HIV Prevention Levels and Factors

The three levels of prevention work were first conceptualized for application to prevention of diseases (Leavell & Clark, 1953), but they are often applied to prevention of other social and health issues not related to HIV. HIV prevention programs focus on one or more of these levels of prevention and it is essential for social workers to understand where on the prevention spectrum they should focus their efforts. Specifying the level of prevention is important for strategic development of policies, plans, and programs. Primary prevention is focused on preventing disease or harm and it engages in actions to prevent its initial occurrence. In HIV work, primary prevention programs focus on preventing HIV exposure to a group that engages in high-risk behaviors, such as unprotected sex or sharing of needles. Secondary prevention focuses on stopping or slowing down a disease or other harmful condition. In the case of HIV, secondary prevention workers focus on educating individuals who have already been diagnosed with HIV and are at risk for transmitting the virus to someone else. Secondary prevention workers will also work to help prevent exposure to other health risks that may complicate the ability to live with HIV. It is possible that social workers could be employed in programs that have both primary and secondary prevention goals or just one of these levels. Tertiary prevention is about reducing the risk of a relapse of a disease or damaging condition. It can be viewed as connecting people who are living with HIV to treatment. After connecting a person to treatment, effort is given to helping them stay in care and be adherent to the treatment or medication recommendations of their health-care providers (Driskell, 2013).

Regardless of the level of prevention targeted by a social worker, quality assessments of the individual client or client system are essential for quality client outcomes. When conducting individual-, group-, or community-level HIV risk assessments and designing prevention interventions, it is important for social workers to work from an ecological perspective and consider five types of factors: biological, psychological, demographic, sociocultural, and behavioral. Biological factors can impact the likelihood of HIV transmission. For example, if a person has another sexually transmitted disease, they can be more susceptible to HIV infection if they are exposed. Psychological aspects of a person, including how they think and feel, can impact their level of HIV risk. If a person feels that contracting HIV is inevitable and cannot be avoided, it increases their risk. Other psychological conditions that can complicate HIV prevention are feeling isolated, depressed, and anxious and having coping mechanisms that involve compulsive behaviors, including drug abuse. Demographic variables are also considered because a person’s age, race, area of residence, and sexual behaviors can put them at higher risk for HIV. For example, African Americans have disproportionately higher rates of HIV diagnoses, and these are shown to be associated with higher rates of poverty and unequal access to health care and prevention programs. Sociocultural factors also impact HIV risk. These can be numerous and may include cultural beliefs about health care, beliefs about condom use, gender-related power differences, sexual orientation, and impacts of stigma surrounding sexual behaviors and drug use. Behavioral factors are also very important when considering HIV risk reduction and prevention. Certain unprotected sexual behaviors and drug-use behaviors increase the chances of HIV infection (Driskell, 2013).

Modes of Transmission

To understand how social workers and other human service workers work toward HIV prevention, it is essential to understand what body fluids and behaviors transmit the virus. HIV lives and reproduces in the following human body fluids of someone who is HIV positive: blood, semen, preseminal fluid, breast milk, vaginal fluids, and anal mucous. Other substances, which do not carry significant amounts of HIV unless they have blood mixed with them, are feces, nasal fluid, saliva, sweat, tears, urine, and vomit. Health-care workers may have exposure to the following body fluids with high concentrations of HIV: amniotic fluid, cerebrospinal fluid, and synovial (joint) fluid (AIDS.gov, 2012a). To reduce stigma and irrational fear, social workers can help educate individuals and communities with regard to how HIV is not transmitted. These routes include shaking hands, using a toilet, using a drinking fountain, drinking from the same glass, sneezing, coughing, through mosquitos, or through pets. There is no risk of transmission through closed-mouthed kissing. There is a remote risk of transmission through deep, open-mouthed kissing if there are sores or bleeding gums and blood is exchanged. There are no documented cases of HIV being transmitted through playing sports, but there is a very low risk if there is direct body contact with a wound that is bleeding and blood is exchanged. HIV is not airborne or food borne (CDC, 2010).

