Infection Prevention and Control Strategies for HIV/AIDS in Ambulatory Care: Utilizing the National HIV/AIDS Strategy for the United States 2022-2025

HIV/AIDS

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HIV has affected the lives of millions throughout the US since it was first discovered in 1981. Through years of collaborative efforts and research advancements, the nation has implemented effective HIV diagnostics, prevention strategies, and improved care and treatment models. CDC data show that new HIV infections fell 8% from 2015 to 2019.¹ Although this is an impressive trend in the progress of addressing the HIV/AIDS epidemic, there are still opportunities to make more effective use of the powerful HIV prevention, care, and treatment tools now available.

According to the vision presented in the National HIV/AIDS Strategy (NHAS), “the US will be a place where new HIV infections are prevented, every person knows their status, and every person with HIV has high-quality care and treatment, lives free from stigma and discrimination, and can achieve their full potential for health and well-being across their lifespan.” Acknowledging that an estimated 1.2 million people in the US had HIV at the end of 2019, how can ambulatory care facilities play a role in addressing this serious public health challenge in the US?²

The 2022-2025 National HIV/AIDS Strategy

The NHAS was developed by the White House Office of National AIDS Policy (ONAP) through federal partnerships and with valuable feedback from the HIV community across the US. On June 5, 2021, the Biden-Harris administration reestablished the ONAP within the White House. The 2022-2025 iteration of the NHAS seeks to provide a detailed and coordinated response to end the HIV epidemic in the US by 2030. To do so, the NHAS has adopted aggressive targets, calling for a 75% reduction in new HIV infections by 2025 and a 90% reduction by 2030, which equates to fewer than 3000 individuals being infected with HIV per year.¹ The US is making significant progress in improving HIV outcomes; however, gaps in the HIV continuum of care appear to be driving HIV transmission, as 1 in 3 people with HIV is not receiving needed HIV care, equating to only 57% of people with HIV being virally suppressed. By recognizing the goals, specific objectives, and objective-based strategies outlined in the NHAS, ambulatory clinics can aid in the fruition of the vision.

Increasing Knowledge of HIV Status

The most effective strategy to reduce new HIV infections is to ensure timely diagnosis and engagement of people with HIV so they achieve and maintain viral
suppression and subsequently not transmit the virus. Prolonging the time a person is unaware of their positive HIV status increases the potential for HIV transmission and new HIV infections. Regardless of specialty, ambulatory clinics can test all people for HIV, at minimum, according to the most current US Preventive Services Task Force (USPSTF) recommendations and CDC guidelines. It has been reported that a considerable number of patients with HIV had experienced missed opportunities for diagnosis, even while expressing an increased risk of infection. USPSTF recommends that clinicians screen for HIV in adolescents and adults aged 15 to 65 years.3 Younger adolescents and older adults who experience an increased risk of infection should also be screened.³ USPSTF also recommends that clinicians screen for HIV infection in all pregnant women, including those who present in labor or at delivery with unknown HIV status.³ The CDC recommends that everyone aged 13 to 64 years get tested for HIV at least once as part of routine health care,⁴ as well as testing at least annually for those with specific risk factors.^5,6

Ambulatory clinics possess a greater probability of addressing missed opportunities for HIV testing due to the probability that individuals will seek some form of health care in an ambulatory facility. Using these circumstances could improve diagnosis delays, disease progression, and lack of access to HIV care and treatment.

Implementing Automated Best Practice Advisories

Clinicians in ambulatory care settings utilizing an electronic medical record (EMR) system can develop and implement simple automated interventions that employ the EMR to provide best practice advisory (BPA) reminders and prepopulate an order for HIV testing. Although the current USPSTF and CDC recommendations have been in place for several years, many ambulatory care settings still have no or limited screening programs to include any program that utilizes automation within the EMR. Studies show that this may be due to perceived barriers such as increased burden on staff, competing priorities, and workflow disruption.⁵ Using an automated BPA could improve the perception of these barriers and increase screening rates. Improved screening rates are a key element of status-neutral testing.

FIGURE. CDC STATUS NEUTRAL HIV CARE AND SERVICE DELIVERY⁷

PrEP, pre-exposure prophylaxis; SSP, syringe service program; STD, sexually transmitted disease.

Source: CDC. Material is otherwise available on the agency website for no charge.

