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# Section 1. Introduction
This Summary for Nonclinical Providers contains the subset of recommendations for nonclinical providers who work in community-based organizations or health departments operating outside health care facilities from the 2014 guideline, Recommendations for HIV Prevention with Adults and Adolescents with HIV in the United States, 2014. i The guideline includes new and longstanding federal guidance on biomedical, behavioral, and structural interventions that can decrease HIV transmission from persons with HIV by reducing their infectiousness and their risk of exposing others to HIV. The guideline updates and expands earlier federal guidance for clinical providers in the 2003 Recommendations for Incorporating HIV Prevention into the Medical Care of Persons Living with HIV. ii The 2014 guideline and this Summary were developed by the Centers for Disease Control and Prevention, the Health Resources and Services Administration, the National Institutes of Health, the American Academy of HIV Medicine, the Association of Nurses in AIDS Care, the International Association of Providers of AIDS Care, the National Minority AIDS Council, and the Urban Coalition for HIV/AIDS Prevention Services.
A Summary for Clinical Providers iii is directed to professionals who provide HIV prevention and care services in health care facilities.
A Summary for Health Departments and HIV Planning Groups iv is directed to professionals who provide population-level services to communities affected by HIV.

# Section 2. About the Summary

# Who is this Summary for?
This Summary is for nonclinical providers who provide individual-level services for persons with HIV in community-based organizations or health departments operating outside of health care facilities. These providers offer HIV testing, health education, riskreduction interventions, partner services, case management, or assistance with linkage or referral to medical and social services. These persons include HIV testing providers, peer and professional health educators, counselors, service linkage facilitators, partner services specialists, case managers, and social workers.

# What does this Summary include?
 Recommendations related to 11 domains of interventions that can decrease HIV transmission by reducing the infectiousness of persons with HIV or by reducing their risk of exposing others to HIV. In some cases, recommendations for nonclinical providers to offer an intervention  were based on federal guidance for clinical providers, but the federal workgroup of experts that developed the recommendations concluded that it would also be beneficial and feasible for nonclinical providers to offer these interventions.
 Examples of practical strategies to support implementation of these recommendations  A list of links to federal guidance that supports these recommendations (Appendix A)
 A link to an online Resource Library of practical materials to help implement these recommendations

# How to use the Summary?
Nonclinical providers can use this Summary - to  Learn how they and their organizations can promote HIV prevention with their clients with HIV  Select interventions that may be well-suited to their clients with HIV  Train staff on best practices in HIV prevention with persons with HIV

# Additional information about the 2014 Recommendations for HIV Prevention with Adults and Adolescents with HIV in the United States
The complete guideline is available at . It is directed to professionals who serve individuals or populations with HIV: clinical providers, nonclinical providers, and staff of health departments and HIV planning groups. It includes:
 Executive summary The sequential box and table numbers in the complete guideline (which is directed to several different audiences) are not identical to the sequential box and table numbers in this Summary that only lists information for nonclinical providers).

# Section 3. The Context of Prevention with Persons with HIV Background
Individual, social, structural, ethical, legal, and policy issues shape the lives of persons with HIV and their ability to use HIV prevention and care services and adopt HIV prevention strategies. This section makes general recommendations about these contextual issues.
Nonclinical providers working outside of health care facilities who understand these issues are better prepared to create a sense of shared responsibility and decision making with their clients with HIV. This may include  motivating clients with HIV to adopt prevention strategies and obtain essential services  endorsing the strategy of "treatment as prevention" to contribute to community well-being  communicating in a sensitive, respectful, and culturally competent manner

# Encourage
 Communication that does not stigmatize or negatively judge persons with HIV or their gender identity, sexual orientation, sexual and drug-use behaviors, and medical or social characteristics  Provision of information about rights and responsibilities of persons with HIV regarding confidentiality, privacy, protection from discrimination, and partner notification  Planning by persons with HIV to notify exposed sex and drug-injection partners through partner notification assistance or self-disclosure that reflects an understanding of the benefits and risks of HIV disclosure in the jurisdiction  Access to services and devices (e.g., condoms) that improve the knowledge, ability, and motivation of persons with HIV to improve their health, protect the health of partners, and reduce transmission of HIV Nonclinical providers working outside of health care facilities can play a crucial role in informing clients about the advantages of starting ART early, supporting adherence to long-term ART use, and providing information on other interventions that can reduce the risk of HIV transmission. Nonclinical providers can also inform clients with HIV about the availability of prophylactic medications for their HIV-uninfected partners when clinically indicated to reduce their risk of HIV acquisition. Some recommendations for nonclinical providers to provide adherence information, education and support were based on federal guidance for clinical providers. However, the federal workgroup of experts that developed the recommendations concluded that it would also be beneficial and feasible for nonclinical providers with appropriate training to offer these services.
Other sections of this Summary address adherence to ART (Section 6); antiretroviral medication use by women using hormonal contraceptives and persons seeking conception (Section 10); use of ART and prophylaxis during pregnancy and the postpartum period (Section 11); and quality improvement and program evaluation (Section 13).