Current HIV Incidence

HIV is transmitted through body fluids through very specific behaviors. Addressing unsafe instances of these behaviors is often the point of intervention for HIV prevention programs where social workers are active. Also relevant to HIV prevention workers are the specific population groups most impacted at the time. Over time, the pattern of HIV incidence by age group, racial group, and transmission category has evolved, thus causing a shift in prevention programming. In the early 21st century in the United States, HIV incidence—that is, the number of new cases in a period of time, such as a year—has remained stable. However, certain age ranges, racial groups, and behavior categories are disproportionately affected by new HIV diagnoses. Data from 2010 show that HIV incidence was highest among individuals aged 25 to 34 (31%), followed by ages 13 to 4 (26%), thus substantiating the need for prevention efforts targeted toward youth and young adults. The rate of new HIV diagnoses among males is 4.2 times that of females (CDC, 2013a).

In 2010 in the United States, African Americans (and other Blacks, such as Caribbean Blacks) continued to bear the most disproportionate burden of new HIV cases. Their incidence rate was 7.9 times as high as the rate in White Americans. The rate for Hispanic/Latinos was 3 times the rate for Whites. Men who have sex with men (MSM) continue to remain the most heavily affected population group. MSM is a term developed by the CDC to identify people at high risk for HIV by behavior, rather than by how they identify. Comparing 2008 with 2010, HIV incidence among MSM increased 12%, with a 22% increase in MSM aged 13 to 24. Although MSM represent about 7% of the male population in the United States, in 2010 MSM accounted for 78% of HIV incidence among males. Overall, when comparing 2008 with 2010, there were decreases in HIV incidence in women, including African American women. However, burden is still high among African Americans and MSM. There were sharp increases in youth, especially young African American MSM. These data show the need for focus on prevention of HIV transmission through male-to-male sexual contact (CDC, 2013a).

From a Crisis Climate to a Chronic Condition

AIDS, the medical condition that can develop from HIV, was first seen in 1981. In the three decades since those initial cases of AIDS, prevention strategies and care models have dramatically changed. This evolution is certainly the result of significant biomedical advancements, but also of its evolution as a social phenomenon. Unlike the crisis climate around AIDS in its first decade, there is now little panic in the United States about the virus. In fact, many people who identify themselves as low risk are not focused on HIV prevention at all. In a way, the pharmacological advancements have led to a societal apathy about HIV prevention.

The advent of antiretroviral medications is often considered the most significant positive development in the story of HIV and AIDS worldwide. It is said that when the first antiretroviral medication to treat HIV, AZT (zidovudine), first came on the market in 1987, people who at the time were dying with AIDS were able to get up and walk. This phenomenon of those on their deathbeds starting to live again is called the Lazarus effect, after the Biblical story of a man being raised from the dead. Since that time, there have been biomedical advancements and other positive developments that have improved the quality of life of those living with HIV and enhanced efforts to prevent transmission of the virus. In fact, the landscape of HIV prevention and care has evolved so much since the 1990s that Dr. Peter Piot, then executive director of UNAIDS (a joint program of the United Nations on HIV/AIDS), called for the global health community’s response to shift “from crisis management to sustained strategic response” (Piot, 2006). AIDS is now considered a treatable, but incurable chronic disease.

Pharmacologic Advances

The most significant biomedical advancements have been pharmacologic and have enabled many people living with HIV to keep their viral load (amount of HIV in their blood) suppressed, thus reducing the chances that they can transmit the virus. Antiretroviral therapy medications are now prescribed as a “drug cocktail,” which is a combination of three or more medications that maximally suppress replication of the HIV and stop the progression of HIV disease. With recent advances, the multiple medications can be combined in one pill. This combination regimen is called highly active antiretroviral therapy (HAART). Successful HAART will reduce the amount of virus in a patient’s blood and result in an increase in a patient’s CD4, or T-cell count, strengthening their immune response (WHO, 2013a).

