Despite substantial advances in the treatment of human immunodeficiency virusAIDS/HIV infection, the estimated number of annual new HIV infections in the United States has remained at 40,000 for over 10 years. HIV prevention has mostly focused on persons who are not infected, in order to help them avoid becoming infected. However, further reduction of transmission of HIV will require using some new strategies, including more emphasis on stoping transmission of HIV. HIV-infected persons who are aware of their HIV infection tend to reduce behaviors that might transmit HIV to others. Nonetheless, recent reports suggest that such behavioral changes often are not maintained and that a substantial number of HIV-infected persons continue to engage in behaviors that place others at risk for HIV infection.

Reversion to risky sexual behavior might be as important in HIV transmission as failure to adopt safer sexual behavior immediately after receiving a diagnosis of HIV. Unprotected anal sex appears to be occurring more frequently in some urban centers, particularly among young men who have sex with men (MSM). Bacterial and viral sexually transmitted diseases (STDs) in HIV-infected men and women receiving outpatient care have been increasingly noted, indicating ongoing risky behaviors and opportunities for HIV transmission. Despite the decline in syphilis infection rate in the general U.S. population, continued outbreaks of syphilis in MSM, many of whom are co-infected with HIV, continue to happen in some areas; rates of gonorrhea and chlamydial infection have risen in this population as well. Rising STD rates among MSM indicate increased potential for HIV transmission, both because these rates suggest ongoing risky behavior and because STDs have a synergistic effect on HIV infectivity and susceptibility. Studies suggest that optimism about the effectiveness of highly active antiretroviral therapy (HAART) for HIV may be contributing to relaxed attitudes toward safer sex practices and increased sexual risk-taking by some HIV-infected persons.

Injection drug use also continues to play a key role in the HIV epidemic; at least 28% of AIDS cases among adults and adolescents with known HIV risk category reported to CDC in 2000 were associated with injection drug use. In some drug using communites, HIV seroincidene and seroprevalence in injection drug users has declined recently. The decline has been a result of several things, including a increased use of sterile needles, lower rates of needle sharing, shifts from injection to noninjection methods of using drugs, and the cessation of drug use. Injection drug use amoung heroin users has helped to increase HIV infection substantially in some areas, serving as a reminder that avoiding all high risk behavior is important.

Doctors and Clinicians caring for HIV-infected persons can help play a key role in help their patients reduce their risk factors. Caregivers can make a big difference to affect patients’ risk factors for transmission of HIV to other people by performing brief tests for HIV transmission risk factors; communicating safe practices; talking about sexual and drug use behavior and positively reinfocing changes to safer behavior. These steps may also help to decreaste a patients’ risks of getting other STDs and bloodborne infections (e.g., hepatitis). Managed care plans can play an important role in HIV prevention by incorporating these recommendations into their practice guidelines, educating their providers and enrollees, and providing condoms and educational materials. Prevention services might be delivered in a clinical or office setting or even through referral to community programs. Some clinicians have expressed concern that reimbursement is often not provided for prevention services and note that improving reimbursement for such services might enhance the adoption and implementation of these guidelines.

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