# Recommendations Box 5. Recommendations-Antiretroviral Treatment for Care and Prevention

# Initiating or resuming antiretroviral treatment (ART)
 Inform all persons with HIV about the following issues regarding antiretroviral treatment (ART) (i.e., treatment with highly effective combinations of antiretroviral drugs to suppress HIV replication) (see Box 5-A):
The health benefits of early initiation of ART, including
- improving or maintaining health when compared with later initiation of ART
- prolonging lifespan
- reducing risk of HIV transmission to others a  The limitations of ART, including
- the need for lifelong treatment
- the need for high adherence
- potential medication side effects
- the use of ART substantially reduces, but may not eliminate, the risk of HIV transmission

# The availability of HIV prophylaxis for uninfected partners when clinically indicated to reduce risk of HIV acquisition
 Inform all persons with HIV (and any of their HIV-uninfected partners referred for evaluation) about the following HIV prophylaxis issues b,c (see Box 5-B):
The availability of preexposure prophylaxis (PrEP) and nonoccupational postexposure prophylaxis (nPEP) for HIV-uninfected partners when clinically indicated to reduce their risk of HIV acquisition

# Section 6. Antiretroviral Treatment Adherence Background
Sustained high adherence to antiretroviral therapy (ART) is essential to improve clinical outcomes and quality of life of clients with HIV and decrease their risk of HIV transmission. The success of ART depends on the extent to which a client takes ART according to the prescribed doses, dosing intervals, and other medication instructions.
Nonclinical providers working outside of health facilities can help their clients achieve high ART adherence by collaborating with clinical providers on adherence support, such as counseling about the benefits of high adherence, training on medication reminder tools, and case management services. Some of the federal guidance that served as the basis for these recommendations for nonclinical providers was intended for health care providers. Based on opinions of the Project Workgroup and recent program experience, the writing group concluded that it would be beneficial and feasible for nonclinical providers to implement these recommendations.
Other sections of this Summary address linkage and reengagement in HIV medical care (Section 4), initiating or resuming ART (Section 5); antiretroviral medication use by women using hormonal contraceptives and persons seeking conception (Section 10); use of ART and prophylaxis during pregnancy and the postpartum period (Section 11); and quality improvement and program evaluation (Section 13).

# Box 6. Recommendations-Antiretroviral Treatment Adherence
 Participate in multidisciplinary teams with health educators, service linkage facilitators, community health workers, case managers, nurses, pharmacists, and physicians to assess and support adherence to antiretroviral treatment (ART) a,b  Inform persons with HIV about the benefits of sustained high adherence, even if they are feeling well, and the risks of low adherence (e.g., illness, drug resistance, transmitting HIV to others)
 Provide adherence support tailored to each person's regimen and characteristics, according to provider role, authority, and setting (see Box 6-A)
 Provide or make referrals for services to address factors that may impair adherence (e.g., demographic, comorbidity, psychosocial, and structural issues) (see  Nonclinical providers who work outside of health care facilities but are not health department employees can directly refer clients to health department partner services specialists who offer voluntary, confidential services. In some jurisdictions, these nonclinical providers who are trained and authorized by the health department to provide partner services can provide partner services in community-based HIV testing and prevention programs. Some recommendations for nonclinical providers to offer selected partner services were based on federal guidance for staff of health departments or clinical providers. However, the federal workgroup of experts that developed the recommendations concluded that it would also be beneficial and feasible for nonclinical providers with appropriate training and authority to offer selected partner services, such as counseling persons with HIV about disclosure, collecting partner contact information, and offering HIV testing to partners.
Other sections of this Summary address STD services for index patients and their partners (Section 9); use of nonoccupational postexposure prophylaxis (nPEP) and preexposure prophylaxis (PrEP) by HIV-uninfected partners (Section 5); and quality improvement and program evaluation (Section 13).  - HIV testing if the partner is not known to be HIV-infected (followed by verification of test results) b

