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# Section 1. Introduction
This Summary for Clinical Providers contains the subset of recommendations for clinical providers who work in health care facilities from the 2014 guideline, Recommendations for HIV Prevention with Adults and Adolescents with HIV in the United States, 2014. - 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 health care providers in the 2003 Recommendations for Incorporating HIV Prevention into the Medical Care of Persons Living with HIV.  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 Nonclinical Providers is directed to professionals who provide individuallevel services for persons with HIV in community-based organizations or health departments operating outside of health care facilities.  A Summary for Health Departments and HIV Planning Groups 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 clinical providers who serve persons with HIV in health care facilities. These providers offer risk assessments, health education, counseling, screening, diagnosis, treatment, and other health-related services. They include physicians, registered nurses, advance practice nurses, physician assistants, dentists, mental health providers, pharmacists, health educators, case managers, social workers, and counselors. Some may be employees or contractors of health departments.

# 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  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?
Clinical providers can use this Summary  to  Learn how they and their health care facilities can promote HIV prevention with their patients with HIV  Select interventions that may be well-suited to their patients 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 and contractors of health departments and HIV planning groups. It includes: 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 clinical 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.
Clinical providers who understand these issues are better prepared to create a sense of shared responsibility and decision making with their patients with HIV. This may include  motivating patients 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  Federal, state, and local laws and policies that regulate the following issues:  rights, responsibilities, and protections of persons with HIV regarding disclosure of their HIV-infection status and the unintentional or intentional exposure of others to HIV  provider responsibilities regarding HIV case reporting, protecting confidentiality, obtaining informed consent for HIV services, avoiding discrimination, and any requirements to inform persons about possible HIV exposure

# 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 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 Clinical providers play a crucial role in describing the benefits of early initiation of ART, offering and prescribing ART, managing long-term ART use, and providing information on other interventions that can reduce the risk of HIV transmission. Clinical providers can also inform their patients with HIV about the availability of prophylactic medications for uninfected partners that can reduce their risk of HIV acquisition.
Other sections of this Summary address adherence to ART (Section 6); use of ART and prophylaxis 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  b In some jurisdictions, collaboration may involve communicating with HIV surveillance programs that monitor HIV viral load levels of reported HIV cases to identify persons with suboptimal treatment response that may be due to low adherence. c The first federal guidance in Appendix A, Section 6, that is the basis for this recommendation only addresses the personal health benefits of high adherence, not the benefits of high adherence in reducing the risk of transmitting HIV to others. d Some experts recommend asking patients to answer the question, "In the last 30 days, how good a job did you do at taking HIV medicines in the way you were supposed to?" using a multistep scale ranging from very poor to excellent.  Other sections of this Summary address behavioral and biomedical strategies to reduce the risk of HIV transmission: linkage to and retention in care (Section 4), antiretroviral treatment (Section 5), ART adherence (Section 6), partner services (Section 8), STD services (Section 9), reproductive health care (Section 10), pregnancy services (Section 11), and services for other medical conditions and social factors that influence HIV transmission (Section 12). Section 13 describes how to improve and evaluate these interventions.

# Recommendations Box 7. Recommendations-Risk Screening and Risk-reduction Interventions

# Organizational-level interventions
 Establish infrastructure to support routine risk screening and brief risk-reduction interventions (see Box 7-A)
 Train staff to create a trusting, supportive and nonjudgmental atmosphere that encourages persons with HIV to be honest, to voluntarily disclose sex and druguse behaviors and health information, and to ask questions

# Box 7. Recommendations-Risk Screening and Risk-reduction Interventions (cont)
Individual-level risk screening services  Screen persons with HIV at initial and later visits (at least yearly or more frequently as needed) for these risk factors: (see Box 7-B)
 Behavioral characteristics that affect their risk of exposing others to HIV (e.g., unprotected sex, sharing drug-injection equipment)
 Biologic or biomedical characteristics that affect their level of infectiousness, (e.g., use of and adherence to antiretroviral treatment (ART), viral load level, sexually transmitted disease (STD) diagnoses, pregnancy)
 Characteristics of partners that affect the partner's risk of acquiring HIV or STD, when information available (e.g., use of condoms, preexposure prophylaxis   Clinical providers can directly refer patients to health department specialists who offer voluntary, confidential services or notify patients that reporting of cases of newly diagnosed HIV to the health department may activate offering of voluntary partner services. In most jurisdictions, physicians are authorized to provide some partner services directly to patients diagnosed with HIV and to partners that these patients refer.
In some clinical settings, other types of providers are trained and authorized to provide selected partner services, such as eliciting partner contact information from persons with HIV.
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).