Incorporating a Status-Neutral Approach to Testing

The status-neutral approach to HIV testing offers prevention services to individuals who test negative, as well as immediate connection to HIV treatment and additional resources for those who test positive.¹ Ambulatory care settings choosing to embrace a status-neutral approach to HIV services can aid in HIV testing, serving as an entry point to resources regardless of status, thus improving HIV prevention and care outcomes. This interconnected continuum of care will allow those who test negative for HIV to be introduced to and offered prevention tools, such as preexposure prophylaxis, information about access to condoms, and sexual health and harm reduction services. This pathway promotes consistent testing, which allows for a more seamless transition to treatment for people who may later test positive for HIV.

For those who test positive, these individuals can be quickly prescribed medications to help them achieve and maintain an undetectable status while also meeting their non–HIV-related health care needs. Supporting the practices that lead to an undetectable viral load essentially eliminates the risk of new HIV infections through sexual HIV transmission while also allowing individuals who are HIV positive to live long, healthy lives. This methodology acknowledges whole person health, which provides care to individuals not based solely on their HIV status but helps to empower “individuals, families, communities, and populations to improve their health in multiple interconnected biological, behavioral, social, and environmental areas,”⁶ according to the NIH. By embedding HIV prevention and care into routine care, which often takes place in ambulatory settings, this sector of health care can help advance “health equity by integrating HIV prevention and care with strategies that address social determinants of health and barriers to accessing and remaining engaged in care,”^1,7 according to The National HIV/AIDS Strategy [Figure].

Summary

The reduction of new HIV cases is predicated on individuals knowing their HIV status. Despite CDC and USPSTF recommendations for widespread HIV screening in health care settings, HIV testing remains delayed, even among those with known risk factors and frequent health care encounters. For example, in one study, approximately half of all gay and bisexual men and people who inject drugs who had been newly diagnosed with HIV were unaware of their infection until diagnosed during the study. The study participants reported that no health care provider had offered them HIV testing despite having seen one within the previous year.⁸

Removing barriers to HIV screening through an automated BPA may improve this problem. An automated BPA is often a simple intervention for most EMR systems and should become a best practice of care within ambulatory care facilities. Because of the frequency of visits, ambulatory care facilities have an increased opportunity to screen individuals for HIV testing. There remains an opportunity to examine ways to restructure staff and workflows, implement technology-based solutions, and enhance quality improvement programs to adequately adopt a status-neutral approach to HIV testing.

References

1. National HIV/AIDS Strategy for the United States 2022–2025. The White House; 2021. Accessed September 12, 2024. https://www.whitehouse.gov/wp-content/uploads/2021/11/National-HIV-AIDS-Strategy.pdf
2. HIV Surveillance Supplemental Report: Estimated HIV Incidence and Prevalence in the United States, 2015–2019. CDC; 2021. Accessed September 12, 2024. https://www.cdc.gov/hiv/pdf/library/reports/surveillance/cdc-hiv-surveillance-supplemental-report-vol-26-1.pdf
3. Human immunodeficiency virus (HIV) infection: screening. US Preventive Services Task Force. June 11, 2019. Accessed September 12, 2024. https://www.uspreventiveservicestaskforce.org/uspstf/recommendation/human-immunodeficiency-virus-hiv-infection-screening#:~:text=to%2065%20years-,The%20USPSTF%20recommends%20that%20clinicians%20screen%20for%20HIV%20infection%20in,infection%20should%20also%20be%20screened
4. Branson BM, Handsfield HH, Lampe MA, et al. Revised recommendations for HIV testing of adults, adolescents, and pregnant women in health-care settings. MMWR Recomm Rep. 2006;55(RR-14):1-CE4.
5. DeMarco RF, Gallagher DM, Bradley-Springer L, Jones SG, Visk J. Recommendations and reality: perceived patient, provider, and policy barriers to implementing routine HIV screening and proposed solutions. Nurs Outlook. 2012;60(2):72-80. doi:10.1016/j.outlook.2011.06.002
6. Whole person health: what it is and why it’s important. National Center for Complementary and Integrative Health. Updated May 2021. Accessed September 12, 2024. https://www.nccih.nih.gov/health/whole-person-health-what-it-is-and-why-its-important
7. Issue brief: status neutral HIV care and service delivery. CDC. Reviewed May 16, 2024. Accessed September 12, 2024. https://www.cdc.gov/hiv/policies/data/status-neutral-issue-brief.html
8. Wejnert C, Prejean J, Hoots B, et al. Prevalence of missed opportunities for HIV testing among persons unaware of their infection. JAMA. 2018;319(24):2555-2557. doi:10.1001/jama.2018.7611