# Recommendations
- Risk-reduction services and devices (e.g., behavioral information, counseling, risk-reduction interventions, latex or polyurethane condoms)
- Information about the availability of PrEP and nPEP for HIV-uninfected persons when clinically indicated to reduce the risk of HIV acquisition and referrals to clinical providers who offer prophylaxis  Linkage to
- HIV care, treatment, and partner services if a preliminary or confirmatory HIV test is positive
- Screening for STD and viral hepatitis if partner is asymptomatic, using tests recommended by CDC a
- Presumptive STD treatment (while awaiting results of STD testing or clinical evaluation) if the partner was exposed to STD
- Testing and clinical evaluation for STD and viral hepatitis if partner has relevant symptoms a
- STD and viral hepatitis care and treatment if the partner is diagnosed with these conditions a
- Other medical and social services that influence HIV transmission (e.g., substance use treatment, mental health services)
 Collect information about members of the partners' social network (including physical and virtual venues frequented), using CDC-recommended methods, if trained and authorized in this approach c
Notes: a Viral hepatitis testing (and treatment of infected persons) has not been shown to influence HIV transmission but is included here because it is often offered in combination with HIV and STD testing for individual and public health benefits. b Partners who are unlikely to obtain prompt HIV testing in clinical settings should be linked to HIV testing at community-based organizations or home. c The first federal guidance in Appendix A, Section 8, describes CDC-recommended methods.

# Section 9. Sexually Transmitted Disease (STD) Preventive Services Background
Sexually transmitted diseases (STDs) are common in persons with HIV and many do not cause obvious symptoms or signs. Five STD may increase the risk of transmitting HIV: syphilis, gonorrhea, chlamydial infection, and HSV-2 in men and women and trichomoniasis in women. STD preventive services are an essential component of HIV prevention because the diagnosis of an STD is an objective marker of unprotected sexual activity that may result in HIV transmission; certain STDs may increase plasma HIV viral load and genital HIV shedding; and STD treatment may reduce STD-related morbidity and lower the risk of HIV transmission.
Nonclinical providers working outside of health care facilities play a crucial role in STD preventive services. These include assessing risk factors for STD; providing sexual riskreduction information and interventions; and linking clients to STD screening, treatment, and partner services. Some nonclinical settings have the capacity to screen clients for gonorrhea and chlamydia (using client-collected specimens) or for syphilis (using blood drawn by onsite providers).
Other sections of this Summary address confidentiality and reporting of HIV and STD information and the duty to warn partners of possible HIV exposure (Section 3); screening for sexual behavior, condom use, and STD symptoms and signs (Section 7); partner services for persons with HIV and their sex partners (Section 8); and quality improvement and program evaluation (Section 13). Notes: The first federal guidance in Appendix A, Section 9, indicates that type-specific serologic testing for herpes simplex virus type 2 (HSV-2) infection can be considered in persons with HIV with unknown herpes infection status. This section does not address screening for other conditions that may affect persons with HIV but have not been shown to facilitate HIV transmission to others, such as viral hepatitis and human papillomavirus infection.

# Recommendations
a Some nonclinical settings have the capacity to screen for gonorrhea and chlamydia (using client-collected urine, vaginal, rectal, and oropharyngeal specimens) or syphilis (using venous blood drawn by nonclinical provider); The first two federal guidance documents in Appendix A, Section 9, describe tests recommended by CDC. Commercially available NAATs for C. trachomatis and N. gonorrhoeae are not cleared by the U.S. Food and Drug Administration (FDA) for urine, vaginal, or rectal specimens collected in nonclinical settings. However, some laboratories have established performance specifications for testing specimens collected in nonclinical settings to meet requirements of the Clinical Laboratory Improvement Act for reporting test results for clinical management. The FDA has not cleared commercially available NAATs to test rectal specimens for gonorrhea and chlamydial infection or oropharyngeal specimens for gonorrhea. However, some laboratories have established performance specifications for testing these types of specimens to meet requirements of the Clinical Laboratory Improvement Act for reporting test results for clinical management. Screening for vaginal trichomoniasis is not performed in nonclinical settings. b The first federal guidance in Appendix A, Section 9, indicates CDC-recommended tests.