For the first six years of the AIDS epidemic there were no medical treatments available, other than palliative care. The first antiretroviral medication for HIV was approved by the U.S. Food and Drug Administration (FDA) in 1987, with numerous other medications classified as antiretroviral therapies to follow. For a long time, the protocol for prescribing antiretroviral therapies was to start HAART when a patient’s CD4 count (number of T cells in the blood, which is part of the immune response) dropped below 200 cells per milliliter. Side effects were numerous and in some cases so severe that patients opted to stop the HAART medications. In recent years, new antiretroviral medications with fewer side effects were developed and approved by the FDA. Many of these medications also have combination formulations that allow for “one-pill-a-day” regimens, as opposed to the complicated, multidose, multipill regimens of the past. Over the years, guidelines about the optimal time to start HAART evolved to recommend starting taking medications sooner, such as when the patient’s CD4 count was 350 or lower or 500 or lower. In March 2012, U.S. treatment guidelines were updated to recommend initiating HAART for all people living with HIV, regardless of CD4 count or psychosocial variables (CDC, 2012a). The WHO recommends in its June 2013 guidelines (WHO, 2013b) for HAART to start immediately, regardless of CD4 count, for several groups including patients with HIV who are pregnant or lactating, have tuberculosis or liver disease, are children under the age of 5, or are in a sexual relationship with a person who is HIV negative. The recent changes in these national and worldwide policies have huge ramifications for health-care and social service workers who work toward HIV prevention. The new updates to the prescribing protocols indicate that HAART guidelines are significant to social-work practitioners who work with people living with HIV because they can provide support and education about the importance of medication adherence and compliance with other instructions given by medical providers. Further, HAART guidelines are also relevant to HIV prevention workers because HIV treatment work is now a major component of HIV prevention work.

Treatment as Prevention

HIV Testing

Early testing for HIV is seen as a key for curbing the HIV epidemic and is the cornerstone of secondary prevention. The majority of HIV tests do not test for the presence of HIV, but instead test for the presence of antibodies to the virus. These antibodies are proteins manufactured by the body in response to the infection, and they are much more easily detected. Following a positive HIV test, a more sensitive confirmatory test is usually performed. Next, two important tests are given to a person diagnosed with HIV: a CD4 (T-cell) count and a plasma HIV RNA assay, which quantifies the patient’s HIV viral load. These two tests will likely be given routinely for the rest of the person’s life.

There are two main types of HIV antibody tests. The first is the enzyme immunoassay test, which uses blood, urine, or saliva. This test is very accurate and less expensive, but can take up to 2 weeks for results. The second type is the rapid HIV antibody test, with different versions using blood, urine, and saliva. These can be expensive, but results can be delivered in 10 to 20 minutes. Following a positive result, a western blot HIV test is usually ordered, which can take up to 2 weeks for a confirmatory result. The availability of tests that deliver quick results enables HIV prevention workers to explain the result of the test, offer supportive counseling, and connect the client with needed services (Rowan & Holley, 2013).

Another type of HIV test is the PCR test, short for polymerase chain reaction test. The PCR does not test for HIV antibodies but instead for the genetic material of the virus itself. This test is routinely given to babies born to mothers who have HIV. It is also used to routinely test the blood supply in donation centers in developed countries. The PCR test can also be used to quantify the viral load in people with HIV.

