The following information on HIV/AIDS for health care professionals was developed with support from the HIV/AIDS, Hepatitis, STD, and TB Administration (HAHSTA) of the District of Columbia's Department of Health. 

HIV in Primary Care

Washington, DC has the highest rate of HIV infection in the country, and 1 out of 5 don't know they are infected.

Early detection and treatment can turn a potential fatal disease into a manageable chronic illness.

• Although HIV care should be co-managed with an ID specialist, primary care doctors play a central role in the care of these patients.

HIV can be prevented by a few simple strategies, including:

• Engaging in safer sex practices (female and male condoms).

• Using a new needle for each injection for IV drug users.

• Screening and treating for HIV during pregnancy.

Most patients with HIV have no symptoms.

Major principles for managing HIV in primary care:

• Test all adults age 13-84, regardless of perceived risk.

• Test all pregnant women and those with active TB or any newly diagnosed sexually transmitted disease.

• Inform you patients that in DC we include HIV testing for everyone 13 and older unless they choose not to get tested ("opt-out").

• There is no requirement for signed consent or pre- or post-test counseling.

For people who may have been exposed to HIV, offer post-exposure prophylactic medications to all healthcare workers, and to non-healthcare workers who have had a high-risk exposure. Refer all patients with potential HIV exposure immediately to an emergency room for evaluation and treatment.

Epidemiology of HIV in Washington, DC

Nearly 15,000 residents of the District of Columbia, or nearly 3% of the population, are living with HIV.

In DC, there are high rates of new HIV cases occurring in men who have sex with men, who may or may not identify themselves as gay or bisexual. Many new infections also occur among heterosexual men and women.

Although most cases of HIV in the US occur in whites, there are proportionally more cases among blacks and Hispanics.

Women are much more likely to contract HIV heterosexually than are men. IV drug abuse accounts for about 10% of new HIV cases.

You can't tell by looking. Many people who fit with no conventional stereotypes of "HIV patients" are infected with HIV. That is why both the DC Department of Health and the federal Centers for Disease Control recommend universal testing.

Screening: Who, when, and why to test

The DC Department of Health (DOH) recommends testing everyone ages 13-84.

This should be done on an "opt-out" basis; that is, the patient is notified that HIV testing will be performed, and has the option to decline.

• Counsel those who opt out about the benefits of early diagnosis.

• Neither written consent nor prevention counseling are required to test for HIV (both can discourage testing).

• Universal testing can help identify the between 20% and 40% of infected DC residents who do not know they are infected. This will allow them to be treated, and can also reduce transmission to others.

Test all patients with a sexually transmitted infection or active TB.

Test all pregnant women as early as possible in the pregnancy, ideally in the first trimester.

• Repeat screening in the third trimester in high-prevalence states. The District, Maryland, and Virginia are all considered areas of high prevalence.

• Timely diagnosis during pregnancy can prevent perinatal infection of infants. 

Several conditions are more common in patients with HIV, and should prompt HIV testing:

• Herpes zoster

• Seborrheic dermatitis

• Thrush

• Recurrent vaginal candidiasis

Post-exposure prophylaxis (PEP) is a medical urgency

After a needlestick exposure, the use of PEP can reduce the risk of HIV acquisition by ~ 80%.8 Administer PEP as soon as possible, and definitely within 72 hours of exposure, and continue it for 28 days.

The CDC recommends PEP for people exposed to HIV by:

•a percutaneous injury (e.g., needle-stick or cut);

•contact with blood, tissue, or potentially infected fluid* on mucous membranes/non-intact skin.

The precise regimen depends on the nature of the exposure, and the status of the patient.

• It generally consists of 2 nucleoside reverse transcriptase inhibitors (NRTIs) such as the combination pill, Truvada, and

• a protease inhibitor (PI), such as Kaletra, may be added for severe exposures.

If a patient seeks care after possible exposure through sexual contact (consensual or forced), drug use, or another source of exposure, the intervention needs to be immediate.

1) Initiate ARV treatment.

2) Contact an infectious disease specialist, but do not allow this to delay treatment initiation.

3) Send patient to the emergency room if contacted outside of office hours.

• Test for HIV and other sexually transmitted diseases (including hepatitis B and C);

• Counsel on risk reduction and emergency contraception if appropriate;

• Follow up at 1, 3, and 6 months for repeat HIV, syphilis, hepatitis B and hepatitis C serologies.

Ways to reduce HIV transmission

HIV transmission between partners can be prevented by early antiretroviral therapy in the infected partner.7 Successful antiretroviral therapy (e.g., that achieves very low viral loads) can sharply reduce the risk of infecting a sexual partner.

Pre-exposure prophylaxis (PrEP) of daily emtricitabine and tenofovir can reduce HIV acquisition by 44 to 78%. For more information: www.cdc.gov/hiv/prep.

Male circumcision reduces the risk of heterosexually acquired HIV infection in men. For more information: www.malecircumcision.org.

If an HIV-positive patient wants to participate in a vaccine trial, refer to the HIV Vaccine Trials Network (HVTN) at www.hvtn.org.

Syringe exchange programs reduce HIV transmission in injectable drug users by providing a way to safely dispose of used syringes and obtain sterile syringes at no cost.