tHE

va HIV

PREVENTION

HANDBOOK:

a GUIDE

FOR

CLINICIANS

Department of

Veterans Affairs

HIV PREVENTION
2

HIV Prevention Handbook

Veterans Health Administration

TABLE OF CONTENTS

I. Introduction.................................................................................1

II. Overview of HIV/AIDS in the United States and 

in the VA Health Care System....................................................6

III. Confidentiality and the VA Health Care System ....................10

IV. Primary and Secondary HIV Prevention ...............................13

V. HIV Transmission and Conditions Associated 

with Infection.............................................................................16 

VI. Conducting an HIV Risk Assessment of VA 

Patients: An Overview ..............................................................20

HIV Risk Assessment Questionnaire for Use in the

Health Care Setting ................................................................24

Taking Patients’ Sexual and Substance 

Use Histories ..........................................................................25

Guidance for the Substance Abuse Treatment Provider.........31

Guidance for the Mental Health Treatment Provider.............35

Guidance for Homeless Care Providers .................................37

HIV Prevention in the Emergency Room Setting ..................37

VII. HIV Prevention Approaches and Strategies...........................39 

Behavior Change Counseling.................................................39

Transtheoretical Model of the Stages of Change Theory.......42

Motivational Interviewing ......................................................46

Partnership for Health: A Brief Safer Sex 

Intervention for Health Care Providers Working with 

HIV-positive Patients..............................................................46

Practical Information on Condom Use...................................47

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VIII. HIV Testing and Counseling of VA Patients .........................54 

l VA Policy on Confidential HIV Testing and Counseling .......54

l HIV Testing: Informed Consent .............................................55

l Types of HIV Testing Methods Available at 

VA Facilities...........................................................................57

l Who in the VA Can Provide HIV Pre- and 

Post-test Counseling? .............................................................57

l Suggestions for Guiding Discussions with Patients 

on HIV Testing .......................................................................58

l Pre-test Counseling: VA Requirements of Pre-test 

Counseling and Documentation .............................................60

l Post-test Counseling: VA Requirements of Post-test 

Counseling and Documentation .............................................61

l Screening for Domestic Violence During 

Post-test Counseling...............................................................61

l VA HIV Partner Counseling and Referral 

Services Guidance ..................................................................63

l VA Policy on HIV Case Reporting to State and Local 

Health Authorities by VA Facilities and Providers.................65

l Referrals From VA Providers for Primary and 

Secondary HIV/AIDS Prevention Services............................65

IX. HIV/AIDS Issues Affecting the VA 

Health Care Provider.............................................................. 67

l Issues for VA Providers..........................................................67

l The Challenge of HIV Prevention..........................................69

l Next Steps Following Integration of HIV 

Prevention Activities...............................................................69

X. References..................................................................................71

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XI. Appendices.................................................................................81

A. Puget Sound, Maine Confidentiality Brochure 

for Patients..............................................................................82

B. AIDS-defining Conditions......................................................84

C. Risk Assessment Battery (questionnaire)...............................85

D. Access to Condoms as HIV Prevention: 

VA IL 10-2001-012 ................................................................96

E. HIV Partner Counseling and Referral Services 

(HIV partner notification contact information) 

for Select States .....................................................................99

F. Guidelines for HIV Testing in VA Facilities Following 

Occupational Exposures: VA IL 10-2001-011 .....................101

G. VA HIV/AIDS-related Circulars, Directives & 

Informational Letters............................................................107

H. HIV/AIDS Information Resources.......................................108

I. HIV/AIDS Treatment Guideline Resources.........................112

XII. Index.........................................................................................115

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The purpose of

The VA HIV Prevention Handbook:

A Guide for Clinicians

The purpose of the Handbook is to assist VA health care providers 

with translating the findings of HIV prevention research into 

everyday practice in clinical settings and health care systems. 

Health care providers include, but are not limited to physicians, 

nurses, nurse practitioners, physician assistants, psychologists and 

social workers. The Handbook provides basic information, tools, 

strategies, and recommendations to guide discussions with patients 

on the prevention of HIV/AIDS. It addresses the sensitive nature 

of issues like substance use and addiction and sexual practices–

behaviors that can make for awkward discussions for both the 

provider and the patient. 

The VA health care system is large with great diversity among 

its patient population, clinical care models, and health care 

professionals. Just as no one HIV prevention intervention can meet 

the needs of all individuals at risk for HIV (due to geographic, 

cultural, gender, and social differences) there isn’t any one approach 

to HIV prevention that will meet the needs of all VA health care 

providers. There are great differences in types of risk behaviors with 

which veterans may present and great variability in patient and health 

care provider needs.

The Handbook includes references to a variety of VA directives 

and informational letters that affect HIV/AIDS care in VA medical 

centers and clinical facilities. These directives and informational 

letters address topics such as HIV testing and counseling (including 

informed consent), partner notification, and condom availability 

through the VHA National Formulary. 

The HIV prevention and transmission information provided in the 

Handbook ranges from the basics to tips for the provider who has 

significant experience in HIV prevention. We encourage you to 

select and use those sections of the Handbook and HIV prevention 

strategies that work best for your practice and your patients.

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I. Introduction

The VA health care system is in a unique position to provide HIV 

prevention services to more than 3.5 million veterans each year. As 

the nation’s largest single provider of HIV/AIDS care, the VA provided 

services to almost 19,000 veterans with HIV in 2000. Like other 

populations in the United States, many veterans may be at risk for 

HIV/AIDS due to factors such as substance use or abuse and unsafe 

sexual practices. 

Health care providers in many VA clinical settings such as infectious 

disease clinics, substance abuse treatment programs, domiciliaries, and 

Vet Centers have been providing HIV prevention services and outreach 

for years. VA providers in these and other areas have requested help 

on how best to implement HIV risk assessment and risk reduction 

interventions for HIV-negative and HIV-positive patients.

Twenty years of HIV prevention research has shown that sustained 

interventions are needed to create and maintain the behavioral changes 

that are necessary to prevent transmission of HIV. Fortunately, such 

interventions have been developed and are available for use in a multitude 

of settings. HIV prevention activities are worth your time and energy 

and can make a difference. 
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HIV Prevention Does Work!

Project LIGHT

This intervention took place in primary care and STD clinics and 

involved a 7-session HIV prevention intervention that focused on 

attitudes about safer sex, skills building and risk-reduction strategies.

Finding: Participants in the 7-session intervention reported less 

unprotected sex, increased condom use and were more likely to use 

condoms consistently over a 1-year period than those individuals who 

received a 1-hour AIDS education session.§

AIDS and the transition to illicit drug injection–results of a 

randomized trial prevention program*

The goal of this intervention was to determine the effects of a small 

group intervention on preventing the transition from sniffing heroin 

to injecting heroin. The intervention took place in a community 

storefront and involved four 1-11⁄2 hour sessions over a 2-week period.

Finding: Men and women who participated in the intervention were 

significantly less likely to inject drugs than those in the comparison 

condition.‡

Condom skills education and sexually transmitted disease 

reinfection*

This intervention took place in the waiting room of an STD clinic and 

involved a 10-15 minute session on effective condom use and a 10-15 

minute question and answer period.

Finding: Men and women who participated in the intervention were 

significantly less likely to return to the STD clinic within the next 12 

months with a new STD than those in the comparison condition.‡
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Reduction in STD infections subsequent to an STD clinic visit: Using 

video-based patient education to supplement provider interventions*

This intervention took place in an STD clinic and involved viewing a 

video, interactive discussions, and free condoms or coupons for free 

condoms at an area pharmacy.

Finding: Men who participated in the intervention had a significantly 

lower rate of new STD infections than men in the comparison 

condition.‡ 

Adoption of protective behaviors among persons with recent HIV 

infection and diagnosis --- Alabama, New Jersey, and Tennessee, 

1997--1998 

“...findings in this study suggest that a high proportion of infected 

persons adopted safer sexual behaviors following diagnosis of HIV 

infection and are consistent with other studies showing adoption of 

safer behaviors after diagnosis in some groups.”†

*These studies meet the CDC’s HIV/AIDS Prevention Research Synthesis Project 

criteria for relevance and methodological rigor and also have the positive and 

significant behavior/health findings required for the CDC Compendium of HIV 

Prevention Interventions with Evidence of Effectiveness.

§Note. From “HIV prevention programs with heterosexuals,” by M. J. RotheramBorus, S. Cantwell, & P. A. Newman, 2000, AIDS, 14 (Supplement 2), S59-S67. 

‡Note. From Compendium of HIV Prevention Interventions with Evidence of 

Effectiveness, by CDC’s HIV/AIDS Prevention Research Synthesis Project, 1999. 

†Note. From “Adoption of Protective Behaviors Among Persons With Recent HIV 

Infection and Diagnosis --- Alabama, New Jersey, and Tennessee, 1997--1998,” 

the by Centers for Disease Control and Prevention, 2000, MMRW, 49 (23), 

512-515.
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II. Overview of HIV/AIDS in the United States 

and in the VA Health Care System

This chapter addresses:

l The HIV/AIDS epidemic in the United States

l Demographics of veterans who access Veterans Health 

Administration (VHA) care

l Veterans with HIV/AIDS

June 5, 2001 marked the 20-year anniversary of the first U.S. published 

report on what came to be known as HIV/AIDS.1 In 1981, the Centers 

for Disease Control and Prevention (CDC) Morbidity and Mortality Weekly 

Report (MMWR) published a report of five cases of Pneumocystis carinii 

pneumonia (PCP) among previously healthy young men in Los Angeles.2 

VA has been involved in the fight against HIV since the beginning of the 

epidemic; among those first reported cases in 1981 were veterans cared for 

by VA providers.

Almost 20 years later, more than 773,000 people in the United States had 

been diagnosed with AIDS and 448,060 had died.3 Currently, there are an 

estimated 800,000-900,000 people infected with HIV living in the United 

States.4 CDC estimates that 300,000 of these individuals do not know they 

are infected.5 These 300,000 individuals may be those who are most at 

risk for transmitting HIV to others as they are not aware of their serostatus 

and may not be practicing risk reduction behaviors. That is why risk 

assessment and HIV testing and counseling both play such a critical role in 

the prevention and control of HIV. 

Early testing and detection of HIV helps individuals with HIV enter 

treatment so that their disease can be monitored and treated appropriately 

and it also helps individuals begin to learn more about what they can do to 

prevent transmitting HIV to others. CDC recently implemented a national 

campaign, SAFE, to increase awareness of these issues and to help increase 

the numbers of individuals who are tested each year for HIV.6

Each year approximately 40,000 people in the United States become 

infected with HIV.7 Concurrently, the number of people living with HIV 

and AIDS has increased each year while the number of AIDS-related deaths 

has decreased. This trend is mainly attributable to the use of antiretroviral 
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therapy, which has effectively slowed the progression of HIV to AIDS. 

This medical advance has had an incredible impact on the quality of life 

of those with HIV/AIDS in the United States, but these medications do not 

serve as a cure, make the management of HIV/AIDS simple or inexpensive, 

or completely prevent disease transmission from one person to another. 

Moreover, these medications are not always easily tolerated and it is still 

unclear how long they will be effective for many patients with HIV. 

Of the estimated 40,000 annual new HIV infections in the United States, 

70% occur among men.8 Forty-two percent of these infections are 

attributed to men who have sex with men (MSM), 33% to heterosexual 

activities, and 25% to injection drug use.9 Startling is the fact that while 

African Americans made up 12% of the U.S. population in 1999,10 by 

December 2000 they accounted for more than 50% of new HIV cases.11 Of 

the estimated annual new U.S. HIV cases among women, 64% are among 

African-American women.12

CDC estimates that 120,000-160,000 adult and adolescent females in the 

United States are living with HIV/AIDS.13 Since 1985, the proportion of 

AIDS cases among adult and adolescent females in the United States has 

tripled from 7% to 23% (1999).14 African-American women and Hispanic 

women make up 77% of reported AIDS cases, yet they represent less than 

one fourth of the U.S. population.15

Note. From HIV/AIDS Surveillance by Race/Ethnicity (L238 slide series, slide #8), 

by the Centers for Disease Control and Prevention, 2000. Retrieved June 6, 2001 

from http://www.cdc.gov/hiv/graphics/images/1238-8.htm

*Includes 120 persons with unknown race/ethnicity

Table 2-1

AIDS Cases Reported in 1999 and Estimated 1999 

AIDS Cases 

N=46,400*

White, not Hispanic

Black, not Hispanic

Hispanic

Asian/Pacific Islander

American Indian

Population

N=277,200,000
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*Includes sex with a bisexual male, a person with hemophilia, a transfusion recipient 

with HIV infection, or an HIV-infected and patients with other or undetermined modes 

of exposure 

Note. From HIV/AIDS Surveillance in Women (L264 slide series, slide #3), by the 

Centers for Disease Control and Prevention, 2000. Retrieved August 23, 2001 from 

http://www.cdc.gov/hiv/graphics/images/1264/1264-3.htm 

Overview of VHA and the Veterans it Serves

VHA, one of three major branches in the VA, focuses on providing 

a comprehensive healthcare system for the nation’s veterans. Its four 

principle missions are to (1) provide medical care to veterans, (2) conduct 

health professional education and training, (3) conduct health research that 

benefits veterans, and (4) provide contingency support to the Department 

of Defense and Public Health Service during times of disaster or national 

emergency.

As of January 2001, VA had 173 medical centers, 773 clinics, 206 Vet 

Centers, 135 nursing homes, and 43 domiciliaries.16 Approximately 3.5 

million veterans receive medical care through the VA each year making VA 

one of the largest health care systems and the largest single provider of 

substance abuse and mental health services.

Veterans seen in the VA health care system represent a significantly older 

segment of the population in comparison to the general population. Also, 

a larger percentage of veterans seen in VA earn low incomes in comparison 

to the general population and veterans who do not seek care in the VA 

health care system. 

Table 2-2

AIDS in Women, by Exposure Category

Reported in 1999, United States

Sex with injection

drug user

11%

Injection drug use

27%

Transfusion recipient

1%

Other/not identified*

32%

Sex with men of 

other or 

unspecified risk

29%
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Note. From “The VA Health Care System: An Unrecognized National Safety Net” 

(p. 202), by N. J. Wilson & K. W. Kizer in Health Affairs, 16 (4), July/August 1997. 

Veterans with HIV/AIDS

VA is the largest, single provider of HIV/AIDS care in the United States. 

This comprehensive system of care is supported by a designated HIV 

coordinator at each VA medical center and the availability of all licensed 

anti-HIV medications on the VHA National Formulary (male and female 

condoms are also available on the Formulary).

According to the information available through the VA Immunology Case 

Registry (ICR), which is a confidential registry, patients with HIV/AIDS 

seen in the VA health care system are older than the U.S. norm (mean 

age of 47 years vs. 37 years) and more representative of ethnic/racial 

minorities (65% of VA HIV/AIDS patients are non-Caucasian vs. 57% of 

non-VA HIV/AIDS patients are non-Caucasian). Data available from the 

ICR suggests that VA patients with HIV/AIDS are more likely to report 

injection drug use as an HIV risk behavior than individuals in the general 

U.S. population with HIV/AIDS. The reported risk factor information 

available through the ICR indicates that men who have sex with men 

account for 34% of VA HIV/AIDS cases, 26% of cases are associated with 

injection drug use, and 18% report heterosexual transmission as the risk 

factor. To date, risk information for a significant portion of VA patients 

with HIV/AIDS is missing and it is important to keep in mind that the 

stigma associated with men who have sex with men (MSM) and behaviors 

such as injection drug use may lead to underreporting of these risk factors 

among veterans.

Table 2-3

Characteristics of Veteran VA Health Care Users and Nonusers 

Compared with the General Population

Characteristics

Age 65 and older

Non-Caucasian

Not married

Education<high school

Income<$20,000

Income<$10,000

Veterans Veteran non- General

VA User VA User Population

35.60% 31.30% 17.00%

25.4 12.5 22.8

35.7 19.4 39

26 15 24.8

70.5 25.7 32.9

38.5 8.7 14.6
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III. Confidentiality and the VA Health Care System

This chapter addresses:

l VA regulations regarding patient confidentiality

l Release of patient records

l Ways to protect the confidentiality of patients with or at risk for 

HIV/AIDS

Confidentiality in the health care setting is not only the patient’s right 

but a starting point in which to build an effective provider-patient 

relationship. 