There are two types of in-home HIV tests. The first kind, such as the Home Access HIV Test System, has been available for many years. A customer buys an over-the-counter blood or saliva sample collection kit from a drugstore and the specimen is sent to a laboratory for testing. Later, the results of the test are delivered by a phone counselor, who encourages people with positive results to seek medical care regarding their HIV diagnosis. The other type of in-home HIV test has been the subject of much controversy. As of July 2012, the FDA approved the over-the-counter sale of the OraQuick HIV rapid test (U.S. FDA, 2012). This is the same test that would be given through a medical or public-health clinic. Advocates for making the test available over the counter suggest that the benefit of the privacy this affords provides an avenue for HIV testing for people who are afraid to be seen taking a test. Further, the privacy of taking the test in one’s own home and observing a result in 20 minutes opens up options for those who are afraid of the stigma of a positive result. Opponents worry that people who receive positive results will not seek medical care, including a confirmatory test, or receive needed supportive counseling. They also caution that in-home testing does not allow for HIV prevention workers to interface with people who receive negative tests to provide accurate education regarding HIV risk reduction and testing for other sexually transmitted diseases. Nonetheless, the recent approval by the FDA has impacted the mission of social service agencies with HIV prevention programs, which used to be the only source of HIV testing outside of medical or public-health settings. Now clients can visit a drugstore to purchase an OraQuick HIV test, or even order one online, and immediately know their status in the privacy of their home.

Different countries of the world and various states across the United States have varied rules with regard to anonymous and confidential HIV testing. Confidential testing means that the results of a client’s HIV test will be attached to his or her name, shared with the medical provider and insurance company, and counted in surveillance data. However, the results are protected by privacy rules in the Health Insurance Portability and Accountability Act of 1996 (AIDS.gov, 2010). Anonymous testing allows for no method of tracing a result to a specific person. The client’s name is never collected and instead the results are linked to a person through a unique identifier. In-home testing allows for anonymous testing in states that require confidential testing.

Other Biomedical Advancements in HIV Prevention

National HIV/AIDS Strategy

Nearly 30 years after the beginning of the HIV pandemic, the United States released its first National HIV/AIDS Strategy (NHAS) in July 2010. Developed by the Obama administration, the NHAS is a comprehensive, coordinated plan to fight HIV and AIDS in the United States. The vision of the NHAS is as follows:

The United States will become a place where new HIV infections are rare and when they do occur, every person, regardless of age, gender, race/ethnicity, sexual orientation, gender identity or socio-economic circumstance, will have unfettered access to high quality, life-extending care, free from stigma and discrimination (Office of National AIDS Policy, 2011).

The National HIV/AIDS Strategy has three primary goals:

HIV Care Continuum Initiative

Although advancements have occurred, the reality is that an estimated one fifth of individuals with HIV in the United States are unaware of their positive status. In July 2013, the Obama administration issued an executive order creating the HIV Care Continuum Initiative. This effort is intended to mobilize and coordinate the federal response to recent advances in HIV testing, services, and treatment, and improve access to all three (Office of National AIDS Policy, 2013). The initiative will work toward further integration of HIV prevention and care efforts; promote expansion of successful HIV testing and service delivery models; encourage innovative approaches to addressing barriers to access of testing and treatment; and ensure that federal resources are appropriately focused on implementing evidence-based interventions that improve outcomes along the HIV care continuum (Office of the Press Secretary, 2013).

The HIV/AIDS Treatment Cascade

The term “HIV treatment cascade” is the centerpiece of recent conversations about problems and opportunities associated with delivery of HIV prevention and care services at federal, state, and county levels. This concept acknowledges the sequence of services necessary to move individuals with HIV through testing to complete and consistent viral suppression through successful HAART. The treatment cascade model addresses the NHAS call for a “more coordinated response” to the HIV epidemic by showing how individuals and communities are responding across the entire continuum of care. This model is comprehensive by addressing responses from diagnosis of HIV to active linkage to care, initiation of antiretroviral therapy, retention in care, and eventual sustained viral suppression (meaning there is no detectable HIV in the blood). The cascade model visually shows the number of individuals living in a region and where they “fall off” the continuum from HIV testing to viral suppression. Figure 1 shows that in the United States, only 28% of those diagnosed with HIV continue across the continuum of care to viral suppression. Put another way, only one of four people living with HIV in the United States successfully accesses the care they need (Valdiserri, 2012). At the International AIDS Conference in August 2012, CDC officials estimated that the percentage is probably closer to 25% completing the continuum and added that there are important disparities across race/ethnicity, age, gender, and risk factors. Data show that African Americans and youth are least likely to be receiving ongoing care and effective treatment (CDC, 2012b). Data can also be analyzed across the cascade at state and local levels, as well as across risk groups, to assess where resources are needed and to target them accordingly. Having data presented in a visual manner, such as the HIV/AIDS treatment cascade, can cause greater impact on funding sources and community stakeholders. The visual data can help social workers garner support for leveraging resources for at-risk individuals, families, organizations, and communities.

