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HIV Risk Reduction Strategies for Sexual Behaviors Eliminating HIV Sexual Transmission Risk Abstaining from Vaginal, Anal, and Oral Sex RiskRisk ReductionReduction StrategiesStrategies ManualManual A Healthcare Provider’s Guide to Reducing HIV Transmission Risk University of Connecticut Center for Health, Intervention, and Prevention Among PLWHA OPTIONS RISK REDUCTION STRATEGIES MANUAL A Healthcare Provider’s Guide to Reducing HIV Transmission Risk Among PLWHA Content Developed for New York State Department of Health AIDS Institute by Center for Health, Intervention, and Prevention (CHIP) University of Connecticut Content Developed and Written by: Stacy Cruess, Ph.D. Deborah Cornman, Ph.D. K. Rivet Amico, Ph.D. Sarah Christie, M.P.H. Lindsay Shepherd, B.S. Roberta Glaros, M.A. NYS Department of Health AIDS Institute For information on Options, contact: Deborah H. Cornman, Ph.D., Associate Director Center for Health, Intervention, and Prevention (CHIP) 2006 Hillside Road, Unit 1248 University of Connecticut Storrs, CT 06269–1248 Phone: 860–486–4645 Fax: 860–486–4876 E-mail: [email protected] Welfare Research, Inc. (WRI) provided editorial and design assistance. © 2007 University of Connecticut. All rights reserved. Funding provided by New York State Department of Health AIDS Institute and Centers for Disease Control (CDC). II Contents How to Use the Risk Reduction Strategies Manual ............................................ VI CHAPTER 1. Introduction ........................................................................................ 1 CHAPTER 2. Quick Reference Guide to HIV Risk Reduction Strategies ................. 13 CHAPTER 3. Predictors of HIV Risk Behavior ........................................................ 19 CHAPTER 4. Assisting Patients with HIV Disclosure .............................................. 29 CHAPTER 5. Sexual Transmission of HIV ............................................................... 45 CHAPTER 6. Sexual Behaviors, Relative Risk, and Safer Alternatives ....................... 55 CHAPTER 7. Identifying Risk Triggers for Safer Sex and Drug Use Lapses .............. 71 CHAPTER 8. Safer Sex Communication Skills ......................................................... 79 CHAPTER 9. Condoms and Lubricants ................................................................... 89 III Contents (cont’d) CHAPTER 10. Strategies for Dealing with Negative Attitudes About Condoms..... 101 CHAPTER 11. Other Barrier Methods: Oral Barriers, Cots, and Gloves ................ 109 CHAPTER 12. Microbicides .................................................................................. 113 CHAPTER 13. Commonly Abused Drugs and Effective Risk Reduction Strategies .... 119 CHAPTER 14. HIV and Injection Drug Use ......................................................... 131 CHAPTER 15. New York State Resources for Healthcare Providers ........................ 147 CHAPTER 16. Internet Resources for Healthcare Providers ................................... 155 APPENDICES ........................................................................................................ 161 The goal of the Options intervention is to frame the healthcare provider and patient as a team. The Options Risk Reduction Strategies Manual and accompanying patient handouts are tools to support both the provider and the patient. IV Appendices A. Incorporating HIV Prevention into the Medical Care of Persons Living with HIV (Centers for Disease Control and Prevention) B. HIV and its Transmission (Centers for Disease Control and Prevention) C. What you Should Know About Oral Sex (Centers for Disease Control and Prevention) D. Female Condom FAQ (Female Health Company) E. What is FC Female Condom? (Female Health Company) F. What is FC2 Female Condom? (Female Health Company) G. FAQ about Microbicides (Global Campaign for Microbicides) H. Drug Fact Sheets (Office of National Drug Control Policy and New York State Department of Health AIDS Institute) I. Drug-Associated HIV Transmission Continues in the U.S. (Centers for Disease Control and Prevention) J. Viral Hepatitis and Injection Drug Users (Centers for Disease Control and Prevention) K. Coinfection with HIV and Hepatitis C Virus (Centers for Disease Control and Prevention) L. Syringe Disinfection for Injection Drug Users (Centers for Disease Control and Prevention) M. Physician Prescription of Sterile Syringes to Injection Drug Users (Centers for Disease Control and Prevention) N. Syringe Exchange Programs (Centers for Disease Control and Prevention) V How to Use the Risk Reduction Strategies Manual he Options Risk Reduction Strategies Manual is a reference tool and is divided into chapters based on the type of risk reduction information T presented, such as safer sex and drug use strategies, HIV transmission information, and communication skills. Providers can take several steps to use the Options Risk Reduction Strategies Manual as a tool when working with their HIV-positive patients: 1. Become familiar with the manual before implementing the Options intervention with patients. Healthcare providers who plan to use the Options intervention with their HIV-positive patients should review this manual before implementing the intervention to become familiar with the information, motivation, and skills development material that may be relevant for their patients. 