In the VA health care system, “confidential” means that under normal 

circumstances only health care professionals involved in the patient’s care 

and treatment will have access to information contained in their medical 

file. This information cannot be released to a third party (e.g., insurance 

company, potential employer, private practice clinician) unless the patient 

provides special written consent (VA Form 10-5345) for such a release.

When meeting with a patient for their first visit, it may be good to clarify 

the patient’s confidentiality rights and the circumstances under which a 

VA provider can disclose a patient’s medical information without prior 

consent. These circumstances involve: 

l when it is necessary to protect the life or health of any individual 

(e.g., homicidal or suicidal intent, sexual or physical abuse of 

a minor)

l when an employee needs to know the information to perform 

his/her job

l when it is pursuant to a published routine use in the patient 

medical records system of records

l when it is pursuant to a request from law enforcement entities

l when requested by a Congressional oversight committee or 

subcommittee, or

l when it is pursuant to a court order.
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In regards to a Congressional request, the VA may disclose information 

to a Congressional office without prior consent in response to an inquiry 

from the Congressional office made at the request of the patient (not at 

the request of a third party, such as a family member). 

HIV/AIDS information in a patient’s VA medical records is formally 

protected through 38 U.S.C. § 7332. Section 7332 states that any 

patient’s medical record maintained in connection with the performance 

of any program or activity (including education, training, treatment, 

rehabilitation, or research) relating to HIV testing and infection, drug 

abuse, alcoholism and alcohol abuse, or sickle cell anemia can be 

disclosed only with the specific written consent (VA Form 10-5345) of the 

individual or as permitted by one of the limited exceptions (see section 

VA HIV Partner Counseling and Referral Services Guidance, page 63 for 

further details). Penalties for unauthorized disclosures include a fine of 

up to $5,000 for the first offense and up to $20,000 for a subsequent 

offense. Unauthorized disclosures also include verbal disclosures. 

Should a VA patient request that a facility release their medical record 

to a third party, you should inform the patient that once the record is 

released, VA has no control over the information within it. This should 

be discussed before the patient has signed a consent form for the release 

of medical records. 

As a provider, you can protect the confidentiality of your patients through 

the manner in which you document HIV risk behaviors in their medical 

records. Because HIV-related discussions frequently involve activities 

that are stigmatized and sometimes illegal, it is important to keep medical 

records as neutral as possible. For instance, if a male patient says 

he has unprotected sex with multiple men, a statement in his medical 

record could read “engaging in high-risk sexual activities” as opposed to 

“engaging in unprotected anal sex with other men.” This phrasing will 

document the patient’s risk so that other providers involved in his care 

will be aware of his risk factors, but it won’t disclose personal information 

that the patient may not want to share with unfamiliar providers. 

It is important to understand that even well-intended actions can 

undermine the confidential relationship you have with your patient. 

Conversations with colleagues about patient information, including HIV/

AIDS status and risk behaviors, should be confined to the appropriate 

settings.
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It is not appropriate to discuss a patient’s care or clinical status in 

public areas in clinical settings such as hallways, nurses’ stations, clinical 

front desks, or elevators. Even though the patient may remain unnamed 

throughout the conversation, certain identifying information may reveal the 

identity of the patient.

It may be helpful to provide your patients with information on VHA 

confidentiality and patient privacy practices. Included in the Appendices is 

an example of a brochure on VA patient confidentiality developed by the 

VA Puget Sound Health Care System (see Appendix A). 
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IV. Primary and Secondary HIV Prevention 

This chapter addresses:

l Opportunities for HIV prevention activities

l HIV primary and secondary prevention activities

l Obstacles to HIV prevention activities in clinical settings

More than 90% of persons in at-risk populations visit their physician each 

year17 and many patients believe that information on one’s sexual health 

is an important part of a health evaluation.18 Yet research indicates that 

only a small percentage of physicians routinely discuss HIV transmission 

and prevention with their patients.19 

For many years in the United States, HIV testing and counseling was 

thought of as the main prevention intervention for people who thought 

they may be at risk for infection or who tested HIV-negative. Today, 

comprehensive HIV prevention involves primary and secondary prevention 

activities. Primary HIV prevention refers to activities directed to keeping 

an HIV negative person negative and secondary HIV prevention refers to 

activities for the person who is HIV positive or has AIDS. The goal of 

secondary HIV prevention is to make sure the infected person (1) does not 

transmit the virus to others, (2) remains healthy over time, and (3) does not 

become re-infected with the virus (if the person is reinfected with strains of 

the virus that are resistant to specific antiretroviral medications, this could 

have a significant impact on disease treatment).

Primary and secondary HIV prevention activities in VA health care settings 

enhance the health of veterans and are an effective means in which to 

decrease the number of new HIV infections.

Primary and secondary HIV prevention activities include:

l HIV risk assessment and risk-reduction counseling,

l HIV testing and counseling,

l partner notification and referral services,

l education on sexual behavior changes and safer sex methods, 

l support of medication adherence for those with HIV/AIDS,

l screening for sexually transmitted diseases (STDs),
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l education on high-risk substance-use behaviors and harm reduction 

practices, 

l screening for drug and alcohol abuse and when appropriate, referring 

for substance abuse treatment,

l psycho-educational and support groups, and

l discussing healthy lifestyle choices.

Screening for STDs is a critical HIV prevention intervention as the 

presence of other STDs indicates that the patient has not been practicing 

safer sex and may be at risk for HIV. An individual with an ulcerative or 

nonulcerative STD such as syphilis, chancroid, genital herpes, gonorrhea, 

chlamydia, and trichomoniasis has a 2-5 times greater risk of becoming 

infected with HIV.20 Prescribing condoms (available through the VHA 

National Formulary) is also an excellent prevention activity. 

Potential obstacles to HIV prevention activities taking place in clinical 

settings involve: 21

l narrow conceptions of medical care and the role of physicians or 

health care providers in HIV prevention, 

l a provider’s discomfort with discussing human sexuality and illicit 

drug use and their attitudes towards persons with HIV or AIDS, 

l constraints on time and resources, and

l the ambiguity of HIV prevention messages.

The very nature of HIV transmission involves behaviors not readily 

discussed in American society. As a health care provider, it is important for 

you to become comfortable discussing sexual and substance-use activities 

with your patients. You will need to create an environment of trust for 

patients so their risk behaviors can be discussed. It is important to assure 

your patient of the confidential nature of such discussions, as concerns 

about confidentially and documentation of such information may prevent 

some patients from disclosing important information about their risk. 

Discussions with patients about HIV/AIDS need not take extensive 

amounts of time. Findings from a 1995-96 study reported that 

a comprehensive evaluation of a patient at risk or concerned 

about HIV took approximately 5-7 minutes.22 Patient-centered 

approaches to the topic took even less time.23
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There are multiple models and interventions that can help you assess 

someone’s transmission risk and aid him/her in making behavioral 

changes. Five such models and interventions are (discussed in detail on 

pages 34-49 of the Handbook): 

l behavior change counseling,

l use of the Transtheoretical Model of the Stages of Change Theory,

l motivational interviewing, 

l a brief intervention for use with HIV-positive patients, and

l practical information on condom use.
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V. HIV Transmission and Conditions Associated 

with Infection

This chapter addresses:

l Bodily fluids proven to spread HIV

l Behaviors associated with a risk for HIV infection

l Frequently asked questions about HIV transmission

l Conditions that may suggest HIV infection

As a VA health care provider conducting HIV prevention activities, it 

is important to understand the specific risk factors associated with HIV 

transmission and medical conditions that may indicate infection. A clear 

understanding of these topics will assist you in providing your patients with 

the most up-to-date clinical information and conducting appropriate HIV 

prevention activities. 

Bodily fluids that have been proven to spread HIV 24:

l blood 

l semen (including pre-seminal fluid)

l vaginal fluid 

l breast milk 

l other body fluids containing blood

l cerebrospinal fluid surrounding the brain and the spinal cord 

l synovial fluid surrounding bone joints 

l amniotic fluid surrounding a fetus 

Behaviors associated with a risk for HIV infection:

l Unprotected anal and vaginal intercourse

l Unprotected oral sex 

l Receipt of blood or blood product transfusions (prior to 1985 of 

most concern)

l Injection of drugs (including steroid, silicone, and hormone 

injections) by medical personnel or through illicit means
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l Needlestick injuries

l Receipt of tattoos or piercings involving unsterilized needles

l Receipt of acupuncture treatment involving unsterilized needles

l Breastfeeding

l Birthing by an HIV-infected mother (mother-to-child transmission)

Frequently Asked Questions about

HIV Transmission

Can I get infected with HIV from mosquitoes?

“No...studies conducted by researchers at CDC and elsewhere 

have shown no evidence of HIV transmission through 

insects...”

Can HIV be transmitted through saliva, tears or sweat?

“Contact with saliva, tears, or sweat has never been shown to 

result in transmission of HIV...”

Can HIV be transmitted by wound-to-wound contact?

“Transmission via wound-to-wound contact, although 

theoretically possible is highly unlikely given the 

improbability of such a scenario and the small concentration 

of virus that is likely to be present...”

Can I get HIV from casual contact (shaking hands, hugging, 

using a toilet, kissing on the cheek, drinking from the same 

glass, or the sneezing and coughing of an infected person)?

“No. HIV is not transmitted by day-to-day contact in the 

workplace, schools, or social settings...HIV is not an airborne 

or food-borne virus, and it does not live long outside the 

body...”

Can I get HIV from open-mouth kissing?

“Open-mouth kissing is considered a very low-risk activity 

for the transmission of HIV. However, prolonged open-mouth 
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kissing could damage the mouth or lips and allow HIV to pass 

from an infected person to a partner and then enter the body 

through cuts or sores in the mouth...”

Can HIV be transmitted in swimming pool water?

“HIV cannot be spread by sharing washing facilities or 

swimming in the same pool with an HIV-infected person...”

 Can HIV be transmitted by aerosol?

“At present time, there are no known instances in which 

bloodborne pathogens have been transmitted to patients or 

workers by respirable particles in a clinical setting...”

Are patients in a dentist’s or doctor’s office at risk of getting 

HIV?

“Although HIV transmission is possible in health care 

settings, it is extremely rare...”

To learn more information on these questions, go to the CDC 

web site http://www.cdcnpin.gov/hiv/faq/transmission.htm

Note. From HIV/AIDS resources: Frequently Asked Questions 

(FAQs) About HIV, by the Centers for Disease Control and 

Prevention. Retrieved July 2, 2001 from http://www.cdcnpin.org/hiv/

faq/transmission.htm
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Conditions That May Suggest HIV Infection

l Any AIDS-defining clinical condition (see Appendix B)

l Significant, self-limited flu-like illness (especially if 

associated with rash, sore throat, and lymphadenopathy) 

in a sexually active or drug-using individual

l Unexplained constitutional symptoms (including weight 

loss)

l Generalized lymphadenopathy

l Persistent diarrhea

l M. tuberculosis

l Unexplained oral thrush

l Sexually transmitted diseases

l Herpes zoster (more the case in younger patients than 

in older patients)

l Unexplained, recurrent seborrheic dermatitis

l Frequent vaginal candidiasis, particularly in the absence 

of antibiotic usage or diabetes

l Thrombocytopenia

Note. From HIV & Primary Care: Putting Prevention into Practice 

(p. 10), by the AIDS Institute, New York State Department of Health, 

1998. Reprinted with permission.

In addition to answering questions on HIV transmission, you should be 

able to recognize certain medical conditions that may suggest a patient is 

infected with HIV or has AIDS.

When a patient presents with any one of the conditions listed below, in 

order to adequately treat the condition you should assess their risk for 

HIV. If the patient does present with a history of risk factors for HIV, 

you should discuss HIV testing and seek their consent to proceed with 

testing and counseling. A list of AIDS-defining conditions can be found 

in Appendix B. 
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Risk behaviors associated with HIV transmission center on one’s exposure 

to bodily fluids through activities such as sex, the use of needles for 

injection purposes, childbirth, and breastfeeding. 

While HIV/AIDS literature frequently categorizes risk for the virus based 

on “membership” in specific populations (e.g., gay or bisexual men, 

injection drug users, sex workers), it is sometimes best to think about a 

patient’s risk for HIV in terms of his/her behaviors. For example, the 

most reported risk behavior among U.S. HIV and AIDS cases are men 

who have unprotected sex with men (MSM), followed by unprotected 

heterosexual activity and drug use. 25 In reality, it is behaviors associated 

with unprotected sex and/or substance use that will put anyone at risk for 

HIV. 

Additionally, some people may not identify with a particular population. 

Not all men who have sex with men identify as gay. So a question such 

as “When you have sex, is it with women, men or both?” will go much 

further than “Are you gay?”

In the United States, unprotected heterosexual sexual activity is considered 

to be one of the fastest growing modes of transmission.26 The AIDS 

VI. Conducting HIV Risk Assessment of VA 

Patients: An Overview

This chapter addresses:

l Behaviors associated with HIV transmission

l An HIV risk assessment questionnaire

l Taking a patient’s sexual history

l Taking a patient’s substance use/abuse history

l Chart on HIV risk associated with sexual activities 

l Guidance for the substance abuse treatment provider

l An infectious disease assessment questionnaire for use in the 

substance abuse treatment setting

l Guidance for the mental health treatment provider

l HIV prevention activities for homeless populations

l HIV prevention activities in the ER setting
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incidence by risk has increased for heterosexuals approximately 15% each 

year until 1996.27 It is estimated that in 1999, 62% of new AIDS cases 

among females were the result of heterosexual contact.28

Note. From HIV/AIDS Surveillance - General Epidemiology (L178 slide series, slide 

#8), by the Centers for Disease Control and Prevention, 2000. Retrieved August 23, 

2001 from http://www.cdc.gov/hiv/graphics/images/1178/1178-8.htm

It is noted that the highest reported risk factor for HIV in the United 

States and VA is still among men having sex with men (MSMs). Recent 

behavioral and social research has focused on young MSMs who are 

engaging in unsafe sexual behavior and homophobia faced by AfricanAmerican MSMs. In some areas of the country there has been a rise in 

the HIV and STD infection rates among young MSMs. It is suggested 

that this increase may be related to (1) beliefs that HIV/AIDS medication 

represent a “cure” and that the disease is easily controlled, (2) complacency 

about safer sex messages, and (3) little or no experience with seeing 

friends/family rapidly deteriorate from the virus. African-American MSMs 

may experience homophobia from the African-American community and 

racism from the gay white community, thus they may feel like they do 

not completely belong in either world. Current HIV/AIDS dynamics and 

trends like these should inform your prevention work.

Health care providers may not believe that certain populations are engaging 

in behaviors that put them at risk for HIV transmission. If a health care 

provider makes assumptions that “older” people are not sexually active 

Table 6-1

Adult/Adolescent AIDS Cases by Exposure Category

and Year of Diagnosis, 1985 - June 1999

United States

Men who have sex with men

(MSM)

Injection drug use 

(IDU)

Heterosexual

contact Other Percent of Cases

MSM

&

IDU

1985 1987 1989 1991 1993 1995 1997 June 1999

80

70

60

50

40

30

20

10

0
Table 6-2

Number of Elderly Male Veterans per 1000

as of September 30, 2000

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or engaging in high-risk substance abuse, a critical discussion on risk 

behaviors and prevention methods may not take place. As a result, an 

invaluable opportunity for educating an at-risk patient about HIV may 

be lost. At the same time, patients over 50 years of age may not see 

themselves as at risk for HIV even though they are having unprotected 

sex.29 They may downplay the rate of HIV transmission through 

heterosexual contact. This age group may include divorced and widowed 

individuals who are dating for the first time in years. 

Ten percent of the people with HIV/AIDS in the United States are age 50 

years or older.30 In 1996, 84% of AIDS cases among people 50 years or 

older were among males.31 In the same year, 43% of the cases experienced 

by this age group were among African Americans.32 People aged 50 years 

or older were likely than people 13-49 years old to report to a health care 

provider with an AIDS opportunistic infection.33 This may suggest that 

older people are being diagnosed with AIDS later in the course of their 

infection.