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Figure 1. Percentage of individuals with HIV engaged in selected stages of the continuum of HIV care (CDC, 2013d).

Elimination of the Travel Ban

In October 2009, President Barack Obama lifted the 22-year-old ban on travel to the United States by people who are living with HIV in other countries. The United States was 1 of only 12 countries in the world with such a ban. The repeal of the ban was considered long overdue because it served to reinforce a stigma against people living with HIV. Shortly after the repeal, a major international AIDS conference was scheduled to be held in Washington, DC, in 2011, a venue that during the ban was not considered for hosting the leading HIV researchers and practitioners of the world (AIDS Healthcare Foundation, 2009).

Needle-Exchange Program Funding

Needle-exchange programs (also called syringe-exchange programs) have been found to be effective as a harm reduction approach. Rather than sharing dirty needles, injection-drug users can exchange them for sterile needles. In 2005, the CDC reported that needle-exchange programs contributed to an 80% reduction in HIV risk behaviors and a 30% reduction in HIV transmissions (AIDS Action, 2009), making them a cost-effective and successful strategy. Exchange programs usually offer HIV testing, counseling services, and referrals for substance-abuse treatment in conjunction with “no questions asked” needle exchanges. Critics long believed that provision of injection-drug paraphernalia would encourage and even endorse illegal drug use, resulting in a ban in 1989 on the use of federal dollars for these programs. In December 2009, President Obama signed into law an end to the longstanding ban on the use of federal money for needle-exchange programs. However, in December 2011, based on arguments against providing injection supplies to illegal drug users, Congress voted to reinstate the ban on using tax dollars to support needle-exchange programs (Office of National Drug Control Policy, 2012). Therefore, needle-exchange programs, which remain the cornerstone of HIV prevention efforts for injection-drug users, must continue to seek funding through sources other than the federal government.

Tenth Anniversary of PEPFAR

President Obama has been praised for his outspoken support for the efforts to end HIV in the United States, such as developing the first National HIV/AIDS Strategy, lifting the travel ban on HIV-positive visitors, fighting against the ban on funding for needle exchanges, and creating the new HIV Care Continuum Initiative. However, before him, President George W. Bush was active in and praised for his efforts to end HIV/AIDS worldwide. The U.S. President’s Emergency Plan for AIDS Relief (PEPFAR) is the largest commitment by any nation in history to fight a single disease. In June 2013, the PEPFAR program celebrated its 10th anniversary, announcing as its motto the ambitious but potentially attainable goal of “Working toward an HIV-free Generation.” Through PEPFAR, the U.S. government has committed over $46 billion to fight the global pandemic in underresourced countries of the world (U.S. President’s Emergency Plan for AIDS Relief, 2013). PEPFAR estimates that in the past 10 years it has funded efforts to connect 5.1 million people in underdeveloped areas with antiretroviral therapy and enabled 1 million babies to be born without HIV to positive mothers who have the virus. A new Key Populations Challenge Fund has been created to invest $20 million worldwide to specifically reach MSM, injection-drug users, and commercial sex workers with HIV prevention and care services (U.S. Department of State, 2013a).

