Strategies have been developed to prevent HIV transmission and to improve adherence to risk reduction and medical care. These include the National AIDS Strategy for the United States Updated to 2020, the 2015 Blueprint on Ending AIDS in New York State by 2020, and the World Health Organization Guidelines.1-4 For any HIV prevention strategies to be implemented, physicians in all specialties need to be aware of them. An article in a previous issue of Psychiatric Times5 and a textbook6 have described the role of psychiatrists in a comprehensive approach to HIV prevention.
This article provides a brief overview of the comprehensive approach and delineates the specific role of psychiatrists in the prevention of HIV transmission both before and after HIV exposure through pre-exposure prophylaxis (PrEP) and post-exposure prophylaxis (PEP). Table 1 provides suggestions for a multidimensional approach to HIV prevention.
Many physicians do not know that transmission can be prevented both before and after exposure to HIV. Psychiatrists can refer HIV-negative persons at substantial risk for infection for PrEP before exposure and PEP after exposure to HIV.7-12
The unique role of psychiatrists and mental health clinicians in HIV prevention
In the US, 1.2 million people are living with HIV, and 1 in 8 does not know that he or she is infected.12 The annual rate of new infections in the US has remained relatively stable over the past decade at a rate of 40,000 to 50,000 new infections each year. The prevalence of HIV infection is higher among persons with mental illness than in the general population, and the prevalence of psychiatric disorders and emotional distress among persons with HIV infection is also higher than in the general population.
HIV is transmitted sexually as well as by injection drug use. However, any substance misuse can play an important role in HIV transmission, since alcohol, stimulants, and other drugs may cause intoxication, impair judgment, and lead to risky behaviors such as unprotected or coerced sexual encounters.
Psychiatrists and other mental health clinicians can play an important role in a comprehensive approach to HIV prevention and engagement in care. Psychiatrists in every subspecialty from child and adolescent to geriatric, addiction, or psychosomatic medicine will encounter opportunities for HIV prevention in every setting from emergency departments and general care to inpatient and ambulatory care. Mental health clinicians in every discipline from addiction counselors to social workers, psychiatric nurse clinicians and practitioners, and psychologists will encounter opportunities for HIV prevention in every setting from emergency departments to drug rehabilitation, methadone maintenance, general care, and inpatient and ambulatory psychiatry. Psychiatrists can prevent HIV transmission by:
• Including HIV testing as part of every routine initial evaluation
• Evaluating for substance use and misuse
• Assessing sexuality and sexual function
• Determining whether a person is HIV negative and at substantial risk for HIV infection
• Making a recommendation and referral for PEP or PrEP that can be lifesaving and has public health implications
Dr. Cohen is Chair and Founder of the Academy of Psychosomatic Medicine HIV/AIDS Psychiatry Special Interest Group; she is a Member, APA Office of HIV Psychiatry Steering Committee; and she is Clinical Professor of Psychiatry, Icahn School of Medicine, Mount Sinai, NYC.
1. Health Resources and Services Administration. National HIV/AIDS Strategy for the United States: Updated to 2020. https://hab.hrsa.gov/about-ryan-white-hivaids-program/national-hivaids-strategy-updated-2020. Accessed July 6, 2017.
2. The White House 2016. National HIV/AIDS Strategy for the United States: Updated to 2020, 2016 Progress Report, December 2016. https://www.whitehouse.gov/sites/whitehouse.gov/files/images/nhas-2016-progress-report.pdf. Accessed July 6, 2017.
3. The New York State Department of Health. 2015 Blueprint on Ending AIDS in New York State by 2020. https://www.health.ny.gov/diseases/aids/ending_the_epidemic/docs/blueprint.pdf. Accessed July 6, 2017.
4. World Health Organization 2016. World Health Consolidated guidelines on HIV prevention, diagnosis, treatment and care for key populations 2016 update. http://www.who.int/hiv/pub/guidelines/keypopulations-2016/en/. Accessed July 6, 2017.
5. Cohen MA, Cozza KL, Bourgeois JA, et al, and the Academy of Psychosomatic Medicine. The role of psychiatrists in HIV prevention. Psychiatric Times. March 2016;33:30-32.
6. Cohen MA, Gorman M, Volberding P, et al, eds. Comprehensive Textbook of AIDS Psychiatry: A Paradigm for Psychosomatic Medicine. 2nd ed. New York; Oxford University Press: 2017.
7. Centers for Disease Control and Prevention. US Public Health Service Pre-exposure Prophylaxis for the Prevention of HIV Infection in the United States: 2014 Clinical Practice Guideline. www.cdc.gov/hiv/pdf/guidelines/PrEPguidelines2014.pdf. Accessed July 7, 2017.
8. Centers for Disease Control and Prevention. Pre-exposure Prophylaxis PrEP, 2016. https://www.cdc.gov/hiv/risk/prep/. Accessed July 7, 2017.
9. Centers for Disease Control and Prevention. Updated Guidelines for Antiretroviral Postexposure Prophylaxis After Sexual, Injection Drug Use, or Other Nonoccupational Exposure to HIV: United States, 2016. https://www.cdc.gov/hiv/pdf/programresources/cdc-hiv-npep-guidelines.pdf. Accessed July 7, 2017.
10. Centers for Disease Control and Prevention. CDC Stacks. Updated Guidelines for Antiretroviral Postexposure Prophylaxis After Sexual, Injection Drug Use, or Other Non-occupational Exposure to HIV: United States, 2016. https://stacks.cdc.gov/view/cdc/38856. Accessed July 7, 2017.
11. Centers for Disease Control and Prevention. CDC Stacks. Recommendations for HIV Prevention with Adults and Adolescents with HIV in the United States, 2014: Summary for Clinical Providers. 2014. http://stacks.cdc.gov/view/cdc/26063. Accessed July 7, 2017.
12. Baeten JM, Donnell D, Ndase P, et al; Partners PrEP Study Team. Antiretroviral prophylaxis for HIV prevention in heterosexual men and women. N Engl J Med. 2012;367:399-410.
13. Grant RM, Lama JR, Anderson PL, et al; iPrEx Study Team. Pre-exposure chemoprophylaxis for HIV prevention in men who have sex with men. N Engl J Med. 2010;363:2587-2599.
14. Thigpen MC, Kebaabetswe PM, Paxton LA, et al; TDF2 Study Group. Antiretroviral pre-exposure prophylaxis for heterosexual HIV transmission in Botswana. N Engl J Med. 2012;367:423-434.
15. Choopanya K, Martin M, Suntharasamai P, et al; Bangkok Tenofovir Study Group. Antiretroviral prophylaxis for HIV infection in injecting drug users in Bangkok, Thailand: a randomised, double-blind, placebo-controlled phase 3 trial. Lancet. 2013;381:2083-2090.
16. Centers for Disease Control and Prevention. Unintended Pregnancy Prevention, 2016. https://www.cdc.gov/reproductivehealth/contraception/unintendedpregnancy/index.htm. Accessed July 7, 2017.
17. Basile KC, DeGue S, Jones K, et al. STOP SV: A Technical Package to Prevent Sexual Violence. https://www.cdc.gov/violenceprevention/pdf/SV-Prevention-Technical-Package.pdf. Accessed July 7, 2017.
18. New York State Department of Health AIDS Institute, 2014. HIV Prophylaxis for Victims of Sexual Assault. https://www1.nyc.gov/assets/doh/downloads/pdf/csi/csi-pep-hcp-faq.pdf. Accessed July 7, 2917.