Another common assumption is that the HIV risk behaviors of substance 

users only involve the use of contaminated injection equipment. This 

narrow definition of a population’s risk behaviors ignores that fact that 

injection drug users may not practice safer sex on a consistent basis, 

especially when they are high. People with a history of non-injection drug 

use are more likely to engage in high-risk sexual activities.34 In addition, 

drug users may be selecting sexual partners from drug networks that have a 
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higher prevalence of HIV.35 Like drug users, alcohol users also may pick 

sexual partners from a drug/alcohol network36 and the disinhibiting effect 

of alcohol can result in unsafe sexual activities.

Take the time to think about your own attitudes and assumptions that may 

influence your HIV prevention activities. Patients may not be as reluctant 

to discuss high-risk activities as providers think. Recent research has 

stated that “patients did not disclose [information] differently whether or 

not they believed their physician would see their disclosures...Despite 

physicians’ concerns that patients are uncomfortable being asked about 

stigmatizing behaviors, data suggest that the majority of patients state they 

would not be embarrassed by talking with their physician about acquired 

immunodeficiency syndrome (AIDS), and that they do not mind answering 

questions about alcohol use and HIV-risk behaviors.”37

It is important to remember that because of their experiences in the 

military, many veterans may be reluctant to discuss same-gender 

sexual activities or substance use activities because of unfounded 

fears that disclosure will jeopardize existing VA benefits. This type 

of disclosure will not result in a loss of VA benefits.

HIV Risk Assessment Questionnaire for Use in the 

Health Care Setting

The questionnaire on page 24 can be used to start the HIV assessment 

process and conversations on risk behaviors. It may help to “normalize” 

questions about sexual and substance-use histories by introducing these 

questions with a comment such as “I am interested in all aspects of my 

patients’ health, so I am asking all my patients these questions to better 

assess their risk for infectious diseases.” One or more “yes” answers to the 

questions may indicate some level of risk behaviors and requires provider 

follow up.

 
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Risk Assessment Questionnaire

1. Have you had two or more sexual partners in the past 10 years?

Yes____ No____

2. Have you had anal sex (a man puts his penis in the anus of other person) with 

any of your sexual partners during the past 10 years?

Yes____ No____

3. How often have you used a condom when having anal sex in the past 10 years?

Never____ Sometimes____ Always____ Have not had anal sex ____

4. Have you ever had a sexually transmitted disease such as gonorrhea, syphilis, 

chlamydia, genital warts, or genital herpes?

Yes____ No____

5. At any time in the past 10 years, have you ever given money or drugs to anyone 

to have sex with you?

Yes____ No____

6. Have you ever had sex with someone so that they would give you money or 

drugs?

Yes____ No____

7. Have you ever injected street drugs, steroids, or vitamins with a needle?

Yes____ No____

8. Have any of your sexual partners in the past 10 years ever injected street drugs, 

steroids, or vitamins with a needle?

Yes____ No____

9. Have any of your sexual partners in the past 10 years been men who had sex 

with other men?

Yes____ No____

10. Have any of your sexual partners in the past 10 years ever had a sexually 

transmitted disease such as gonorrhea, syphilis, chlamydia, genital warts, or 

genital herpes?

Yes____ No____

Note. From “Development and Testing of an HIV-risk Screening Instrument for 

Use in Health Care Settings”, by B. Gerbert, A. Bronstone, S. McPhee, S. Pantilat, 

& M. Allerton, 1998, American Journal of Preventive Medicine, 15 (2), 103-113. 

Copyright 1998 by Elsevier Science Inc. Reprinted with permission.
“When was the last time you 

had sex and was that person 

your regular partner?”

“Have you had other 

partners in the past 

year?”

“Have you had sex with 

anyone you know or suspect 

has HIV infection?”

“Do you have any questions 

about the safety of any sexual 

practice?”

“Have you ever had 

a sexually transmitted 

disease?”

“When you have sex, do you use a 

condom?” [When appropriate, explore 

other types of barrier protection such 

as dental dams.]

“Do you have sex with men 

or women [or both]?”

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Taking Patients’ Sexual and Substance Use Histories

Taking a patient’s sexual and substance-use histories allows you to further 

assess their risk for HIV and their general health status. There are many 

assessment tools and approaches used in these types of history taking. 

No one tool or approach is exactly right for all situations and as such, 

the examples referenced in this section are based on literature reviews, 

their use of non-confrontational language, and the need for brevity. It is 

important to take a patient’s history in a room or setting where privacy and 

confidentiality can be ensured. 

Taking a Sexual History

Taking a patient’s sexual history should be a routine part of a 

medical exam so let the patient know that you ask these sorts of 

questions of all of your patients and that they are not being singled 

out to discuss their sexual history.

Taking a patient’s sexual history is like any other type of history; you 

ask basic questions and build on those questions if necessary. The 

following sexual history questions can help you branch into a more detailed 

discussion with your patient:

“When was the last time you 

had sex with someone other 

than this last individual?”

Note. From HIV & Primary Care: Putting Prevention into Practice (p. 12), by the AIDS 

Institute, New York State Department of Health, 1998. Reprinted with permission.
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Often, patients will answer “no” to some of these questions because they 

may feel uncomfortable or embarrassed. A “no”, however, does not 

eliminate the need for you to review safer sex practices with the patient.38

Some patients want to know the degree of HIV transmission risk associated 

with specific sexual activities. It may be helpful to use Chart 6-1 to initiate 

discussions on this topic once your patient has begun to provide you with 

some information on his or her sexual history or has indicated that they 

have not routinely practiced safer sex. Chart 6-1 will help patients begin to 

assess their own relative risk for HIV. 
NO

RISK

HIGHEST

RISK

Abstinence;

Monogamous

relationship

(both partners

uninfected);

Self masturbation;

Dry (social kissing)

Mutual

Masturbation;

Deep kissing

Oral

intercourse*

Vaginal

intercourse;

female to male

Vaginal

intercourse;

male to female

Receptive

anal

intercourse

Insertive anal intercourse**

Chart 6-1

Risk of Sexually 

Transmitted HIV Infection

*Risk associated with gender of partners not differentiated due to lack of research.

**Data suggests that HIV transmission through inserti

ve anal intercourse is more efficient than oral intercourse but less efficient than 

recepti

ve anal intercourse. The relati

ve risk of transmission through inserti

ve anal intercourse compared to vaginal intercourse is 

unclear.

Note. From HIV & Primary Care: Putting Prevention into Practice (p. 55), by the AIDS Institute, New 

York State Department of 

Health, 1998. Reprinted with permission. 

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Taking a Substance-use History in a Primary Care Setting

Epidemiology strongly supports the nexus between substance abuse and 

the risk for infectious diseases. These risk behaviors include injection 

drug use, unsafe sexual practices while high or intoxicated, and/or 

trading sex for drugs or drug money. 

Substance use and abuse, especially injection drug use, which may 

involved the sharing of hypodermic syringes, cottons (material used to 

filter the drug mixture), or other drug ‘works’, has always been one of 

the leading risk factors for HIV in the United States.39 CDC reports 

that injection drug use has accounted for 25% of all cases of AIDS in 

the United States. This statistic does not include cases of infection 

experienced by men who have sex with men and inject drugs, and 

individuals who have heterosexual sex with an injection drug user. 

As the nation’s largest single provider of substance abuse treatment, VA 

sees a large number of veterans who are at risk for HIV because of their 

current substance abuse or history of injection drug use. Because many 

of these veterans may not currently be in substance abuse treatment or 

may not have been identified as drug or alcohol abusers, it is important 

to integrate routine substance-use histories as part of primary care 

screening. 

The most recent estimates indicate that there were approximately 

317,000 veterans with a diagnosis of substance abuse and 540,000 

veterans with a psychiatric diagnosis (excluding a substance abuse 

diagnosis) receiving care in the VA in 1999. The VA has 31 opiate 

agonist or opiate substitution treatment clinics and provided treatment to 

30,000 opiate dependent veterans in 1999.

Health care providers screening for drug and alcohol problems perform 

a critical function and have the potential to identify many patients who 

need further assessment or treatment in order to reduce their risk for 

HIV. 

Unfortunately, most medical schools do not include training on how to 

screen for these problems and many providers may feel uncomfortable or 

ill equipped to assess for information on as sensitive a topic as substance 

use. Consequently, many medical care providers have not been very 

good at identifying active drug and alcohol users. 
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In approaching substance-use screening in primary care settings, patients 

must feel comfortable in discussing their use. It may be helpful for 

providers to:

l ‘normalize’ screenings by prefacing them with a comment that they, 

the provider, have begun to routinely ask about alcohol and drug 

use with all their patients to better evaluate their complete health 

needs, 

l conduct screening in a private setting and ask questions and use 

probes that are non-judgmental,

l use substance abuse screening questions that focus on gaining an 

accurate assessment of the quantity and frequency of use,

l start substance abuse screening by asking about alcohol and more 

commonly used substances and then proceed to questions about 

injection drug use,

l ask about early drug use in a patient’s youth or early adult years 

and then proceed up to questions about current use, 

l ask about illegal drug use during service (especially when coping 

with combat stressors) when working with combat veterans, and 

l perceive substance addiction as any other chronic disease.

There are several self-administered questionnaires that can help the 

patient and health care provider identify patterns of drug and/or alcohol 

use that require further assessment or treatment. These include the 

Michigan Alcohol Screening Test (MAST),40 the Drug Abuse Screening 

Test (DAST),41,42 and the Alcohol Use Disorders Identification Test 

(AUDIT).43 A dual strategy approach such as the use of self-administered 

questionnaire and a provider-screening interview increases the chance for 

patient disclosures. It is important to keep in mind that many people are 

willing to talk about their use but are never asked. 

Two initial screening questions that researchers found to be effective in 

initially screening for alcohol and other drug-use problems in a large 

primary care setting are: 

1. Have you ever felt that you wanted or needed to cut down on your 

drinking or drug use in the last year? 

2. In the last year, have you drunk or used more drugs that you meant 

to?44 
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It is imperative to note that injection drug use currently accounts for 

most hepatitis C virus transmission in the United States.45 The National 

Institute on Drug Abuse reports that hepatitis C infection occurs rapidly 

among new injection drug users as 50-80% become infected with the 

virus within 6-12 months of injection initiation.46 Any patient that reports 

that they have used injection drug use equipment should be considered at 

risk the hepatitis C virus. 

According to the hepatitis C virus antibody screening flow chart 

accompanying VA IL 10-2001-009, any individual who presents 

with an history of injection illicit drug use - past or present - 

any number of injections - skin or intravenous site, should be 

counseled and tested for the hepatitis C virus antibody.

Substance Abuse Treatment as HIV Prevention

Substance abuse treatment has been a cornerstone of national HIV 

prevention efforts.47 Substance abuse treatment programs play two 

critical, yet distinct roles in HIV prevention. First, treatment programs 

serve to reduce the frequency of high-risk behaviors such as the injection 

of drugs, aiding in the direct prevention of HIV transmission. But also 

by gaining access to treatment, injection drug users also gain important 

access to a broader range of public health interventions such as risk 

reduction counseling and HIV testing and screening.48 

Substance abuse treatment programs were the site of the earliest HIV 

prevention efforts with high-risk populations such as injection drug users 

and there is a large body of literature that has established an association 

between participation in treatment and lowering one’s risk for HIV.49

While substance abuse treatment is a highly effective HIV intervention, 

limited access to treatment can be a potential barrier for many injection 

drug users and other high-risk substance-abusing populations. In 

addition, relapse is a common occurrence so many substance abusers may 

move in and out of treatment over time. As such, their risk for HIV will 

likely vary over time, but there still appears to be an overall decline in 

the frequency of drug use and related risk behaviors even for those who 

relapse after treatment.50
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Should you need to provide prevention counseling to patients who 

continue to inject, CDC recommends that people who inject drugs should 

be regularly counseled to:

l stop using and injecting drugs or

l to enter and complete substance abuse treatment.

For injection drug users who cannot or will not stop injecting drugs, the 

following steps may be taken to reduce personal and public health risks:

l never reuse or “share” syringes, water, or drug preparation 

equipment,

l only use syringes obtained from a reliable source (such as 

pharmacies or needle exchange programs),

l use a new, sterile syringe to prepare and inject drugs,

l if possible, use sterile water to prepare drugs; otherwise, use clean 

water from a reliable source (such as fresh tap water),

l use a new or disinfected container (“cooker”) and a new filter 

(“cotton”) to prepare drugs,

l clean the injection site prior to injection with a new alcohol swab, 

and

l safely dispose of syringes after one use.51

Guidance for the Substance Abuse Treatment Provider 

The VA HIV and Hepatitis C Prevention Service, the National HIV/

Hepatitis C Program, and the Centers of Excellence on Substance 

Abuse Treatment and Education recently created a joint recommendation 

regarding hepatitis C and HIV counseling and testing for all veterans 

receiving specialty care for substance use disorders (SUDs). The 

recommendation states that upon entry into a VA substance abuse 

treatment program, patients with SUDs should routinely be (1) tested for 

hepatitis C and counseled about the testing and results and (2) assessed for 

HIV risk and receive mandatory pre-test counseling for HIV. 

HIV pre-test counseling should include information about risk factors for 

HIV, the confidential and voluntary nature of the HIV test in VA, the 

meaning and specificity of the HIV test, and information on measures 

to be taken for preventing transmission of HIV (for a complete list of 

information required for pre-test counseling, see page 60). The veteran 
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should then be asked if he or she wishes to be tested for HIV and their 

ability to give informed consent should be evaluated. 

If the veteran does not wish to be tested for HIV, the counselor or provider 

should continue ongoing risk assessment and risk reduction counseling. If 

the veteran does consent to be tested, the provider should proceed with 

a referral to a HIV test counselor or proceed with counseling and testing 

according to VA policy. 

If a patient in a substance abuse treatment program tests positive for HIV, 

he or she should be referred to the infectious diseases clinic or their primary 

care provider in the VA Medical Center in order to receive evaluation and 

treatment of their HIV. If a patient tests positive for hepatitis C, he or she 

should also be referred to the identified hepatitis C provider at their facility 

for further evaluation and management in order to avoid liver damage. If 

a patient in a substance abuse program has a negative test result on the 

HIV or hepatitis C test but continues to engage in risk behaviors, he or she 

should receive risk reduction counseling and be encouraged to continue to 

be retested every six months until their risk behaviors have stopped.

This handbook contains two screening instruments that can be administered 

in an alcohol and substance abuse treatment setting. The first instrument, 

Simple Screening Instrument for Outreach for Alcohol and Other Drug 

Abuse and Infectious Disease (Treatment Improvement Protocol, Series 

#11) is found on pages 33-34 and the Risk Assessment Battery is found 

in Appendix C. 

The goal of the Simple Screening Instrument for Outreach for Alcohol 

and Other Drug Abuse and Infectious Disease is to determine the risk 

for infectious diseases experienced by substance abusers and addicts. To 

learn more about this instrument and the infectious diseases associated 

with specific questions, contact SAMHSA’s National Clearing House 

for Alcohol and Drug Information at 1-800-729-6686 or by e-mail at 

info@health.org and ask for the document. 
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Screening for Infectious Diseases 

in the Substance Abuse Service Setting

1. Have you seen a doctor or other health care provider in the past 3 months? 

(yes/no)

2. a. Do you live on the street on in a shelter? (yes/no)

b. Have you ever been in jail? (yes/no)

3. Have you ever been told you have a positive HIV test [test for the AIDS 

virus]? (yes/no)

4. Women: Have you missed your last two periods? (yes/no)

5. Have you ever had a positive skin test for TB? I mean a test where you 

got a shot in the forearm, and a few days later had a hard bump like a 

blister appear? (yes/no)

6. Have you ever been told you have TB? Has anybody you know or have 

lived with been diagnosed with TB in the past year? (yes/no)

7. a. Within the last 30 days, have you had any of the following symptoms 

lasting for more than 2 weeks?

l Fever

l Drenching night sweats that were so bad you had to change your 

clothes or the sheets on the bed

l Productive cough

l Coughing up blood

l Shortness of breath

l Lumps or swollen glands in the neck or armpits

l Losing weight without meaning to

l Diarrhea (runs) lasting more than a week

b. Do you live with someone who has any of the following symptoms?

l Coughing up blood

l Drenching night sweats

c. Do you know or are you close to anyone with these symptoms? 

