression of disease has been markedly decreased. In addition to antiretroviral treatment, prophylactic regimens can prevent opportunistic infections and improve survival. Prophylaxis and early intervention prevent several infectious diseases, including tuberculosis and syphilis, which are transmissible to others. Recommendations for screening tests, vaccinations, and prophylaxis are listed in Table 31–5.
Table 31–5.Health care maintenance and monitoring of HIV-infected individuals. ||Download (.pdf) Table 31–5. Health care maintenance and monitoring of HIV-infected individuals.
For all HIV-infected individuals:
CD4 counts every 3–6 months (can decrease to every 12 months if viral load suppressed on antiretroviral treatment for 2 years and CD4 count greater than 300 cells/mcL)
Viral load tests every 3–6 months and 1 month following a change in therapy
Genotypic resistance testing at baseline and if viral load not fully suppressed and patient taking antiretroviral treatment
Complete blood count, chemistry profile, transaminases and total bilirubin, at baseline and every 3–6 months
Urinalysis at baseline and annually during antiretroviral treatment (every 6 months if antiretroviral treatment regimen includes TDF)
Glucose or hemoglobin A1c at baseline and annually during antiretroviral treatment
Lipid panel at baseline, 4–8 weeks after starting or changing an antiretroviral treatment regimen that affects lipids, and annually for everyone over 40 years of age
PPD or interferon-gamma release assay (IGRA) at baseline and annually if at high risk for exposure to persons with active TB
INH for those with positive PPD or IGRA, normal chest radiograph, and no history of treatment for active or latent TB
RPR or VDRL at entry and periodically based on sexual activity
Toxoplasma IgG serology at baseline
Hepatitis serologies: hepatitis A antibody, hepatitis B surface antigen, hepatitis B surface antibody, hepatitis B core antibody, hepatitis C antibody
Herpes zoster vaccine1
Inactivated influenza vaccine annually in season
Hepatitis A vaccine for those without immunity to hepatitis A
Hepatitis B vaccine for those who are hepatitis B surface antigen and antibody negative. (Use 40 mcg formulation at 0, 1, and 6 months; repeat if no immunity 1 month after three-vaccine series.)
Combined tetanus, diphtheria, pertussis vaccine
Human papillomavirus vaccine for HIV-infected women age 26 years or less
Haemophilus influenzae type b vaccination
Bone mineral density monitoring for postmenopausal women and men 50 years of age or older
Papanicolaou smears annually; if three smears are negative, can switch to longer intervals (see Complications, Section M. Gynecologic Manifestations)
Consider anal swabs for cytologic evaluation
For HIV-infected individuals with CD4 less than 200 cells/mcL:
Pneumocystis jirovecii prophylaxis (see Treatment, Section B. Prophylactic Treatment of Complications of HIV Infection)
For HIV-infected individuals with CD4 less than 75 cells/mcL:
Mycobacterium avium complex prophylaxis (see Treatment, Section A. Complications of HIV Infection)
For HIV-infected individuals with CD4 less than 50 cells/mcL:
Consider CMV prophylaxis
Because of the increased occurrence of tuberculosis among HIV-infected patients, all such individuals should undergo an intradermal PPD test or an interferon-gamma release assay (IGRA) blood test at baseline and yearly thereafter if they remain at risk of exposure (eg, incarcerated, living in congregate settings). Those with a positive PPD (defined for HIV-infected patients as greater than 5 mm of induration) or a positive IGRA assay (results that are reported as positive and not negative or indeterminate) should be clinically evaluated for active tuberculosis, including by a chest radiograph. Patients with an infiltrate in any location, especially if accompanied by mediastinal adenopathy, should have sputum sent for acid-fast staining. Patients with active tuberculosis should be treated as outlined in Chapter 9 (see Tables 9–14 and 9–15). Patients with a positive PPD or IGRA assay, a normal chest radiograph, or negative sputum sample for active tuberculosis infection are classified as having latent tuberculosis infection. Patients with latent tuberculosis infection who have not been previously treated for (active or latent) tuberculosis should receive isoniazid (300 mg orally daily or twice weekly) with pyridoxine (50 mg orally daily) for 9 months. In patients with advanced immunodeficiency, both the PPD and IGRA assay are more likely to be falsely negative or (for IGRA assay) indeterminant. Therefore, it may be worth retesting patients with initially low CD4 counts once they have received antiretroviral treatment and have immune reconstitution (CD4 count greater than or equal to 200 cells/mcL).
et al. Transmission of drug-resistant tuberculosis in HIV-endemic settings. Lancet Infect Dis. 2019 Mar;19(3):e77–88.
et al. Advances in the understanding of Mycobacterium tuberculosis
transmission in HIV-endemic settings. Lancet Infect Dis. 2019 Mar;19(3):e65–76.
