Behavioral Interventions for Prevention in HIV Care

The advent of highly active antiretroviral therapy (ART) for the treatment of human immunodeficiency virus (HIV) infection in the mid-1990s leading to dramatic improvements in HIV-related morbidity and mortality, also heralded a fundamental shift in the public health approach of HIV prevention—from the prevention of HIV acquisition among the HIV uninfected that focused on safer sexual and needle use practices, to prevention of ongoing transmission from those infected. Prior to the ART treatment breakthrough, HIV care had not much to offer beyond management of opportunistic infections and palliative care. At the time, for those at risk for HIV infection, there was little incentive for HIV testing and receiving a dreaded diagnosis, especially when asymptomatic. The prospect of better health outcomes, including for asymptomatic HIV-infected persons with low CD4 counts, changed the attitude towards HIV testing and care, and national programs such as the Serostatus Awareness to Fighting the Epidemic (SAFE) campaign, launched in 2001, actively promoted HIV testing, even among lower risk populations, and linkage to HIV care for those found to be infected [1]. Two subsequent developments have further strengthened this approach. First, a growing body of observational and randomized intervention studies, unequivocally demonstrated the benefits of antiretroviral treatment immediately after HIV diagnosis regardless of level of immunosuppression as measured by CD4 count [2], thus further stimulating early diagnosis and treatment. Second, while it was long thought that HIV viral suppression through the use of ART would reduce the likelihood of HIV transmission, the proof of this concept and the dramatic efficacy of “treatment as prevention” (TasP) was not demonstrated until the results of the HPTN052 study were published in 2011 [3]. A corollary of this fundamental insight were findings from contemporaneous studies showing the efficacy of ART in preventing the acquisition of HIV, a practice now commonly referred to as pre-exposure prophylaxis (PrEP) [4, 5]. Together, PrEP and TasP have revolutionized HIV prevention from a paradigm that was dominated by efforts to change high-risk behaviors, to one that emphasizes the use of antiretroviral treatment for both the prevention of viral acquisition and forward transmission. However, while behavior change interventions benefited the H. Burnside (&) Denver Public Health, Denver Health, Denver Prevention Training Center, 605 Bannock Street, MC2600, Denver, CO 80204, USA e-mail: [email protected]