(yes/no)

8. Do you use needles to shoot drugs? (yes/no)

9. Do you use coke or crack? (yes/no)
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10. In the last 6 months, have you had any VDs [venereal diseases, 

STDs, sexually transmitted diseases], like syphilis, the clap [gonorrhea], 

chlamydia, or NGU [nongonococcal urethritis, trichomoniasis, trick]? 

(yes/no)

11. Have you, or anyone you’ve had sex with, had any of the following 

symptoms within the last 30 days?

l Sore or ulcer on the penis/vagina [“down there”]?

l Rash, spots, or other skin problems, especially on your palms or the 

soles of your feet?

Women:

l A vaginal discharge that is different from what you usually have?

l Pain when you have vaginal sex?

Men:

l Discharge from the penis?

12. Have you had sex with more than two people–at different times–in the 

past 6 months? I mean any type of vaginal, rectal, or oral contact, like 

you went down on your partner or he/she went down on you, with or 

without a condom. (yes/no)

13. Have you used your rectum for sex? (yes/no) [Use regionally appropriate 

terminology to indicate penile penetration, as opposed to other types of 

sexual contact.]

14. In the past 6 months, have you had sex with someone in return for 

anything, like money, alcohol or other drugs, a place to stay, or just to 

survive? (yes/no)

15. Have you ever been forced to have sex against your will? (yes/no)

Note. From Simple Screening Instruments for Outreach for Alcohol and Other 

Drug Abuse and Infectious Disease: Treatment Improvement Protocol Series-11

(DHHS Publication No. {SMA} 94-2094, p. 21), by the Substance Abuse and 

Mental Health Services Administration, U.S. Department of Health and Human 

Services, 1994.
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Guidance for the Mental Health Treatment Provider 

HIV risk assessment and risk reduction counseling can also occur as part 

of a routine evaluation and treatment in mental health settings such as Vet 

Centers and psychiatry clinics. 

Veterans with chronic mental illnesses may be at greater risk for HIV 

because of: 

l deficits in social skills that are needed to negotiate safer sex with 

partners,

l sexual disinhibition,

l cognitive impairment or poor judgment,

l hypersexuality or mania, or

l associated substance use.

A 1997 study suggested that U.S. veterans with posttraumatic stress 

disorder (PTSD) or other mental or emotional problems and substance 

abuse face a 10-fold increased risk of HIV infection when compared to 

veterans without either.52

In addition to a link between severe stress exposures and a broad array of 

diseases,53 PTSD can also be associated with stress-related risk behaviors 

that may place veterans at risk for HIV. The relationship between PTSD 

and substance use is well known. In attempting to cope with, self-manage, 

or ‘numb’ symptoms of PTSD, a veteran may engage in substance use or 

abuse or associated unprotected sexual behaviors that may place him or 

her at risk for HIV. If the PTSD is secondary to sexual assault or trauma, 

it may be much harder to engage in the self-efficacy and interpersonal 

skills necessary to negotiate safer sex practices such as consistent condom 

use with a sexual partner.

The seriously and persistently mentally ill are another population at higher 

risk for HIV and with a higher prevalence of the disease. A review of 

studies on HIV risk behavior among seriously mentally ill populations 

found lifetime rates of injection drug use from 4-35%, and higher rates 

of risky sexual behaviors, including such activities with partners known 

to be at increased risk for HIV.54 It is likely that psychiatric symptoms, 

substance abuse, and social vulnerability inadvertently contribute to risk 

in this population.55
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While a substance-use history is frequently a part of a mental health 

intake evaluation, sexual history items can also be integrated into routine 

questions about social relationships. In asking patients in a mental 

health setting about their medical history, questions about specific sexual 

activity, the relationship between substance use and sexual risk, use of 

condoms, and previous diagnoses of STDs can also be included. Again, 

it is important to emphasize with the patient that you routinely ask these 

questions of all your patients as you are concerned with all aspects of their 

health and emphasize the confidentiality policy of VA.

Should your patient present with risk factors for HIV, you should discuss 

the possible need for HIV testing and counseling. You may want to start 

the discussion with prompts such as those found on page 58. In addition, 

you should:

l assess the patient’s ability to provide informed consent, 

l refer patients to the HIV test counselor at your facility if they 

consent to testing and are able to provide informed consent, and

l determine if the patient wants you to accompany them to the testing 

or provide a time to see them while they are waiting for their result 

and immediately after receiving the results of their test. 

Discussions to evaluate a patient’s readiness to adopt behaviors to reduce 

their risk as well as general HIV prevention counseling can be integrated 

into other therapeutic goals. Again, it is important to continue to assess 

risk for HIV on an ongoing basis for veterans who receive mental health 

services as their risk for HIV may change in response to changes in their 

psychological functioning and life events. Factors such as depression, 

hopelessness, manic presentations, and diminished judgment may increase 

patients’ risk status, and may have to be addressed before a patient can 

change his or her risk behaviors. 

Mental health settings in VA can make condoms available to patients by 

leaving them in areas such as restrooms where patients can pick them 

up unnoticed. Both male and female condoms can also be prescribed 

to patients through the VHA National Formulary (listed under ‘medical 

supplies’). 

It may also be helpful to provide educational materials on HIV prevention 

in clinic waiting rooms and examination rooms. Patients can read the 

material while they are waiting and it provides a cue to patients that this is a 

topic they can bring up with their mental health services provider.
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Guidance for Homeless Care Providers

In March 1990, the U.S. Census counted 39,000 male veterans in 

emergency homeless shelters. This number underestimates the number 

of homeless veterans as many homeless individuals do not reside in 

shelters.56 In the same year, there were 149 homeless veterans 

per 100,000 individuals vs. 126 homeless non-veterans per 100,000 

individuals.57

Homelessness and HIV/AIDS co-occur at very high rates. Risk factors 

such as severe mental illness, substance abuse, and a history of injection 

drug use all occur at higher rates among urban homeless populations, 

leading to increased risk for HIV. Homeless populations are also likely to 

have poor access to health care, substance abuse treatment, or condoms–

all things that can help prevent HIV and related risk.58

VA’s proud tradition of Stand Downs for homeless veterans, held each 

year in cities across the United States, provide excellent opportunities 

for health screening and support of homeless veterans. Stand Downs 

are often co-sponsored by VA Medical Centers, Vet Centers, veteran 

service organizations, and homeless care providers. Many Stand Downs 

include HIV prevention interventions such as substance abuse screening 

and treatment referrals, referrals for HIV testing, condom distribution, 

referrals for HIV treatment, and hepatitis C screening and testing. 

Homeless veterans may be reluctant to participate in on-site HIV 

testing at a Stand Down. Homeless health care providers have 

reported that they get better participation with HIV testing and 

risk assessment if homeless veterans at Stand Downs can be given 

an appointment and seen in a clinic for these services.

HIV Prevention in the Emergency Room Setting

It is important to note that HIV prevention can take place in the emergency 

room (ER) setting. In 1996, 10% of visits to a physician occurred in an 

ER setting.59 While it is highly unlikely that there is adequate time to 

conduct comprehensive HIV prevention in the ER setting, brief prevention 

activities can take place. They include:

l asking patients about condom use, number of sexual partners, type 

of sexual activity, and injection drug use,
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l making referrals to VA substance abuse programs, toll-free HIV/

AIDS hotlines, VA AIDS/infectious disease clinics, and community 

organizations,

l recommending HIV testing for patients considered at high risk,

l writing a prescription for condoms for patients who are at risk 

because of sexual or substance use behaviors, and 

l offering HIV prevention reading materials, access to electronic 

resources, or access to an HIV test counselor during the 

waiting time.
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You may have only one opportunity to address HIV/AIDS issues with 

some patients or multiple opportunities to address it with patients seeking 

on-going medical treatment. As such, primary and secondary HIV 

prevention approaches and strategies used in health care settings should be 

easily administered, effective and brief. 

Some models and interventions that can assist you in your approach 

to primary and secondary HIV prevention include: (1) behavior change 

counseling, (2) the Transtheoretical Model of the Stages of Change Theory, 

(3) motivational interviewing, (4) the Partnership for Health intervention 

for HIV-positive patients, and (5) practical information on condom use. All 

of these examples contain overlapping themes and activities that are central 

to helping your patient make and maintain healthy behavior decisions.

Behavior Change Counseling

Behavior change counseling is an “ongoing process through which the 

patient assumes responsibility for making incremental behavior changes 

that address the problem.”60

The goals of behavior change counseling are to:

l assess each patient’s level of awareness and concern,

l assist the patient in reaching a better understanding of potentially 

harmful behavior,

l determine the patient’s readiness for change, and

VII. HIV Prevention Approaches and Strategies

This chapter addresses:

l Behavior change counseling

l Transtheoretical Model of the Stages of Change Theory

l Motivational interviewing

l Partnership for Health: A brief safer sex intervention for health 

care providers working with HIV-positive patients

l Practical advice on the use of male and female condoms and 

dental dams
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l help the patient bring about the desired change (i.e., suggest options 

for changing potentially harmful behaviors, help the patient make 

decisions that promote health, and provide referrals for services 

beyond the scope of the clinician or the clinical setting).61

Assess each patient’s level of awareness and concern and assist the patient 

in reaching a better understanding of potentially harmful behavior

Determining a patient’s level of HIV/AIDS knowledge and their concerns 

about their behavior is an excellent first step. Patients may be knowledgeable on HIV transmission risk, yet unable to make use of this information 

in evaluating their own risk. It is through questions that you will determine 

what types of information you need to share with the patient.

“What are you doing to 

make sure you don’t get HIV 

through sex?”

“Under what conditions do 

you not use a condom?”

“How frequently do you use 

condoms, and with whom?”

“When do you use 

condoms and what type of 

condoms do you use?”

“Do you have any questions 

about what you can do to 

prevent HIV?”

“What are any barriers to 

your protecting your self 

through HIV?”

“Are you concerned about whether 

you are putting yourself as risk for 

HIV through drug use?”

Determine the patient’s readiness for change

This is a process where you determine the patient’s placement on a 

behavior change continuum. For example, a patient thinking about using 

barrier protection and a patient who has used barrier protection consistently 

for the past six months, are at different points of the continuum. A 

useful model for determining a patient’s readiness to change is the 

Transtheoretical Model of the Stages of Change Theory (see pages 44-45).
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Prevention Activities That Help Promote 

Healthful Changes 

l Demonstrating male and female condom use 

l Sharing techniques for negotiating condom use

l Sharing techniques that aid in HIV medication adherence

l Providing referrals to substance abuse and mental health 

services within the VA

l Providing referrals to organizations that offer services 

not provided by the VA health care system (e.g., harm 

reduction services*, group therapy sessions for HIVpositive transgender clients, outreach to men who have 

sex with men in anonymous settings) 

l Helping the patient to generate a list of advantages of risk 

reduction practices, such as substance abuse treatment, 

safer sex, and not sharing needles

l Helping the patient to identify and begin to address 

barriers to risk reduction

l Helping the patient understand undertaking risk reduction 

behaviors as an altruistic measure to help prevent the 

transmission of HIV to others 

l Discussing with a patient how to introduce safer or 

protected sex with a partner

l Discussing with patients about how and when to disclose 

their serostatus to a new partner

Help the patient bring about the desired change

There are a multitude of activities that can help a patient bring about 

desired changes–changes that help the patient stay HIV negative or keep the 

HIV-positive patient from being reinfected or infecting others. Suggested 

behavior change options (e.g., substance abuse referrals or, if your patient 

is continuing to use drugs, to not share needles; using a condom) should fit 

the patient’s circumstances.

* Harm reduction is an “approach to treatment that emphasizes incremental decreases 

in substance abuse or HIV risk behaviors as treatment goals. This method attempts 

to keep clients in treatment even if complete abstinence is not achieved.” Substance 

Abuse and Mental Health Services Administration. (2000). Substance abuse treatment 

for persons with HIV/AIDS: Treatment improvement protocol (TIP) series 37 (DHHS 

Publication No. [SMA] 00-3410). Washington, DC: U.S. Government Printing Office.
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Transtheoretical Model of the Stages of Change Theory

This theory was developed in 1982 to stage cigarette smokers so that 

they could be offered an appropriate smoking cessation intervention. The 

Stages of Change Theory consists of different stages that people face when 

addressing a behavioral change. These stages to not occur in a linear 

fashion, but a cyclical one.62

Precontemplation: At this stage, the 

person has no intention of changing the 

behavior (i.e., never uses condoms) in 

the near future. Authors of the theory 

state that many individuals at this stage 

do not recognize their behavior as 

a problem. If the person expresses 

no intention to change their behavior 

within the next six months, they will be 

labeled a precontemplator. 63 

Contemplation: This stage involves identification by the person that they 

want to change the behavior, but no commitment has been made to this 

change. An individual could be in this stage for an extended period of time 

(i.e., 18 months). During this time they may be examining the pros and 

cons of behavior change and the effort it will take to address it.64 

Preparation: “is a stage that combines intention and behavioral criteria...

Individuals in this stage are intending to take action in the next month 

and have unsuccessfully taken action in the past year...Although they 

have made some reductions in their problem behaviors, individuals in the 

preparation stage have not yet reached a criterion for effective action, such 

as abstinence from smoking, alcohol abuse, or heroine use.”65 

Action: “is a stage in which individuals modify their behavior, 

experiences, or environment in order to overcome their problems. Action 

involves the most overt behavioral changes and requires considerable 

commitment of time and energy.”66 A person is considered to be in the 

action stage if they can successfully alter their problem behavior for a 

period of one day to six months. The hallmarks of the action stage are 

modification of the target behavior to an acceptable criterion as well as 

significant overt efforts to change.67

Five Stages of Change

l Precontemplation

l Contemplation

l Preparation

l Action

l Maintenance
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Maintenance: at this stage, an individual should be free of the problem 

behavior and “be able to consistently engage in a new incompatible 

behavior for more than six months.”68 In the maintenance stage people 

work to prevent relapse and consolidate the gains attained during action.69 

While not reflected in all of the literature, termination is considered a 

sixth stage. In this stage, a person is “presumed to have no temptation 

to relapse and a complete sense of self-efficacy concerning their ability to 

maintain health behavior.”70

Relapse is the norm for most attempts at behavior change.71 Relapse is 

more likely to occur during the action stage than the maintenance stage72 

although maintainers can experience temptations to relapse for years after 

being in that stage.73

Being able to determine the stage a patient is in regarding their desire 

and ability to change a behavior will help you develop HIV prevention 

strategies. Using the question “How are you currently dealing with 

preventing HIV infection through sex or drug use?”, Chart 7-1 illustrates 

statements patients may make and strategies that may prove useful.
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CHART 7-1

Responses to Risk-behavior Questions, 

Corresponding Stages of Behavior Change, and Possible Intervention

Question:

“How are you currently dealing with preventing HIV 

infection through sex or drug use?”

“I don’t think about it.”

Precontemplative. Either 

unaware of risk or has no 

intention to change.

Type of answer

“I worry about it, but I don’t 

really know what to do, if 

anything.”

“I’ve thought about it. I 

guess I’d like to try 

something.”

Contemplation of resistance by 

the patient. Education may 

enhance awareness.

Stage of behavior change

Contemplative. Considers 

change but has no 

specific plan.

Prepared. Ready for 

change. Planning for 

change and may have taken 

initial action.

Education as to options. 

Assessment of barriers to change 

and discussion of benefits of change, 

resources, and intervention options.

Discuss options for initiating 

change.

Possible intervention
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Veterans Health Administration “I’ve started using condoms, but not all the time.” OR “I’ve started cleaning my works.” OR [“I’m in a treatment program.”] OR [“I’ve been clean for three months.”] “I have been using a condom now for about six 

months, nearly all the time.”

