Despite substantial advances in the treatment of human immunodeficiency virusAIDS infection, the estimated number of annual new HIV infections in the United States has remained at 40,000 for over 10 years. HIV prevention in this country has largely focused on persons who are not HIV infected, to help them avoid becoming infected. However, further reduction of transmission of HIV will require using some new strategies, including more emphasis on stoping transmission of HIV. People who are infected with HIV and are aware tend to reduce risky behaviors that might transmit HIV to others. Nonetheless, recent reports suggest that such behavioral changes often are not maintained and that a substantial number of HIV-infected persons continue to engage in behaviors that place others at risk for HIV infection.

Reversion to risky sexual behavior might be as important in HIV transmission as failure to adopt safer sexual behavior immediately after receiving a diagnosis of HIV. Unprotected anal sex seems to be happening more often in some urban centers, especially amoung young men who have sex with other men. Viral and bacterial STDs in HIV infected patients receiving care has been noticed more frequently, indicating ongoing risky behaviors. Despite the decline in syphilis infection rate in the general U.S. population, continued outbreaks of syphilis in MSM, many of whom are co-infected with HIV, continue to happen in some areas; rates of gonorrhea and chlamydial infection have risen in this population as well. Increased STD rates amoung MSM show increased potential for HIV transmission, both these rates suggest ongoing risky sexual behavior, and because STDs increases HIV’s infectivity and susceptibility. Studies suggest that optimism about the effectiveness of highly active antiretroviral therapy (HAART) for HIV may be contributing to relaxed attitudes toward safer sex practices and increased sexual risk-taking by some HIV-infected persons.

Injection drug use also continues to play a key role in the HIV epidemic; at least 28% of AIDS cases among adults and adolescents with known HIV risk category reported to CDC in 2000 were associated with injection drug use. In some drug using communites, HIV seroincidene and seroprevalence in injection drug users has declined recently. This decline has been attributed to several factors, including increased use of sterile injection equipment, declines in needle-sharing, shifts from injection to noninjection methods of using drugs, and cessation of drug use. However, injection-drug use among young adult heroin users has increased substantially in some areas a reminder that, as with sexual behaviors, changes to less risky behaviors may be difficult to sustain.

Doctors and Clinicians caring for HIV-infected persons can help play a key role in help their patients reduce their risk factors. Caregivers can make a big difference to affect patients’ risk factors for transmission of HIV to other people by performing brief tests for HIV transmission risk factors; communicating safe practices; talking about sexual and drug use behavior and positively reinfocing changes to safer behavior. These steps may also help to decreaste a patients’ risks of getting other STDs and bloodborne infections (e.g., hepatitis). Managed care plans can play an important role in HIV prevention by incorporating these recommendations into their practice guidelines, educating their providers and enrollees, and providing condoms and educational materials. Prevention services might be delivered in a clinical or office setting or even through referral to community programs. Some clinicians have expressed concern that reimbursement is often not provided for prevention services and note that improving reimbursement for such services might enhance the adoption and implementation of these guidelines.

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