# Recommendations

# 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 STDs 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.
Clinicians play a crucial role in STD preventive services. These include assessment of behavioral and biological factors that may increase the risk of transmitting HIV or STD; sexual risk-reduction interventions; screening asymptomatic persons for STD pathogens; physical examination, diagnostic testing of persons with STD signs or symptoms; treatment; and partner services.
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).

# Recommendations Box 9. Recommendations-STD Preventive Services
At the initial HIV-related encounter and thereafter at a frequency appropriate to setting and risk assessment results: e Pregnant women should be screened for vaginal trichomoniasis at the same frequency as nonpregnant women (i.e., at their initial HIV care visit and annually thereafter). f Characteristics of women at high risk are defined by the most recent CDC STD Treatment Guidelines.
 Inform

# 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.
Clinical providers may provide 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, they can offer reproductive health counseling, contraceptive services, and information on special conception methods that can reduce risk of HIV transmission.
Other sections of 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 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 future pregnancy  Assist persons with HIV who do not wish to conceive in making informed decisions about contraception that consider  the benefits of dual contraceptive methods (condoms plus other contraception)

# Recommendations
 the high efficacy and safety profile of hormonal contraception and IUDs for women with HIV  the benefits of using water-based spermicides and condom lubricants that do not contain nonoxynol-9
 Inform women with HIV who are considering medically attended pregnancy termination that available evidence indicates that HIV infection does not increase the risk of complications after the procedure  Inform women with HIV who are using or considering using ART and hormonal contraception at the same time about possible drug interactions that might influence the efficacy of the ART or the hormonal contraception

# 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 status and/or pregnancy testing)   Special conception methods that lower, but do not eliminate, HIV transmission risk (compared with unprotected penile-vaginal intercourse), including  specifically timed, periovulatory unprotected intercourse  intravaginal or intrauterine artificial insemination, in vitro fertilization, or intracytoplasmic sperm injection using semen of an HIV-uninfected donor or specially processed ("washed") sperm of an HIV-infected man

# 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.
Clinical providers can offer a wide variety of prevention and care 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.
Other sections of 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).  Inform women and HIV-uninfected partners they refer about  the availability of preexposure prophylaxis (PrEP) for HIV-uninfected partners when clinically indicated to reduce risk of HIV acquisition during unprotected sexual intercourse  the availability of nonoccupational postexposure prophylaxis (nPEP) for HIV-uninfected partners to reduce the risk of HIV acquisition in the event of inadvertent sexual or parenteral HIV exposure within the past 72 hours (e.g., unprotected intercourse, condom breakage, shared drug-injection equipment)

# Recommendations
 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 about options for free or subsidized ART, such as AIDS Drug Assistance Program or pharmaceutical drug assistance programs to help address financial concerns that may deter ART use  Inform women of delivery options that can reduce risk of perinatal transmission  Discuss risks and benefits of cesarean delivery and recommend scheduled cesarean delivery at 38 weeks gestation for women with suboptimal viral suppression near the time of delivery (i.e., HIV RNA levels >1000 copies/mL)
 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.

# Section 12. Services for Other Medical Conditions and Social Factors that Influence HIV Transmission Background
A variety of special medical and social services can support persons with HIV who experience significant personal, social, and structural challenges, such as poverty, mental illness, substance use, and unstable housing. These specialty services can improve health outcomes and quality of life, reduce the risk of HIV transmission, and enable the use of HIV prevention and care services (See Appendix B). Specialty services can hasten initiation of antiretroviral treatment (ART); support retention in HIV care and adherence to ART; and encourage persons with HIV to engage in riskreduction interventions, partner services, sexually transmitted disease services, and reproductive health services that prevent HIV transmission. Some clinical providers have the resources and expertise to offer these specialty services onsite. Other providers can link or refer persons with HIV to other specialty providers or agencies and follow up to check if the services were accessed. Section 3 of this Summary describes factors that influence the delivery of HIV prevention and care services for special populations with HIV. Section 13 describes methods to improve or evaluate specialty services for persons with HIV.

# Recommendations