OR

“I’ve started using a syringe exchange program.”

OR

[“I found out about a drug treatment program.”]

“I was really good for a long time, but then I 

started seeing somebody new and I just stopped. 

I’m not sure it was the right thing to do”

OR

“I went cold turkey for a while, but I ran into 

some old friends who were using and I picked 

up again.”

Action. Initiated change.

Maintenance. Adopted a 

new behavior

Relapse.

Time or changing factors result 

in discontinuing adopted 

behavior.

 Identify and acknowledge 

successful actions. Explore 

resources, and referrals. 

Problem solve to help increase 

behavior changes.

Evaluate factors supporting 

and potentially discouraging 

maintenance.

Evaluate the need for 

re-initiating behavior. 

Discuss factors influencing 

cessation of desired 

behavior.

Note: From HIV & Primary Care: Putting Prevention into Practice (p.55), by the AIDS 

Institute, New 

York State Departmnt of Health, 1998. Reprinted with permission. Data from 

“In search of how people change. Applications to addictive behavior” (p. 1102-1114), by J.O. 

Prochaska, C.C. DiClemente, & J.C. Norcross, (1992), American Psychologist, 47(9), 1992.
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Motivational Interviewing

Motivational interviewing* is another method used to help the patient 

review and evaluate behaviors that may put him/her at risk for HIV 

infection or transmission, and help the patient express concerns about the 

risk behaviors (a characteristic of the contemplation stage) and desires to 

change the risk behaviors.74 Motivational interviewing has been defined as 

“recognizing a problem, searching for a way to change, and then beginning 

and sticking with that change strategy.”75 

Activities Associated with Motivational Interviewing

l Assessing stages of change for risk behavior

l Helping the patient personalize his/her risk

l Negotiating client goals

l Illuminating discrepancies between the patient’s behavior 

change and existing behaviors (i.e., using clean needles, but not 

using condoms)

l Discussing the client’s idea of their own longevity (i.e., 

connecting personal determination to one’s wishes for 

longevity)

l Providing personal risk feedback 

l Encouraging action

Note. From Motivational Interviewing: Preparing People to Change Addictive 

Behavior by W. R. Miller & S. Rollnick, 1991. New York: Guilford Press.

Partnership for Health: A Brief Safer Sex Intervention for 

Health Care Providers Working with HIV-positive Patients

Partnership for Health (PfH) is an intervention that integrates risk 

reduction counseling into primary care for individuals who are HIV 

positive. In this model, health care providers make use of prompts 

such as educational posters and informational brochures to talk briefly 

with their HIV-positive patients about the importance of safer sex and 

disclosure of their HIV status to their sex partner(s).76 

* To learn more about motivational interviewing, go to the journal of Behavioural 

and Cognitive Psychotherapy (Vol. 23), 1995, S. Rollnick, & W. R. Miller or 

http://www.motivationalinterview.org 
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The core of the PfH intervention is a 4-hour training program for providers 

that helps them develop skills to talk with their patients about safer sex 

during regular office visits. Through these brief patient and provider 

interactions, the PfH seeks to decrease new infections by emphasizing the 

importance of patient behavior to protect themselves and their sex partners, 

and disclosure of their HIV status to their sex partners. In addition to 

provider counseling at every visit, informational inserts are available for the 

patients in both English and Spanish. Inserts address the following topics: 

l What is safer sex? 

l How to tell someone you have sex with that you have HIV

l Answers to your important questions about safer sex and viral load 

l With a little creativity, condoms can make sex safer and more sensual 

l Building supportive relationships 

l What if my sex partner refuses to use a condom? 

l Situations that may lead to unsafe sex 

l What can I do to help stop the epidemic? 

For further PfH information, contact the Partnership for Health, Department of 

Preventive Medicine, Keck School of Medicine, University of Southern California, 

1441 Eastlake Ave., MS44, Los Angeles, CA 90033 or the PfH project manager 

at 323-865-0345.

Practical Information on Condom Use

In the absence of a vaccine or cure, consistent use of barrier 

methods such as condoms remains the single best method of preventing 

sexual transmission of HIV among people who are sexually active. 

Multiple cohort studies, including those of serodiscordant couples, have 

demonstrated a strong protective effect of condom use against HIV 

infection. 

Consistent use of condoms has been found to reduce the risk of 

HIV transmission by 87-95%.77

Condoms also play an important role in the prevention of transmission of 

STDs that are transmitted through genital secretions or genital ulcerative 

diseases when the ulcers or lesions occur in areas covered or protected by 

the condom.78
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It is recommended that VA patients with HIV routinely be asked if they 

wish to receive a prescription for condoms in order to help prevent 

transmission of HIV to others through sexual contact. They should then 

be asked their preference for male or female condoms, or lubricated or 

non-lubricated condoms. Condoms are usually listed in VHA National 

Formulary under ‘medical supplies’. 

Other patient populations who should be prescribed condoms include 

patients whom: 

l are not HIV+ but who report high-risk activities such as unprotected 

sex with multiple partners, 

l have been diagnosed with an STD,

l have a history of injection drug use or substance abuse, and/or

l have tested positive for hepatitis C or B.

The potential need for condoms should also be discussed with veterans 

who request Viagra or other treatments for impotency or erectile 

dysfunction if they also report sexual risk behaviors or multiple sexual 

partners. 

Both male and females condoms are available on the VHA National 

Formulary. This means that condoms should be available at all VA 

pharmacies. As stated in VHA Directive 2001-044, “Items listed in the 

FORMULARY shall be made available throughout the VA health care 

system and cannot be made non-formulary at the Veterans Integrated 

Service Network (VISN) or local level. Restrictions can be established 

at the national, VISN or local level for formulary items that require close 

monitoring to ensure appropriate use. Restrictions may include evidencebased guidelines and/or prescribing privileges for providers with certain 

expertise. Restrictions will not be based solely on economic issues and 

will not be so limited as to prevent patients with legitimate needs from 

receiving FORMULARY medications.” VHA IL 10-2001-012 addresses 

the important role that condoms play in the prevention of HIV (see 

Appendix D).

Recent research has examined nonoxynol-9 and personal lubricants, two 

products often used in conjunction with condoms. After the results of a 

study that focused on nonoxynol-9 were released at the International AIDS 

Conference in Durban, South Africa (2000), this spermicide’s effectiveness 

in preventing HIV transmission has been a debated issue. This study 
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concluded that nonoxynol-9 is ineffective against HIV transmission and 

that it may in fact cause vaginal irritation which may facilitate HIV 

transmission. As such, the CDC recommends that nonoxynol-9 “not be 

recommended as an effective means of HIV prevention.”79

Researchers also examined the use of three personal lubricants (Astroglide, 

Vagisil and ViAmor) as a means to block the replication of HIV. In the 

laboratory setting, these non-irritating products were found to be highly 

active against HIV-infected CEM lymphocytes and also effective against 

cell-free HIV.80 

When making condoms available to patients or suggesting their use, the 

following information on condom type, storage, and use is helpful:
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Male Condom Guidance

l Use latex or polyurethane condoms, not natural skin 

condoms. Research shows that HIV can pass through 

natural skin condoms.

l Condoms should be stored in a cool dry place, they should 

not be placed in direct heat or sunlight and should not be put 

into wallets.

l Condoms should not be used after their expiration date 

(date printed on individual condom wrapper).

l A condom should be inspected prior to use for damaged 

packages, and signs of aging such as brittleness, stickiness, 

and discoloration.

l Put the condom on before sex play begins as pre-ejaculatory 

fluid, which comes from the penis, may contain HIV.

l Air should be pressed out of the tip of the condom before 

being placed on the penis.

l When rolling the condom down the base of the penis, leave 

room at the tip for ejaculate.

l If a lubricant is used, it should be a water-soluble lubricant 

(e.g., ID Glide, Astroglide) in order to prevent breakdown of 

the condom. Products like petroleum jelly and lotion are not 

considered water-soluble lubricants and should not be used.

l After sex, hold on to the base of the condom and pull out 

while the penis is still erect so the condom doesn’t slip off.

l Use a condom only once and properly dispose of it.
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 Female Condom Guidance

l Condoms should be stored in a cool dry place, they should not 

be placed in direct heat or sunlight.

l Condoms should not be used after their expiration date (date 

printed on individual condom wrapper).

l Condoms should be inspected prior to use for damaged 

packages, and signs of aging such as brittleness, stickiness, and 

discoloration. The female condom is lubricated so it will be 

somewhat wet.

l Put the condom in before sex play begins as pre-ejaculatory 

fluid, which comes from the penis, may contain HIV.

l The condom can be inserted up to eight hours before sex.

l Before inserting the condom, you can squeeze lubricant into the 

condom pouch and rub the sides together to spread it around.

l The female condom has a firm ring at each end of it. To insert 

the condom, squeeze the ring at the closed end between the 

fingers (like a diaphragm), and push it up into the back of the 

vagina. The open ring must stay outside the vagina at all times, 

and partly covers the lip area.

l Do not use a male condom with the female condom.

l Do not use a female condom with a diaphragm.

l If the penis is inserted outside the condom pouch or if the outer 

ring (open ring) slips into the vagina, stop and take the condom 

out. Use a new condom before you start sex again.

l Don’t tear the condom with fingernails or jewelry.

l Use a female condom only once and properly dispose of it in 

the trash (not the toilet).
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 Dental Dam Guidance

l A dental dam is a square piece of latex that can help 

prevent contact with body fluids present during oral sex. 

An alternative to using a dental dam would be to cut open a 

male latex condom or a female condom to make a barrier.

l To use a dental dam, first check it visually for any holes.

l If the dental dam has cornstarch on it, rinse this off with 

water (starch in the vagina can cause an infection).

l Cover the women’s genital area with the dental dam.

l For oral-anal sex, cover the opening of the anus with a new 

dental dam.

l A dental dam should be used for each act of oral sex; it 

should never be reused.

Note. From HIV & Primary Care: Putting Prevention into Practice 

(p. 152), by the AIDS Institute, New York State Department of Health, 

1998. Reprinted with permission.
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Both female and male patients may need guidance on condom negotiation 

skills. Patients should be advised to discuss safer sex and condom use 

before they find themselves in a sexual situation.

Advise patients to: 

l Schedule a time and place outside of the bedroom to talk–condom 

negotiation is proven to be more difficult when you’re in a sexual 

situation.

l Think about what your boundaries, concerns and desires are before 

you initiate conversation. Make sure you don’t do or agree to do 

anything that you’re not 100% comfortable trying. Remember: it’s 

okay to change your mind.

l Realize that your partner’s principles may not match up exactly with 

your own, and that you may need to work to come up with solutions 

and alternatives that are acceptable to both of you.81

Tips for Negotiating Condom Use

l Make sure you clearly state what you want

l Use only “I” statements (e.g., “I want to use a condom when we 

have sex.”)

l Listen to what your partner is saying

l Be respectful–acknowledge your partner’s feelings and opinions

l Be positive

l Use reasons for safer sex that are about you, not your partner82 
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HIV testing and counseling is an important part of HIV prevention 

activities. It provides prevention education opportunities for both the 

person who tests negative and the person who tests positive. 

Through pre-testing counseling, a patient can gain an understanding of 

how certain behaviors put them at risk for infection. Through post-testing 

counseling, patients are given the test results and thus they become aware 

of their HIV status. One’s knowledge of their serostatus can have an 

incredible effect on subsequent behaviors and risk reduction techniques.83 

In one such study, 90% of the study participants reported that they had 

changed their sexual behavior since learning of their HIV infection.84 

Techniques for behavior change can be discussed during HIV pre- and 

post-test counseling. 

VA Policy on Confidential HIV Testing and Counseling

VA HIV testing and counseling for patients is voluntary and confidential 

and requires written informed consent from the patient. HIV testing in the 

VA system is not universal (meaning all patients should not be tested) and 

depends on the identification of risk factors by the provider or veteran or 

VIII. HIV Testing and Counseling of VA Patients

This chapter addresses:

l VA policy on confidential HIV testing and counseling

l The informed consent process for HIV testing 

l VA staff who can provide HIV pre- and post-test counseling

l Guiding discussions of HIV testing with patients

l Benefits of HIV testing and counseling

l VA HIV pre-test counseling requirements and documentation

l VA HIV post-test counseling requirements and documentation

l Screening tested individuals for domestic violence

l Partner notification and referral guidance

l Reporting of HIV cases to state and local health authorities

l Referrals for primary and secondary prevention services
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a veteran’s request for testing. As stated in VA Circular 10-88-151 and 

Circular 10-88-151, Supplement No. 1, the VA makes confidential HIV 

testing and counseling available to all patients who request it. 

For clarification purposes confidential and anonymous testing are defined 

below:

Confidential HIV testing: The person being tested for HIV will 

be asked to provide their name for testing purposes. The person 

providing HIV testing and counseling as well as other health 

and social service providers at the facility who are entitled to 

review medical records or who are providing care to the patient 

will have access to the test result. Confidentiality laws and 

regulations protect this information. 

Anonymous HIV testing: The person being tested for HIV does 

not provide their name to the testing counselor and facility/

center whom is testing them. The person is assigned a unique 

identifier that they will use to get their test results. The person 

being tested and the testing counselor are the only ones to know 

the test result. Anonymous HIV testing is offered by some 

public health departments and community-based clinics.

While the VA does not offer anonymous HIV testing and counseling to 

its patients, VA health care practitioners are encouraged to refer patients 

wanting such a test to a nearby anonymous testing site. To refer 

someone to an anonymous testing site in their geographic area, contact 

the CDC National STD and AIDS Hotlines 24 hours a day, 365 days 

a year at 1-800-342-AIDS (1-800-342-2437), 1-800-AIDS-TTY (1-800-

243-7889) TTY, 1-800-344-SIDA (1-800-344-7432) Spanish, or go to 

http://www.hivtest.org/ to locate a testing site.

HIV Testing: Informed Consent 

The VA is clear that written informed consent prior to HIV testing is 

required. Current 38 Code of Federal Regulations Section 17.32 states, 

“Testing for...HIV must be voluntary and must be conducted only with the 

prior informed and (written) signature consent of the patient or surrogate. 

Patients who consent to testing for HIV must sign VA form 10-012, 

‘Consent for HIV Antibody Testing.’ This form must be filed in the 

patient’s medical record. Testing must be accompanied by pre-test and 

post-test counseling.”
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It is important to review the consent form (VA Form 10-012) with the 

patient in order to evaluate whether they have any questions, any difficulty 

reading or the form, or any difficulty understanding the items.

Examples of patients unable to provide informed consent are:

l a patient who is psychologically unable to cope with the results,

l a patient who is under the influence of a substance or medication that 

prevents his/her comprehension,

l a patient who has been coerced, and/or

l a patient who cannot communicate with the clinician because of a 

significant language barrier.85 

If you suspect your patient has limited comprehension of the significance, 

meaning and ramification of an HIV test, you should purposely ask the 

client to repeat his/her understanding of selected concepts you discussed for 

a broader assessment. You can also ask standard mental status questions to 

make sure that the patient is well oriented to time and place, such as:

l Tell me where you are?

l Who is the current president?

l Can you tell me today’s date?

Should you deem the patient at risk for HIV and unable to provide 

informed consent, you may want to contact the patient’s guardian (if one 

has been designated) or durable power of attorney. You can discuss your 

concerns with the guardian and if requested by them, HIV testing and 

counseling can be performed on the patient after the guardian provides the 

necessary informed consent. If the patient does not have a legal guardian 

or a durable power of attorney for health care, then it may be necessary, in 

limited circumstances, for a court to appoint a guardian. 

You will need to assess the urgency of HIV testing. In a patient who is 

incapacitated and comatose following head trauma, the “need to know” 

may stem from occupational injury to a health care worker or to aid in the 

diagnosis or treatment of a condition such as pneumonia. 

It is possible that the patient’s inability to comprehend the information 

may be temporary. In some instances, the patient may be stabilized with 

medication and return for HIV testing and counseling at a later date. If a 

patient comes to the appointment intoxicated, it is best to reschedule as this 

person would not be able to provide informed consent.
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Types of HIV Testing Methods Available at VA Facilities

At this time, the types of HIV testing methods available at VA facilities 

vary. This is because the VA does not mandate that all types of FDAapproved HIV tests be made available at each VA facility that offers 

HIV testing and counseling. As such, facilities may use the regular 

blood test, the rapid blood test, and/or the oral test. The only VA policy 

guidance on type of testing method to use involves occupational exposures. 