Although the U.S. commitment to partner with other nations toward an HIV-free generation worldwide is admirable and aligns well with social-work values, it is not without its critics. One criticism was that although HIV incidence decreased through the introduction of antiretroviral therapy, rates of incidence did not drop as much as expected. Many speculated that PEPFAR initially invested in programs that were not culturally appropriate for the region of the world where they were deployed, often pushing an Americentric model. Further, faith-based organizations that received a large portion of PEPFAR funding initially used an abstinence-only approach to HIV prevention, which imposed social values on other cultures and was not practical for heterosexual couples desiring to have children. Eventually, restrictions were eased and prevention approaches that included condom distribution and education were added. Another criticism was that the massive financial investments of U.S. funds in medications and programming could have been spent on addressing domestic HIV problems (Rowan, 2013).

HIV Risk Reduction and Safer Sex Continuum

In the early 21st century, HIV prevention work with individuals is characterized by an approach that includes risk screening and a harm reduction approach. Because it is naive to believe that the old “ABC” (abstinence, be faithful, use condoms) message is appropriate or complete, new approaches aim to assess the level of sexual risk behaviors and help the client move toward safer sex behaviors on the sexual risk continuum. The safer sex HIV risk continuum is as follows, for these unprotected (no condom) behaviors (AIDS.gov, 2012c; Rowan & Holley, 2013):

It is essential that clients be educated that this continuum does not apply to other sexually transmitted infections, such as herpes and human papillomavirus, and conditions such as pubic lice. For example, oral sex can easily spread herpes but is unlikely to spread HIV. Also, inclusion of correct and consistent use of a condom significantly reduces the risk of each sexual behavior.

For high-risk individuals, a prevention case management model may be appropriate. Prevention case management combines risk-avoidance counseling with traditional case management. Components can include assessment for health-related risks other than HIV, such as hepatitis B and C; assessment for mental-health or substance-use treatment services; safety planning for people in abusive relationships; counseling regarding previous and current trauma; crisis intervention services; and referral and linkage to and monitoring of related medical and supportive services (Brooks, 2010; Edwards & Rowan, 2013).

Evidence-Based Behavioral Risk-Reduction Interventions

Evidence-based interventions are those that have proven to be effective through scientific evaluation of outcomes. The intervention models are expected to be effective if they are replicated with “integrity”— that is, as closely to the protocol described in the original study or studies as possible. An intervention’s measure of fidelity is the degree to which its implementation adheres to the model that was originally tested. In social work, competent evidence-based practice combines well-researched models with clinical experience, social-work ethics, client preferences, and cultural factors in delivery of services. Therefore, effective implementation of behavioral HIV prevention interventions based on published studies requires social workers, clients, and researchers to work together to maintain fidelity to the extent possible, while adapting models to address specific characteristics of target population groups. Through the process of tailoring interventions to cultural, age-based, race-specific, regional, behavioral risk factor–specific, or other unique variables, interventions can be adapted to be more successful in preventing HIV transmission with targeted, high-risk groups of people (Social Work Policy Institute, 2010).

Since the beginning of the 21st century, behavioral researchers have produced a large array of successful, evidence-based interventions for targeted HIV prevention. The CDC has made a commitment through the creation of the High-Impact HIV/AIDS Prevention Program in 2011 to make materials for evidence-based intervention models easily available to local HIV prevention programs. The program replaced the Diffusion of Behavioral Interventions Program, which was started in 1989 and is well known to HIV prevention program planners and researchers. Currently, the CDC’s online Compendium of Effective HIV Prevention Interventions lists 74 risk-reduction evidence-based interventions. Through rigorous scientific evaluation, they are classified as having either best evidence or good evidence, with results demonstrating efficacy for individual-, group-, and community-level behavioral interventions. Further, they are classified by the high-risk populations with whom they were tested (CDC, 2011).

Effectiveinterventions.org is an easily accessible website that describes the components of each successful evidence-based HIV prevention intervention. Social workers interested in securing grant funding through governmental programs or foundations can use these models to construct programs based on scientific evidence that show success when they are implemented with fidelity and with the population group for which they were designed. A few of the 74 currently available are described below. Note how each is customized for a specific risk factor, age, race, or sexual minority group and intervenes at the individual, group, or community level.