2. Refer to the manual as needed when working with patients to reduce their risk behaviors. The Options intervention can help the providers uncover barriers to safer sex and drug use behavior when working with a patient. Once specific barriers have been identified, providers can then refer to the appropriate section(s) of this manual as a reference tool to help them most effectively work with the patient to address those barriers. — For example, if during an Options intervention session a provider discovers that the patient often has unprotected sex because he doesn’t like to wear condoms, the provider can refer to Chapter 10, Strategies for Dealing with Negative Attitudes about Condoms, for suggestions on how to help the patient be more open to using condoms. 3. Use relevant patient handouts to reinforce information provided during meetings with patients. VI Target Risk Behaviors for Interventions—Sexual Risk The majority of research conducted to date on prevalence of sexual risk behaviors among individuals living with HIV has been with men who have sex with men (MSM). Research suggests that although many HIV-positive MSM attempt to make some behavioral changes to reduce the risk of transmitting HIV, a significant number continue to engage in at least some forms of risky sexual behavior after a diagnosis of HIV. • In a study of recently diagnosed HIV+ MSM, although men appeared to make efforts to reduce transmission risks after diagnosis, many continued to engage in some risky behaviors. For example, unprotected anal intercourse with unknown status or one-time partners was less frequent after diagnosis, but rates of unprotected anal intercourse with last sex partner did not change.4 • In a study of more than 1,000 HIV+ MSM in New York City and San Francisco, 47.3% reported engaging in unprotected anal sex during the past 3 months with an HIV-negative or status unknown non-main partner, while 21.3% reported unprotected anal sex with HIV-negative and status unknown main partners (see Table 1). 5 VII VIII Chapter 1 Introduction Overview he Options Risk Reduction Strategies Manual is a supplement to the Options Intervention Protocol Manual and is intended for physicians and Tother healthcare providers who work with HIV-positive patients. This manual is a resource for information and risk reduction strategies that providers can use to help patients reduce their HIV transmission risk behaviors. It presents information on HIV risk reduction in a practical and nonjudgmental way to help providers effectively incorporate prevention counseling into clinical care with their HIV-positive patients. Rationale for Prevention in the HIV Clinical Setting Although HIV prevention efforts have historically focused on “at-risk” populations (i.e., uninfected individuals at-risk for acquiring HIV due to risky sex or drug use behaviors), recently the focus of prevention has broadened to include individuals already infected with the virus. While many HIV-positive individuals attempt to practice safer behaviors to protect themselves and their partners, they may find it difficult to maintain the behavioral changes. In addition, efforts at reducing HIV transmission risks may be inconsistent. Helping HIV-positive patients reduce sexual and drug use risk behaviors and maintain behavior changes has significant implications for three main reasons: 1. Reducing the Risk of HIV Transmission to Uninfected Partners HIV-infected individuals represent a source from which future infections may be generated. If HIV-positive individuals continue to practice unprotected sex, they put their uninfected partners at risk for acquiring HIV. In addition, even if they engage in unprotected sex with other known HIV-positive individuals, they and their partners are at risk for acquisition of other STIs and HIV dual infection (see next page). 2. Reducing the Risk of STI Acquisition HIV-infected individuals who engage in unprotected sex put themselves at risk of acquiring other sexually transmitted infections (STIs) that may accelerate their HIV disease progression. 3. Reducing the Risk of HIV Dual Infection Dual infection occurs when an HIV-positive individual is infected with two different strains of HIV from different sources; it can be due to coinfection or superinfection. The frequency of HIV dual infection
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