IL 10-2001-011 states that the most advanced and rapid HIV detection 

technologies should be made available in the event of an occupational 

exposure at a VA facility.

Who in the VA Can Provide HIV Pre- and Post-test Counseling?

VA Circular 10-88-151, Supplement No. 1 states that “[t]he [VA] AIDS 

Program Office has not identified a single profession to perform counseling 

but emphasizes the health care professional designation (e.g., one whose 

profession requires formal academic preparation, standards of practice, and 

a code of ethics such as nurses, social workers, psychologists) and suggests 

that individual[s] participate in the national training program.”86 Currently, 

health care providers who have gone through training and are deemed 

“HIV counselors” and health providers available to do HIV counseling are 

allowed to conduct HIV pre- and post-test counseling in VA facilities.
“Because of the growing epidemic in our area, all physicians are talking with 

their patients about HIV and AIDS. I’d like to talk with you about it too. 

Would it be all right to do that now?”

“In order to provide the most complete medical picture we can get on all of 

our patients, I’d like to talk with you about a number of things, including HIV 

and AIDS. This will help me to provide the best medical care I can for you. 

Are you familiar with HIV or AIDS? I’d like to give you some information 

about it. Where should we start.”

“You have been a patient here for some time. Because of new medical 

guidelines, I am starting to talk with all of my patients about HIV and AIDS. 

Have you ever considered the possibility of taking the HIV antibody test?”

“Based upon your current medical profile and some of the information you 

have shared with me, I think we should consider the HIV antibody test at 

this time. I would like to know your HIV status in order to provide the best 

medical care for you.”

“In light of recent medical development, all physicians are talking with their 

patients about HIV/AIDS prevention. Can we talk about this now?”

All patients

New patient

Continuing patient

Patient with medical indication or risk profile

Pregnant patient or one considering pregnancy

Note. From HIV & Primary Care: Putting Prevention into Practice (p. 31-32), by the 

AIDS Institute, New York State Department of Health, 1998. Reprinted with permission.

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Suggestions for Guiding Discussions with Patients on HIV Testing

Opening the discussion of HIV testing–In order to help the patient feel at 

ease, the health care provider should make it clear that the patient is not 

being singled out for HIV testing. This can be done in a variety of ways, 

using statements such as the following:
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Benefits of HIV Testing

l Your health care provider or counselor will tell you how to 

protect yourself from getting infected with the virus in the future.

l You can end the uncertainty which may come from not knowing 

if you are infected.

l Your health care provider can give you medical treatment to 

help you stay healthy and slow down HIV illness. [The VA has 

every FDA-approved HIV drug on its Formulary]

l Your health care provider can tell you how to prevent passing 

the virus to others.

l You can learn your status in order to help prevent spreading 

HIV to others like sex partners who will be at risk if you are 

positive and don’t practice safer sex.

l If you have had a child since you were infected, you child may 

need additional care and treatment. Your health care provider 

can tell you about medical care available for children who may 

be infected with HIV.

If you are a woman who is pregnant or considering a pregnancy 

and you test positive:

l Your health care provider can tell you about the risk of passing 

the virus from mother to child.

l Your health care provider can tell you about medication that 

may reduce the chances of passing the virus from mother to baby.

l You can protect your baby by not breast-feeding. If you have 

HIV, your breast milk can infect your baby. If you think that 

you might be at risk for HIV infection, and you do not take the 

HIV test, you risk passing the virus to your baby if you decide 

to breast-feed.

l Your health care provider can test your baby to find out if he 

or she is infected with HIV, and, if so, give the special medical 

care your baby needs. 

Note. From HIV & Primary Care: Putting Prevention into Practice (p. 132), by 

the AIDS Institute, New York State Department of Health, 1998. Reprinted with 

permission.
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Pre-test Counseling: VA Requirements of Pre-test Counseling 

and Documentation

The VA pre-test counseling requirements were first set forth in VA Circular 

10-88-151. That circular established both the counseling requirements and 

the appropriate documentation of those counseling efforts. Specifically, the 

1988 Circular provides that pre-test counseling should include, but not be 

limited to, the following information:

l the meaning, sensitivity, and specificity of the HIV test;

l the potential social ramifications of a positive test result;

l policies and guidelines for confidentiality of the test results;

l policy on nondiscrimination in health care services for patients with 

HIV infection and the health care services available in the VA;

l policy and guidelines on disclosure to public health authorities;

l policy on disclosure to spouse and/or sexual partner;

l measures to be taken for prevention of HIV transmission; and

l information relative to authorized disclosures, either with or without 

consent, of HIV test or treatment records.87 

In addition to the counseling requirements set forth above, VA Circular 

10-88-151 states that all elements of the counseling process should be 

documented on the progress notes of the medical chart. More specifically, 

pre-test documentation should include, but not be limited to, the following 

elements:

l the fact that pre-test counseling was conducted;

l the date and time written consent was given;

l a brief description of the content covered in counseling;

l the patient’s response to and participation in the counseling sessions;

l the patient’s mental status at the time of counseling;

l a brief assessment of the patient’s comprehension of the 

significance, meaning, and ramifications of the test; and

l the fact that the patient freely consented to testing.88

It is important to evaluate whether the patient will need ongoing support 

while waiting for an HIV test result as this can be a very difficult time. 

Patients should be provided with a telephone number of a test counselor 
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or provider whom they can contact if they have questions during the 

time that they are waiting for their HIV test result. Finally, it is very 

important to counsel the patient that while waiting for their test result they 

should practice risk reduction activities such as safer sex and/or not sharing 

needles or works. 

Post-test Counseling: VA Requirements of Post-test Counseling 

and Documentation

VA Circular 10-88-151 states that post-test counseling should be adapted to 

both the test result and the particular needs of the individual patient. 

1) Counseling for a negative result should include, but not be limited 

to, the validity of the negative result if the patient is in a group at 

high risk for HIV infection, possible retesting, and reinforcement of 

risk reduction behaviors. 

2) If the test results are positive, post-test counseling should include, 

but not be limited to, reinforcement of the availability of heath care 

services within the VA and community and public health resources; 

the advantages of notification of spouse or other sexual partners of 

possible exposure to the HIV and reinforcement of preventative HIV 

transmission measures to be taken by the patient.89

Post-test documentation should include, but not be limited to:

l the results of the test;

l a brief discussion of the content covered in the counseling;

l an assessment of the patient’s emotional/mental status; and 

l referrals made, if any, and plans for future services.90

It is important to realize that discussions of HIV prevention strategies 

during post-test counseling may not be fully absorbed by the patient. 

During HIV post-testing counseling, the HIV-negative person may be 

solely focused on the relief of not testing positive and the HIV-positive 

person may be trying to process their test result. 

Screening for Domestic Violence During Post-test Counseling

Partner or domestic violence is not gender specific and consists of physical, 

sexual, psychological, and economic abuse occurring in sexual and nonsexual relationships.91 

There may be times when a patient may appear to be fearful for their 

safety upon learning of a positive HIV test result. In those cases, or if you 
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Domestic Violence Screening Questions for Use 

During a Primary Care Visit or During Post-test 

Counseling

l I’m concerned about prevention and safety, especially in 

the family. Are you in any relationship where you are 

afraid for your personal safety, or where someone is 

threatening you, hurting you, forcing sexual contact, or 

trying to control your life?

l What happens when you and your partner fight?

l Have you ever been in a relationship where your partner 

hurt you, threatened you, forced sexual contact, or tried to 

control your life?

Note. From Family Peace Project, Family & Community Medicine Medical 

College of Wisconsin, by B. Ambuel, B. L. K. Hamberger, 1995. Retrieved 

July 11, 2001 from http://www.family.mcw.edu/ClinicalProtocols3.htm

Should a patient appear at risk for domestic violence, it is important to have 

a specific plan about what you can do to support them. It is important to 

talk with them to assess the level of threat to the patient and any children or 

other vulnerable individuals who live in the home. 

If the patient acknowledges current abuse or partner violence, communicate 

belief, support, and confidentiality. Help the patient assess the current level 

of danger by asking, “Do you feel safe going home?” Also, assess any 

indices of lethality such as weapons available and drug or alcohol abuse. 

Offer the patient telephone numbers such as local shelters, legal advocacy, 

and the police. Help the patient make an emergency plan, offer follow-up 

visits or phone contact, and document in the chart. 

have suspected potential abuse, screening for partner or domestic violence 

should be considered during HIV post-test counseling. It is possible that 

the patient may be at risk for domestic violence if their partner(s) learns 

they received HIV testing and counseling and/or the patient tested positive. 
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If you suspect abuse and the patient denies any abuse, tell the patient 

that you are concerned about their safety and tell them about community 

resources that they can use if they ever need them. Do not confront or 

challenge the patient, but offer follow-up and document your concerns.*

VA HIV Partner Counseling and Referral Services Guidance 

If you provide HIV pre- and post-testing counseling to VA patients, it 

is possible that patients who test positive may ask for your advice or 

assistance with partner notification (also known as partner counseling and 

referral services [PCRS]). This could involve you giving the patient 

guidance on disclosure of their HIV status or the patient asking if he/she 

can have their spouse or sex partner(s) come to the facility and you are 

present while the partner is told.

Regarding PCRS, patients may need to be coached on: 

l the best way to inform each partner,

l how to deal with the psychological and social impact of disclosing 

one’s HIV status to others,

l how to respond to a partner’s reaction, including the possibility of 

personal violence directed toward the client or others, and

l how and where each partner can access HIV prevention counseling 

and testing.92

The VA defines a partner as the spouse of the patient and/or an individual 

who has been identified by the patient as a sexual partner during the course 

of professional counseling or testing. Disclosures may be made where 

the individual who was tested has provided a specific written consent (VA 

Form 10-5345) for such disclosure. Should the person being tested die, 

a disclosure may be made on the request of the next of kin, executor, 

or personal representative if such disclosure is needed by the survivor to 

obtain benefits. 

Disclosure of a VA patient’s HIV-positive test result or status can be made 

without the patient’s consent, under specific circumstances. Current 38 

 

*For more information on diagnosis and management of partner violence, contact the 

Family Peace Project of the Department of Family & Community Medicine, Medical 

College of Wisconsin, 210 NW Barstow, #201, Waukesha, WI, 53188, (414) 548-6903, 

http://www.family.mcw.edu/FamilyPeaceProject.htm
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U.S.C. Section 7332 provides that disclosure without the specific consent 

of the HIV tested patient may be made under the following circumstances:

1. To medical personnel to the extent necessary to meet a bona fide 

medical emergency.

2. To qualified personnel for the purpose of conducting scientific 

research, management audits, financial audits, or program 

evaluation; however, redisclosure of such data is subject to further 

restrictions.

3. In response to an appropriate request from a proper federal, state, 

or local public health authority charged with the protection of the 

public health and to which federal or state law appropriately requires 

disclosure of such information, if a qualified representative of such 

authority has made a written request for that record.

4. Where authorized by an appropriate court order.

5. To the appropriate component of the Armed Forces which is 

providing health care to the veteran.

In addition to the circumstances set forth above, one more notable 

exception to the disclosure rule is set forth in 38 U.S.C. Section 7332. 

More specifically, that section provides that a physician or “professional 

counselor” may disclose, under certain conditions, without the patient’s 

consent, only under the following conditions:

1. the physician or counselor has made a reasonable effort to counsel 

and encourage the patient to voluntarily provide this information to 

the spouse or sexual partner,

2. the physician or counselor reasonably believes the patient will not 

provide the information to the spouse or sexual partner, and

3. disclosure is necessary to protect the health of the spouse or sexual 

partner.

Most state public health departments have a PCRS program in place. It is 

the professional and ethical responsibility of a VA provider to make use of 

PCRS by contacting the state or local health department in such instances 

in order to protect the health of the spouse or known sexual partner of a 

veteran with HIV (see Appendix E for a list of PCRS contact information 

for select states).
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VA Policy on HIV Case Reporting to State and Local Health 

Authorities by VA Facilities and Providers

HIV case reporting is a statistical activity intended to provide for the 

ongoing systematic collection of HIV information for use in public health 

practice. Through the reporting of new HIV cases, risk factors, and or 

outcome specific data, it is possible for the states to provide an ongoing 

snapshot of the local epidemiology of HIV and assess the efficacy of 

prevention activities and assist with planning and treatment allocation. 

Case reporting is not partner counseling and referral services activities, 

which are intended to identify individuals who can benefit from early 

intervention in the disease process. 

As presented in IL 10-2001-002, the VA General Council is of the opinion 

that the VA is under no legal obligation to comply with a state mandatoryreporting law to report patients’ HIV results to state or local health 

departments, yet supports cooperation. The IL conclusion states:

“VA’s Office of General Counsel Advisory Opinions hold that 

VA providers are not under legal obligation to comply with a state 

mandatory HIV reporting law. However, in the spirit of cooperation 

with state and local health authorities, VA providers are allowed 

and encouraged to comply with those official requests provided 

appropriate authorities make written requests, and VA regulations 

concerning release of medical information are followed.” 93

Referrals from VA Clinicians for Primary and Secondary HIV/

AIDS Prevention Services

As pointed out earlier, HIV testing is only one example of an HIV 

prevention activity. When considering interventions to reduce patients’ 

risk for HIV, it is important to consider other referrals that may address 

behaviors that increase risk for HIV. For example, substance abuse 

treatment is a highly effective form of HIV prevention as it reduces the 

incidence of drug-related behaviors that are associated with transmission 

of HIV.94 

Referrals to mental health services may help prevent HIV transmission by 

addressing disinhibition, poor social skills and judgment, hypersexuality, 

hopelessness, and associated substance use. Mental health referrals are 

also helpful in treatment of depression and other psychological factors that 

may contribute to poor adherence with antiretroviral regimens. Dietary 

or nutritional referrals may also help with nutritional support necessary to 

address one’s general health and adherence to medication. 
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Ongoing case management, which can be offered by a variety of VA 

providers, is also highly effective in providing HIV-postive patients or 

those at risk with the ongoing support needed to develop and maintain 

behaviors that will reduce their risk for HIV. 

Finally, it is important to remember that even the best risk reduction 

counseling and support may not be effective until more critical underlying 

conditions such as mental illness, domestic or partner violence, and other 

acute or chronic conditions can begin to be addressed. Any attempt to 

reduce risk for a patient who is at high risk for HIV needs to assess and 

take into consideration all the psychosocial conditions and stressors of a 

patient as they relate to his or her ability to protect themselves. 
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IX. HIV/AIDS Issues Affecting the VA Health

Care Provider

This chapter addresses:

l Occupational exposures

l Universal precautions

l Provider frustration and burnout

l Challenges of HIV prevention

l Next steps

Issues for VA Providers

Occupational Exposures

In July 2001, VA released IL 10-2001-011, which addressed the guidelines 

for HIV testing in VA facilities following occupational exposures. This 

letter addressed a variety of scenarios that may occur during the course of 

an occupational exposure (i.e., difficulty in testing of source patient, record 

keeping, and testing methods). 

The IL states that the U.S. Public Health Service guidelines for the 

management of health care worker exposures to HIV and recommendations 

for post-exposure prophylaxis should be used for general guidance by all 

VA health care facilities for occupation exposures to HIV. A copy of the IL 

on occupational exposure can be found in Appendix F.

Universal Precautions

Universal precautions, as first defined by CDC, are safety measures taken 

when providing health care or first aid and are designed to prevent 

transmission of HIV, hepatitis B, and other bloodborne pathogens. First 

published in 1987, universal precautions took the place of the need for the 

isolation category “blood and body fluid precautions” in the 1983 CDC 

Guidelines for Isolation Precautions in Hospitals.95, 96, 97

According to CDC, universal precautions apply to blood, other body 

fluids containing visible blood, semen, and vaginal secretions. Universal 
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precautions also apply to tissues and to the following fluids: cerebrospinal, 

synovial, pleural, peritoneal, pericardial, and amniotic fluids. Unless they 

contain visible blood, universal precautions do not apply to feces, nasal 

secretions, sputum, sweat, tears, urine, or emesis. Universal precautions 

do not apply to saliva except when visibly contaminated with blood or in 

dental settings where blood in saliva is common. 

