The importance of HIV counseling

With significant advances in HIV treatment over the last ten years, including Pre-exposure prophylaxis (PrEP) treatment and improved medication regimes for those who have the virus, public alarm about acquiring HIV has ebbed.

However, Mellissa Withers, PhD, associate professor at the USC Institute on Inequalities in Global Health at the University of Southern California Keck School of Medicine in Los Angeles, suggests that physicians still need to counsel patients to use protection and get screenings for the virus because it infects an estimated 38,000 people in the United States alone every year.

“Because [living with HIV] is not a death sentence anymore, people aren’t using condoms and they’re still engaging in risky behaviors,” Withers says.

Worse, she says, as much as 14 percent of the 1.1 million people who live with HIV in the U.S. don’t have any symptoms.

Because there are a lot of different ways to acquire HIV, Withers urges physicians to suggest HIV screening to all patients and to not make assumptions about who might need such a screening.

“Just make the recommendation standard in your practice and at least offer testing to everybody,” she says.

Withers says physicians should counsel patients not to have unprotected sex until both/all partners have had cleared health screenings. “Even if you’re in a monogamous relationship, there’s a small window where an HIV test might not detect something in the first few months,” she says.

Even for people who use PrEP, they should also use prophylactic protection, Withers encourages, since PrEP doesn’t protect against other STIs.

Since bringing up the topic of HIV is often sensitive, she suggests physicians discuss the issue of screening with a simple script, such as:

“A lot of people who have HIV don’t know they have it, and there are a lot of different ways to acquire HIV. Even if you don’t have symptoms, you may still have it, so it’s really important to get on medication as early as possible if you have it. Have you ever been screened for HIV?”

Screening is important because early diagnosis is key, Withers says. Treatment is much more effective the earlier a patient can get on the medication.

Treatment is also a form of prevention.

“The treatments have now come so far that HIV can be effectively managed and the viral load reduced so it’s really undetectable. This pretty much eliminates the chance that it could be passed onto someone else, at least during sex,” she explains.

While treatment for HIV has made it possible for people with the virus to live almost as long as normal life expectancy, Withers points out there are other considerations, such as childbearing that have to be handled carefully when a person is infected. “A large percentage of people who have HIV get diagnosed young, and they may want children,” Withers says.

It is now possible for partners with HIV to successfully have children without passing on the virus, but it requires assisted reproductive technologies and cesarean birth, and not everyone may be able to afford to do those things.

Additionally, people who have the virus must regularly have their viral load assessed with frequent blood draws, and must be disciplined about taking their medications.

If physicians screen a patient who turns up positive for HIV, Withers says they should refer that patient to an infectious disease specialist, though the providers may work together to coordinate care.

Physicians might also want to refer an HIV-positive patient to a mental health provider, since, Withers says, “It can be a big shock and people can get depressed.”

Of equal importance in stopping the spread of the virus, she says, “Physicians should have a discussion with the patient about disclosure to their partner or partners. Embarrassment and shame sometimes mean that a patient doesn’t disclose and that, obviously, is a problem.”

In fact, physicians are mandated by law to report cases of HIV to their county public health department.

Regular screenings and simple conversations can stop the spread of this once-devastating virus.