Because of the increased number of cases of syphilis among MSM, including those who are HIV-infected, all such men should be screened for syphilis by a rapid plasma reagin (RPR) or Venereal Disease Research Laboratories (VDRL) test every 6 months. Increases of syphilis cases among HIV-infected persons are of particular concern because these individuals are at increased risk for reactivation of syphilis and progression to tertiary syphilis despite standard treatment. Because the only widely available tests for syphilis are serologic and because HIV-infected individuals are known to have disordered antibody production, there is concern about the interpretation of these titers. This concern has been fueled by a report of an HIV-infected patient with secondary syphilis and negative syphilis serologic testing. Furthermore, HIV-infected individuals may lose fluorescent treponemal antibody absorption (FTA-ABS) reactivity after treatment for syphilis, particularly if they have low CD4 counts. Thus, in this population, a nonreactive treponemal test does not rule out a past history of syphilis. In addition, persistence of treponemes in the spinal fluid after one dose of benzathine penicillin has been demonstrated in HIV-infected patients with primary and secondary syphilis. Therefore, the CDC has recommended an aggressive diagnostic approach to HIV-infected patients with reactive RPR or VDRL tests of longer than 1 year (or unknown) duration. All such patients should have a lumbar puncture with cerebrospinal fluid cell count and cerebrospinal fluid VDRL. Those with a normal cerebrospinal fluid evaluation are treated as having late latent syphilis (benzathine penicillin G, 2.4 million units intramuscularly weekly for 3 weeks) with follow-up titers. Those with a pleocytosis or a positive cerebrospinal fluid-VDRL test are treated as having neurosyphilis (aqueous penicillin G, 2–4 million units intravenously every 4 hours, or procaine penicillin G, 2.4 million units intramuscularly daily, with probenecid, 500 mg four times daily, for 10 days) followed by weekly benzathine penicillin G 2.4 million units intramuscularly for 3 weeks. Some clinicians take a less aggressive approach to patients who have low titers (less than 1:8), a history of having been treated for syphilis, and a normal neurologic examination. Close follow-up of titers is mandatory if such a course is taken. For a more detailed discussion of this topic, see Chapter 34.
et al. Screening for syphilis: updated evidence report and systematic review for the U.S. Preventive Services Task Force. JAMA. 2016 Jun 7;315(21):2328–37.
U.S. Preventive Services Task Force (USPSTF), Bibbins-Domingo
et al. Screening for syphilis infection in nonpregnant adults and adolescents: U.S. Preventive Services Task Force Recommendation Statement. JAMA. 2016 Jun 7;315(21):2321–7.
HIV-infected individuals should receive immunizations as outlined in Table 31–5. Patients without evidence of hepatitis B surface antigen or surface antibody should receive hepatitis B vaccination, using the 40-mcg formulation; the higher dose is to increase the chance of developing protective immunity. If the patient does not have immunity 1 month after the three-shot series, then the series should be repeated. HIV-infected persons should also receive the standard inactivated vaccines such as tetanus and diphtheria boosters that would be given to uninfected persons. Most live vaccines, such as yellow fever vaccine, should be avoided. Measles vaccination, while a live virus vaccine, appears relatively safe when administered to HIV-infected individuals and should be given if the patient has never had measles or been adequately vaccinated. The new recombinant adjuvanted herpes zoster vaccine (Shingrix), two doses 2–6 months apart, is recommended for HIV-infected persons with CD4 counts greater than 200 cells/mcL. However, it is not known if it is efficacious in preventing herpes zoster in this population.
et al. Hepatitis B virus vaccination in HIV-infected people: a review. Hum Vaccin Immunother. 2017 Jun 3;13(6):1–10.
A randomized study found that multivitamin supplementation decreased HIV disease progression and mortality in HIV-infected women in Africa. However, supplementation is unlikely to be as effective in well-nourished populations.
HIV-infected individuals should be counseled with regard to the importance of practicing safer sex even with other HIV-infected persons because of the possibility of contracting a sexually transmitted disease, such as gonorrhea or syphilis. There is also the possibility of transmission of a particularly virulent or a drug-resistant strain between HIV-infected persons. Substance abuse treatment should be recommended for persons who are using recreational drugs. They should be warned to avoid consuming raw meat, eggs, or shellfish to avoid infections with Toxoplasma, Campylobacter, and Salmonella. HIV-infected patients should wash their hands thoroughly after cleaning cat litter or should forgo this household chore to avoid possible exposure to toxoplasmosis. To reduce the likelihood of infection with Bartonella species, patients should avoid activities that might result in cat scratches or bites. Although the data are not conclusive, many clinicians recommend that HIV-infected persons—especially those with low CD4 counts—drink bottled water instead of tap water to prevent cryptosporidia infection.
Because of the emotional impact of HIV infection and subsequent illness, many patients will benefit from supportive counseling.