Universal precautions involve the use of protective barriers such as gloves, 

gowns, aprons, masks, and/or protective eyewear, which reduce the 

risk of exposure of potentially infectious materials to the health care 

provider’s skin or mucous membranes. In addition, it is recommended 

that all health care providers take precautions to prevent injuries 

caused by needles, scalpels, or other sharp instruments. For additional 

information on universal precautions, please visit the CDC web site at 

http://www.cdc.gov/ncidod/hip/Blood/Universa.htm

Frustration and ‘Prevention Burnout’ Experienced by Health Care 

Providers 

Because of the nature of HIV/AIDS and the social, emotional, and physical 

cost of high-risk behaviors, it is only natural for health care providers 

practicing HIV prevention to experience burnout and frustration. Working 

with patients to help them develop and maintain safe behaviors can be 

extremely gratifying and also very difficult at times. 

Under the best of circumstances, providers may experience frustration 

when patients have a hard time adopting new behaviors, whether it is 

smoking cessation, weight loss or dietary changes. When the behaviors are 

ones that are necessary and effective in reducing risk for a life threatening, 

incurable, and transmittable disease like HIV, it can be even more difficult. 

Providers who have lost patients to HIV/AIDS may find it even more 

difficult when a patient at high risk is not working to reduce their risk. 

While it is known what is necessary to reduce risk for HIV, but there is 

no one “magic” intervention that will get everyone to change his or her 

risk behaviors. 

As a provider, it is important to recognize and monitor your own levels of 

stress and frustration experienced with this type of work. It is not unheard 

of to feel anger towards patients who continue high-risk activities despite 

warnings. Whether it is in an informal or formal setting, it is appropriate 

for you and colleagues to process these emotions.
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Some important questions to ask yourself and your colleagues may include: 

l What are some possible obstacles that are keeping this patient from 

changing his/her behaviors? 

l What is this patient’s level of readiness to adopt these behavior 

changes? 

l Who else on the clinical team can I enlist to help support the patient 

in making these changes? 

l Why I am working harder than the patient on these changes? 

l At what point do I need to refer this patient to another provider to 

continue work on these issues?

The Challenge of HIV Prevention

It is important to remember that knowledge alone is rarely if ever sufficient 

to motivate behavior change in those who are at risk for HIV. Individuals 

who continue to engage in high-risk behaviors may do so for a variety of 

reasons.98 In order to provide the best advice, it is important to understand 

why risky behaviors are continuing despite attempts to intervene. 

First, ask the patients about the circumstances surrounding their most 

recent high-risk behaviors. On interview, the most likely reasons will 

be intoxication, unavailability of condoms or a clean needle, or lack 

of negotiation skills or power in the relationship. Referrals to support 

services, specialty services, or community agencies to help address these 

problems will help at-risk patients begin to overcome these obstacles.99 

Next Steps Following Integration of HIV Prevention Activites

Once you have begun to integrate HIV prevention interventions into your 

routine clinical care, what are the next steps? As with any other change 

in clinical practice, steps may be needed to maintain HIV prevention 

efforts and to evaluate their effectiveness. There are a number of ways to 

informally evaluate the effects of interventions, in addition to more formal 

quality assurance approaches. It is important to identify follow-up steps 

that will work for your clinical setting. 

Integration of HIV prevention in clinical settings can be evaluated and 

supported by: 

l providing training in HIV prevention to all new staff,

l monitoring feedback from patients,
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l providing ‘refresher’ training to staff periodically,

l allowing time for and encouraging staff training,

l looking at available data on factors such as the number of 

prescriptions written for condoms,

l reviewing patient charts for documentation of risk assessment or 

counseling,

l checking in with other providers to monitor their progress in 

integrating HIV prevention,

l creating local clinical reminders or other prompts for providers,

l making educational materials readily available to patients and staff, 

and

l making use of technical assistance from community AIDS service 

organizations and other community organizations.
71

References

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1

 Centers for Disease Control and Prevention. (1981). Pneumocystis 

pneumonia: Los Angeles [Electronic version]. Morbidity and Mortality 

Weekly Report, 30, 250-252.

2

 Ibid.

3

 Centers for Disease Control and Prevention. (2001). A 

glance at the HIV epidemic. Retrieved June 7, 2001 from 

http://www.cdc.gov/nchstp/od/mmwr/At-a-glance%20Key%20Facts.pdf

4

 Centers for Disease Control and Prevention. (1999). Guidelines 

for national human immunodeficiency virus case surveillance, including 

monitoring for human immunodeficiency virus infection and acquired 

immunodeficiency syndrome [Electronic version]. Morbidity and Mortality 

Weekly Report, 48 (RR13), 1-29.

5

 Ibid.

6

 Janssen, R. S., Holtgrave, D. R., Valdiserri, R. O., Shepherd, M., Gayle, 

H. D., & De Cock, K. M. (2001). The serostatus approach to fighting 

the HIV epidemic: Prevention strategies for infected individuals. American 

Journal of Public Health, 91 (7), 1019-1024.

7

 Centers for Disease Control and Prevention. (2001). A 

glance at the HIV epidemic. Retrieved June 7, 2001 from 

http://www.cdc.gov/nchstp/od/mmwr/At-a-glance%20Key%20Facts.pdf

8

 Ibid.

9

 Ibid.

10 Centers for Disease Control and Prevention. (2001). AIDS cases 

reported in 1999 and estimated 1999 population, by race/ethnicity, United 

States [L238 Slide series, slide #8]. Retrieved June 6, 2001 from 

http://www.cdc.gov/hiv/graphics/minority.htm 

11 Centers for Disease Control and Prevention. (2001). A 

glance at the HIV epidemic. Retrieved June 7, 2001 from 

http://www.cdc.gov/nchstp/od/mmwr/At-a-glance%20Key%20Facts.pdf

12 Ibid.
72

References

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13 Centers for Disease Control and Prevention (2000, September). HIV/

AIDS among U.S. women: Minority and young women at continuing risk 

[Fact sheet]. Retrieved July 19, 2001 from http://www.cdc.gov/hiv/pubs/

facts/women.pdf

14 Ibid.

15 Ibid.

16 Department of Veterans Affairs. (2001). National VA site tracking 

(VAST) summary report [as of January 8, 2001]. Retrieved June 6, 2001 

from http://vaww.pssg.med.va.gov/content/FY01Q1VASTList.pdf

17 Samet, J. H, Winter, M. R., Grant, L., & Hingson, R. (1997). 

Factors associated with HIV testing among sexually active adolescents: A 

Massachusetts survey. Pediatrics, 100 (3), 371-377.

18 Edne, J., Rockwell, S., & Glasglow, M. (1984). The sexual history in 

general medicine practice. Archives of Internal Medicine, 144, 558-561.

19 Makadon, H. J, & Silin, J. G. (1995). Prevention of HIV infection 

in primary care: Current practices, future possibilities. Annals of Internal 

Medicine, 123, 715-719.

20 Wasserheit, J. N. (1992). Epidemiologic synergy: Interrelationships 

between human immunodeficiency virus infection and other sexually 

transmitted diseases. Sexually Transmitted Diseases, 9, 61-77.

21 Makadon, H. J, & Silin, J. G. (1995). Prevention of HIV infection 

in primary care: Current practices, future possibilities. Annals of Internal 

Medicine, 123, 715-719.

22 Epstein, R. M., Morse, D. S., Frankel, R. M., Frarey, L., Anderson, 

K., & Beckman, H. W. (1998). Awkward moments in patient-physician 

communication about HIV risk. Annals of Internal Medicine, 128, 

435-442.

23 Ibid.

24 Centers for Disease Control and Prevention. (1998, November). What is 

HIV? Retrieved June 7, 2001 from http://www.cdc.gov/hiv/pubs/faqs.htm
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25 Centers for Disease Control and Prevention. (2000). HIV/AIDS 

surveillance report, 12 (1). Atlanta, Georgia: Author.

26 Rotheram-Borus, M. J., Cantwell, S., & Newman, P. A. (2000). 

HIV prevention programs with heterosexuals. AIDS, 14 (Supplement 2), 

S59-S67.

27 Centers for Disease Control and Prevention. (1998). Trends in the HIV 

& AIDS epidemic. Atlanta, GA: CDC

28 U.S. Department of Health and Human Services. (2001, July). A new 

decade of AIDS in the United States [newsletter]. HRSA Care ACTION.

29 American Association of Retired Persons. (1998, October). HIV/AIDS 

and older adults [News release]. Retrieved December 12, 1999 from 

http://www.aarp.org/press/1998/nr100198.html

30 Frazier, L. (1999, May 17). New targets in campaigns to halt AIDS. 

Washington Post, p. A1.

31 Centers for Disease Control and Prevention. (1998). AIDS among 

persons aged greater than or equal to 50 years -- United States, 1991-1996. 

Morbidity and Mortality Weekly Report, 47 (2), 21-27.

32 Ibid.

33 Ibid.

34 Leigh, B. C., & Stall, R. (1993). Substance use and risky behavior for 

exposure to HIV. American Psychologist, 48, 1035-1045.

35 Renton, A., Whitaker, L., Ison, C., & Harris, Jr., J. (1995). Estimating 

the sexual mixing patterns in the general population from those in people 

acquiring gonorrhoea infection: Theoretical foundation and empirical 

findings. Journal of Epidemiology and Community Health, 49 (2), 205-213.

36 Paul, J. P., Stall, R., & Davis, F. (1993). Sexual risk for HIV 

transmission among gay/bisexual men in substance-abuse treatment. AIDS 

Education and Prevention, 5, 11-24.
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37 Gerbert, B., Bronstone, A., Pantilat, S., McPhee, S., Allerton, M., & 

Moe, J. (1999). When asked, patients tell: Disclosure of sensitive healthrisk behaviors. Medical Care, 37 (1), 104-111.

38 AIDS Institute, New York State Department of Health (1998). HIV & 

Primary Care: Putting Prevention into Practice [Manual].

39 Centers for Disease Control and Prevention. (2001). HIV and AIDSUnited States, 1981-2000. Morbidity and Mortality Weekly Report, 50 (21), 

430-433.

40 Selzer, M. (1971). The Michigan Alcoholism Screening Test: The 

quest for a new diagnostic instrument. American Journal of Psychiatry, 

127, 1653-1658.

41 Skinner, H. A. (1982). The Drug Abuse Screening Test. Addictive 

Behavior, 7, 363-371.

42 Gavin, D. R., & Ross, H. E. (1989). Diagnostic validity of the DAST 

in the assessment of DSM-III drug disorders. British Journal of Addiction, 

84, 301-307. 

43 Saunders, J. B., Aasland, O. G., de la Fuente, J. R., & Grant, M. (1993). 

Development of the Alcohol Use Disorder Identification Test (AUDIT): 

WHO collaborative project on early detection of persons with harmful 

alcohol consumption - II. Addiction, 88, 791-804).

44 Brown, R. L., Leonard, T., Saunders, L. A., & Papasouliotis, O. (2001). 

A two-item conjoint screen for alcohol and other drug problems. Journal 

of the American Board of Family Practice, 14, 95-106.

45 Centers for Disease Control and Prevention. (1998, October). 

Recommendations for prevention and control of Hepatitis C virus infection 

and HCV-related chronic disease [Electronic version]. Morbidity and 

Mortality Weekly Report, 47 (RR-19), 1-39.

46 National Institute on Drug Abuse. (2000, May). Community drug alert 

bulletin: Hepatitis C [Bulletin]. Bethesda, MD: Author.

47 Metzger, D. S., Navaline, H., & Woody, G. E. (2000). The role of drug 

abuse treatment in the prevention of HIV infection. In J. L. Peterson and 
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R. J. DiClemente (Eds.), Handbook of HIV Prevention (pp. 147-156). New 

York: Kluwer Academic/Plenum Press.

48 Ibid.

49 Ibid.

50 Ibid.

51 Centers for Disease Control and Prevention. (1998, November). How 

can people who use injection drugs reduce their risk for HIV injection? 

Retrieved June 21, 2001 from http://www.cdc.gov/hiv/pubs/faq/faq26.htm

52 Holl, R. A., Beam-Goulet, J., & Rosenheck, R. A. (1997). Mental 

disorder as a risk factor for human immunodeficiency virus infection in 

a sample of veterans. Journal of Nervous & Mental Disease, 185 (9), 

556-560.

53 Bascarino, J. A. (1997). Diseases among men 20 years after exposure 

to severe stress: Implications for clinical research and medical care. 

Psychosomatic Medicine, 59, 605-614. 

54 Carey, M. P., Carey, K. B., & Kalichman, S. (1997). Risk for human 

immunodeficiecy virus (HIV) infection among persons with severe mental 

illness. Clinical Psychology Review, 17 (3), 271-291.

55 Ibid.

56 Klein, R. E., & Stockford, D. D. (2001, May). Data on the 

socioeconomic status of veterans and on VA program usage [Slides]. 

Washington, DC: U.S. Department of Veterans Affairs.

57 Ibid.

58 Culhane, D. P., Gollub, E., Kuhn, R., & Shpaner, M. (2001). The 

co-occurrence of AIDS and homelessness: Results from the integration 

of administrative databases for AIDS surveillance and public shelter 

utilisation in Philadelphia. Journal of Epidemiology and Community 

Health, 55, 515-520.
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59 Schappert, S. M. (1999, November). Ambulatory care visits to physician 

offices, hospital outpatient departments, and emergency departments: 

United States, 1997. Vital & Health Statistics - Series 13: Data from the 

National Health Survey, (143), 1-39. 

60 AIDS Institute, New York State Department of Health (1998). HIV & 

Primary Care: Putting Prevention into Practice [Manual].

61 Ibid.

62 Family Health International/AIDSCAP. (1996). Behavior change: 

A summary of four major theories [Electronic version]. Retrieved 

June 11, 2001 from http://www.fhi.org/en/aids/aidscap/aidspubs/behres/

bcr4theo.html

63 Prochaska, J. O., DiClemente, C. C., & Norcross, J. C. (1992). In 

search of how people change: Applications to addictive behavior. American 

Psychologist, 47 (9), 1102-1114. 

64 Ibid.

65 Ibid.

66 Ibid.

67 Ibid.

68 Ibid.

69 Ibid.

70 Fisher, J. D., & Fisher, W. A. (2000). Theoretical approaches to 

individual-level change in HIV risk behavior. In J. L. Peterson & R. J. 

DiClemente (Eds.), Handbook of HIV prevention (pp. 1-55). New York, 

NY: Plenum Publishers.

71 Prochaska, J. O., Redding, C. A., Harlow, L. L., Rossi, J. S., & Velicer, 

W. F. (1994, Winter). The Transtheoretical Model of Change and HIV 

prevention: A review. Health Education Quarterly, 21 (4), 471-486.
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72 Ibid.

73 Ibid.

74 Baker, A., & Dixon, J. (1991). Motivational interviewing for HIV 

risk reduction. In W. R. Miller & S. Rollnick (Eds.), Motivational 

interviewing: Preparing people to change addictive behavior

(pp. 293-302). New York, NY: The Guilford Press.

75 Miller, W. R. (1991). Increasing motivation for change. In R. 

K. Hester & W. R. Miller (Eds.), Handbook of alcoholism treatment 

approaches: Effective alternatives (2nd ed., pp. 89-104). Boston, MA: 

Allyn & Bacon, Inc.

76 Richardson, J. (2001). HIV 2001: Team care in the VA [Training]. 

Training presented to VA health care providers on May 16, 2001 in 

Dallas, Texas.

77 Flynn Publications. (2001, April). Condom debate prompts call for 

CDC guidelines. STD Advisor, 4 (4), 37-48.

78 Centers for Disease Control and Prevention. (2001, July 10). 

Latex condoms and sexually transmitted diseases [Letter]. Atlanta, GA: 

Author.