# Section 10. Reproductive Health Care for Women and Men Background
Reproductive health care involves several essential services for adolescents and adults with HIV who are of reproductive age and wish to prevent unplanned pregnancies or reduce the risk of sexual HIV transmission when attempting conception.
Nonclinical providers working outside of health care facilities may provide important information, education, and referral for these services to individuals, HIV-concordant couples (in which both members are HIV-infected), or HIV-discordant couples (in which only one member is infected). For example, nonclinical providers can refer clients who want to prevent or delay pregnancy to contraceptive services and refer clients who want to conceive to health care providers who are familiar with special conception methods that reduce the risk of HIV transmission.
Other sections in this Summary address methods-including use of ART-to prevent sexual or perinatal transmission of HIV during recognized pregnancies of HIV-infected women or HIV-uninfected women who have partners with HIV (Section 11); linkage to HIV medical care (Section 4), general aspects of use of ART by persons with HIV and antiretroviral prophylaxis by HIV-uninfected partners (Section 5); ART adherence (Section 6); methods to reduce sexual transmission of HIV (Section 7); services for sex partners of persons with HIV (Section 8); and quality improvement and program evaluation (Section 13). Persons who do not wish to conceive  Provide education, reproductive health counseling, or make referral for contraceptive services as appropriate to provider role and setting to women and men who wish to prevent or delay future pregnancy

# Recommendations

# Provide services
 Assess pregnancy status of HIV-infected women and reproductive plans of women and men with HIV, with methods and frequency as appropriate to provider role and setting (e.g., self-reported pregnancy or referral for pregnancy testing)
 Offer periodic HIV testing to HIV-uninfected members of HIV-discordant couples, particularly those who are attempting conception or who report unprotected intercourse Note: Some topics may only be suited for nonclinical providers with appropriate skills and training.

# Section 11. HIV Prevention Related to Pregnancy Background
Pregnant women with HIV can transmit HIV to their fetuses and newborns if they do not use effective prevention strategies. The physiologic state of pregnancy can also increase the risk of sexual HIV transmission from HIV-infected pregnant women to uninfected male partners as well as from HIV-infected male partners to uninfected pregnant women.
Nonclinical providers working outside of health care facilities can offer a variety of preventive services that can prevent HIV transmission from HIV-infected women with recognized pregnancies and can prevent HIV transmission to pregnant HIV-uninfected women who have HIV-infected sex or drug injection partners. These include providing information about methods to prevent HIV transmission during pregnancy, linking pregnant women with HIV to pregnancy care, and offering HIV testing to pregnant women and their partners.
Other sections in this Summary address linking pregnant women to HIV medical care (Section 4); general aspects of antiretroviral treatment (ART) for persons with HIV and prophylaxis for HIV-uninfected partners (Section 5); general aspects of ART adherence (Section 6); behavioral risk-reduction interventions suited to HIV-infected partners of pregnant women (Section 7); notification of sex and drug-injection partners of pregnant women with HIV or of HIV-uninfected pregnant women (Section 8); screening pregnant women for sexually transmitted disease (STD) services (Section 9); contraception services and reproductive health counseling that can be offered after delivery (Section 10); and quality improvement and program evaluation (Section 13).  Advise women to urge sex partners and drug-injection partners to get HIV testing and to use condoms to prevent HIV acquisition  Provide education, counseling and/or referral for postpartum contraception services to all women who wish to prevent or delay future pregnancy, as appropriate to the setting  Inform women and their partners that breastfeeding by HIV-infected women is not recommended in the United States and that formula feeding is recommended for the infants of these women

# Recommendations

# Specific prenatal services
 Promptly link women to HIV medical care, preferably to settings where providers have expertise in managing pregnancy in women with HIV  Support adherence to antiretroviral treatment (ART) during the prenatal and postnatal periods for optimal maternal health and prevention of perinatal and sexual transmission  Offer latex or polyurethane male and/or female condoms  Offer women support, information, and assistance to notify their sex and druginjection partners about their HIV status Note: A woman with HIV must explicitly grant her provider permission to discuss her HIV infection status with her partners.  Staff not trained in new encounter form reminder were least likely to provide information or referral for partner services Act  Trained 100% of staff on new partner services procedures  Revised reminder system to automatically print partner services information for all newly diagnosed clients before check out.
Source: Adapted from the chapter on "Quality Improvement" in the second guidance document in Appendix A, Section 13.