79 Centers for Disease Control and Prevention. (2000, August 4). 

Notice to readers: CDC statement on study results of product containing 

nonoxynol-9 [Electronic version]. Morbidity and Mortality Weekly 

Report, 49 (31), 717-718.

80 Baron, S., Poast, J., Nguyen, D., & Cloyd, M. W. (2001). Practical 

prevention of vaginal and rectal transmission of HIV by adapting the 

oral defense: Use of commercial lubricants. AIDS Research and Human 

Retroviruses, 17 (11), 997-1002.

81 Cunningham, K. (2001). Safer sex can be sexy: Protecting yourself 

and your lover has never been so hot. Retrieved July 23, 2001 from 

http://estroclick.chickclick.com/articles/23033p1.html
78

References

Veterans Health Administration

82 Center for AIDS Intervention Research. Partners in prevention, women’s 

edition [Curriculum manual]. Milwaukee, WI: Department of Psychiatry 

and Behavioral Medicine, Medical College of Wisconsin.

83 Centers for Disease Control and Prevention. (2000). Adoption 

of protective behaviors among person with recent HIV infection and 

Diagnosis --- Alabama, New Jersey, and Tennessee, 1997--1998. Morbidity 

and Mortality Weekly Report, 49 (23), 512-515.

84 Ibid.

85 AIDS Institute, New York State Department of Health (1998). HIV & 

Primary Care: Putting Prevention into Practice [Manual].

86 Department of Veterans Affairs. (1988). VA DM&S Circular 

10-88-151: Public law 100-322, section 124: Testing for HIV (human 

immunodeficiency virus) and informed consent. Washington, DC: Author.

87 Ibid.

88 Ibid.

89 Ibid.

90 Ibid.

91 AIDS Institute, New York State Department of Health (1998). HIV & 

Primary Care: Putting Prevention into Practice [Manual].

92 Centers for Disease Control and Prevention. (1998, December). 

HIV partner notification and referral services: Guidance [Electronic 

version]. Retrieved June 29, 2001from http://www.cdc.gov/hiv/pubs/pcrs/

pcrs-doc.htm

93 Department of Veterans Affairs. (2001, February). Information Letter 

10-2001-002: Case reporting of human immunodeficiency virus (HIV) to 

state and local health authorities by VA facilities and providers [Electronic 

version]. Retrieved October 4, 2001 from http://www.va.gov/publ/direc/

health/infolet/10200102.pdf
79

References

Veterans Health Administration

94 Des Jarlais, D. C., Guydish, J., Friedman, S. R., & Hagan, H. (2000). 

HIV/AIDS prevention for drug users in natural settings. In J. L. Peterson & 

R. J. DiClemente (Eds.), Handbook of HIV prevention (pp. 159-177). New 

York, NY: Kluwer Academic/Plenum Publishers.

95 Centers for Disease Control and Prevention. (1987). Recommendations 

for prevention of HIV transmission in health-care settings. Morbidity and 

Mortality Weekly Report, 36 (S-2S). 

96 Centers for Disease Control and Prevention. (1988). Update: Universal 

precautions for prevention of transmission of human immunodeficiency 

virus, hepatitis B, and other bloodborne pathogens, in health-care settings. 

Morbidity and Mortality Weekly Report, 37, 377-388.

97 Centers for Disease Control and Prevention. (1989). Guidelines for 

prevention of transmission of Human immunodeficiency virus and hepatitis 

B to health-care and public-safety workers. Morbidity and Mortality 

Weekly Report, 38 (S-6), 1-36.

98 Coates, T. J. (1999). HIV prevention in clinical practice. AIDS Clinical 

Care, 11, 1-3.

99 Ibid.

Veterans Health Administration 81

Appendices

APPENDICES
82 Veterans Health Administration

Appendices

(Appendix A)

Puget Sound, Maine Confidentiality Brochure for Patients

PATIENT MEDICAL INFORMATION -

CONFIDENTIALITY AND PRIVACY

Confidentiality of your medical information is important to us. This 

means that we keep your medical information private - for you and your 

clinical providers.

Keeping your information private: Good health care depends on a good 

relationship with your care provider, a relationship based on the trust 

that we will respect your privacy about the information you provide. We 

protect your privacy in a number of ways so that you can feel secure.

We protect confidentiality: We protect personal information on our 

computer network. We have strict policies governing access to, and 

release of, information. In effect, your medical record is contained within 

an “electronic” safe-deposit box. All information gathered for treatment is 

kept secure so that only authorized staff can access your record.

Our staff members have signed an agreement that they will protect your 

information and respect its confidential nature. 

How do we use your medical information?: VA Puget Sound Health Care 

System uses a state-of-the-art computer system that allows our providers 

to access your record at the time and place that it is needed, making 

critical medical information available to our provider almost instantly. 

This ready access contributes to high quality care for you.

No one can look at your medical information without the appropriate 

authorization. No one can access your medical data for medical research 

purposes unless you agree, or unless the information is used in a way that 

your identity is not known. In order to improve the quality of medical 

care, we sometimes review medical records to make sure our doctors and 

nurses are practicing high quality care. In these quality reviews, patient 

names are not used.

How do we ensure privacy and confidentiality?: Your care is a personal 

matter, and we know that you want private things to remain private.
Veterans Health Administration 83

Appendices

We develop and comply with policies to ensure our employees respect 

confidentiality. We comply with all applicable Federal laws.

We ask your permission before we release your medical record 

information to someone outside our Medical Center, unless the Privacy 

Act (5 U.S.C. Sec. 552a) authorizes disclosure without your consent. If 

we are required by law to release information, we will make a good faith 

effort to notify you.

If you have questions regarding this important matter, please talk with 

your caregiver or call us at 1-800-329-VETS (8387) and ask for Terry 

Liljencrantz, x62144, in the “Release of Information Section.” 
84 Veterans Health Administration

Appendices

(Appendix B)

Conditions Included in the 1993 

AIDS Surveillance Case Definition

l Candidiasis of bronchi, trachea, or lungs

l Candidiasis, esophageal

l Cervical cancer, invasive*

l Coccidioidomycosis, disseminated or extrapulmonary

l Cryptococcosis, extrapulmonary

l Cryptosporidiosis, chronic intestinal (>1 month’s duration)

l Cytomegalovirus disease (other than liver, spleen, or nodes)

l Cytomegalovirus retinitis (with loss of vision)

l Encephalopathy, HIV-related

l Herpes simplex: chronic ulcer(s) (>1 month’s duration); or 

bronchitis, pneumonia, or esophagitis

l Histoplasmosis, disseminated or extra pulmonary

l Isosporiasis, chronic intestinal (>1 month’s duration)

l Kaposii’s sarcoma

l Lymphoma, Burkitt’s (or equivalent term)

l Lymphoma, primary, of brain

l Mycobacterium avium complex or M. kansasii, disseminated or 

extrapulmonary

l Mycobacterium tuberculosis, any site (pulmonary or 

extrapulmonary)

l Pneumocycstit carinii pneumonia

l Pneumonia, recurrent*

l Progressive multifocal leukoencephalopathy

l Salmonella septicemia, recurrent

l Toxoplasmosis of brain

l Wasting syndrome due to HIV

*Added in the 1993 expansion of the AIDS surveillance case definition.

Note. From “1993 Revised Classification System for HIV Infection and Expanded 

Surveillance Case Definition for AIDS Among Adolescents and Adults,” MMWR, 41 

(RR-17), 1992, December.
Veterans Health Administration 85

Appendices

(Appendix C)

Risk Assessment Battery

(R A B)

q Check If Asked By Interviewer

ID#_________________________

DATE: ______________________

Administered by: ______________

Checked by: ___________________

Please read each of the following questions very carefully. As you 

will see, many of these questions are personal. We understand this 

and will make every effort to protect the privacy of your answers. 

It is very important that you answer every question honestly. In fact, 

it’s better not to answer a question at all than to tell us something 

that is not accurate or true. Some questions may not seem to have 

an answer that is true for you. When this happens, you should 

simply choose the answer that is most right. Don’t spend too much 

time on any one question.

Remember, always ask for help if you’re unsure about what to do. 

Thank you for your time and cooperation.

University of Pennsylvania &

Philadelphia Veterans Administration Medical Center

Center for Studies of Addiction

3900 Chestnut Street

Philadelphia, PA 19104

NIDA MDD v. 2.1; 12/21/95
86 Veterans Health Administration

Appendices

PAST MONTH DRUG AND ALCOHOL USE

A. In the past month, how often have you injected cocaine and 

heroin together (Speedball)?

0. q Not at all

1. q A few times

2. q A few times each week

3. q Everyday

B. In the past month, how often have you injected heroin (not 

mixed)?

0. q Not at all

1. q A few times

2. q A few times each week

3. q Everyday

C. In the past month, how often have you snorted heroin (not 

mixed)?

0. q Not at all

1. q A few times

2. q A few times each week

3. q Everyday

D. In the past month, how often have you smoked heroin?

0. q Not at all

1. q A few times

2. q A few times each week

3. q Everyday

E. In the past month, how often have you injected cocaine (not 

mixed)?

0. q Not at all

1. q A few times

2. q A few times each week

3. q Everyday
Veterans Health Administration 87

Appendices

F. In the past month, how often have you snorted cocaine (not 

mixed)?

0. q Not at all

1. q A few times

2. q A few times each week

3. q Everyday

G. In the past month, how often have you smoked crack, rock, 

or freebase cocaine?

0. q Not at all

1. q A few times

2. q A few times each week

3. q Everyday

H. In the past month, how often have you injected amphetamines, meth, speed, crank or crystal?

0. q Not at all

1. q A few times

2. q A few times each week

3. q Everyday

I. In the past month, how often have you snorted amphetamines, 

meth, speed, crank or crystal?

0. q Not at all

1. q A few times

2. q A few times each week

3. q Everyday

J. In the past month, how often have you smoked amphetamines, meth, speed, crank or crystal?

0. q Not at all

1. q A few times

2. q A few times each week

3. q Everyday
88 Veterans Health Administration

Appendices

K. In the past month, how often have you used benzodiazepines 

(benzos, benzies) such as Xanax, Valium, Klonipin or Ativan?

0. q Not at all

1. q A few times

2. q A few times each week

3. q Everyday

L. In the past month, how often have you taken painkillers - 

pills such as Percodan, Percocet, Vicodin, Demerol, Dilaudid, 

Darvon, Darvocet or syrup (Codeine)?

0. q Not at all

1. q A few times

2. q A few times each week

3. q Everyday

a. Which types of painkillers did you use?_______ 

M. In the past month, how often did you inject Dilaudid?

0. q Not at all

1. q A few times

2. q A few times each week

3. q Everyday

N. In the past month, how often have you used acid, LSD, or 

other hallucinogens?

0. q Not at all

1. q A few times

2. q A few times each week

3. q Everyday

O. In the past month, how often have you used marijuana?

0. q Not at all

1. q A few times

2. q A few times each week

3. q Everyday
Veterans Health Administration 89

Appendices

P. In the past month, how often have you used beer, wine or 

liquor?

0. q Not at all

1. q A few times

2. q A few times each week

3. q Everyday

PART I: NEEDLE USE

1. In the past six months, have you injected drugs?

0. q No

1. q Yes

2. In the past six months, have you shared needles or works?

0. q No or I have not shot up in the past six months 

3. q Yes

3. With how many different people did you share needles in the 

past six months?

0. q 0 or I have not shot up in the past six months

1. q 1 other person

2. q 2 or 3 different people

3. q 4 or more different people

4. In the past six months, how often have you used a needle after 

someone (with or without cleaning)?

0. q Never or I have not shot up or shared in the past six 

months

1. q A few times or less

2. q A few times each month

3. q Once or more each week
90 Veterans Health Administration

Appendices

5. In the past six months, how often have others used after you 

(with or without cleaning)?

0. q Never or I have not shot up or shared in the past six 

months

1. q A few times or less

2. q A few times each month

3. q Once or more each week

6. In the past six months, how often have you shared needles 

with someone you knew (or later found out) had AIDS or was 

positive for HIV, the AIDS virus?

0. q Never or I have not shot up or shared in the past six 

months

1. q A few times or less

2. q A few times each month

3. q Once or more each week

7. Where did you get your needles during the past six months? 

(Check all that apply)

0. q I have not shot up in the past six months

1. q From a diabetic

2. q On the street

3. q Drugstore

4. q Shooting gallery or other place where users go to 

shoot up

5. q Needle Exchange Program

6. q Other:_________

8. In the past six months, how often have you been to a shooting 

gallery/house or ..... other place where users go to shoot-up?

0. q Never

1. q A few times or less

2. q A few times each month

3. q Once or more each week
Veterans Health Administration 91

Appendices

9. In the past six months, how often have you been to a Crack 

House or other place where people go to smoke crack?

0. q Never

1. q A few times or less

2. q A few times each month

3. q Once or more each week

10. Which statement best describes the way you cleaned your 

needles during the past six months? (Please choose one)

0. q I have not shot up in the past six months

1. q I always use new needles

2. q I always clean my needle just before I shoot up

3. q After I shoot up, I always clean my needle

4. q Sometimes I clean my needle, sometimes I don’t

5. q I never clean my needle

11. If you cleaned your needles and works in the past six months, 

how did you clean them? (Check all that apply)

0. q I have not shot up in the past six months

1. q Soap and water or water only

2. q Alcohol

3. q Bleach

4. q Boiling water

5. q Other:___________

6. q I did not clean my needles in the past six months 

7. q I ALWAYS used new needles in the past six months

12. In the past six months, how often have you shared rinsewater?

0. q Never or I have not shot up in the past 6 months_____

1. q A few times or less

2. q A few times each month

3. q Once or more each week
92 Veterans Health Administration

Appendices

13. In the past six months, how often have you shared a cooker?

0. q Never or I have not shot up in the past 6 months

1. q A few times or less

2. q A few times each month

3. q Once or more each week

14. In the past six months, how often have you shared a . cotton?

0. q Never or I have not shot up in the past 6 months

1. q A few times or less

2. q A few times each month

3. q Once or more each week

15. In the past six months, how often have you divided or shared 

drugs with others by using one syringe (yours or someone 

else’s) to squirt or load the drugs into the other syringe(s) 

(backloading, for example)?

0. q Never or I have not shot up in the past 6 months

1. q A few times or less

2. q A few times each month

3. q Once or more each week

PART II: SEXUAL PRACTICES

16. How would you describe yourself?

1. q Straight

2. q Gay or Homosexual

3. q Bisexual

Please note: For the following questions, sex means any vaginal 

intercourse, anal intercourse (in the butt) or oral sex (blowjobs, 

for example)
Veterans Health Administration 93

Appendices

17. With how many men have you had sex in the past six months?

0. q 0 men

1. q 1 man

2. q 2 or 3 men

3. q 4 or more men

18. With how many women have you had sex in the past six 

months?

0. q 0 women

1. q 1 woman

2. q 2 or 3 women

3. q 4 or more women

19. In the past six months, how often have you had sex so you 

could get drugs?

0. q Never

1. q A few times or less

2. q A few times each month

3. q Once or more each week

20. In the past six months, how often have you given drugs to 

someone so you could have sex with them?

0. q Never

1. q A few times or less

2. q A few times each month

3. q Once or more each week

21. In the past six months, how often were you paid money to 

have sex with someone?

0. q Never

1. q A few times or less

2. q A few times each month

3. q Once or more each week
94 Veterans Health Administration

Appendices

22. In the past six months, how often did you give money to 

someone so you could have sex with them?

0. q Never

1. q A few times or less

2. q A few times each month

3. q Once or more each week

23. In the past six months, how often have you had sex with 

someone you knew (or later found out) had AIDS or was 

positive for HIV, the AIDS virus?

0. q Never

1. q A few times or less

2. q A few times each month

3. q Once or more each week

24. In the past six months, how often did you use condoms when 

you had sex?

0. q I have not had sex in the past 6 months

0. q All the time

1. q Most of the time

2. q Some of the time

3. q None of the time

PART III: CONCERNS ABOUT HIV AND TESTING

If you know that you are HIV positive, skip to question # 28.

25. How worried are you about getting HIV or AIDS?

0. q Not at all

1. q Slightly

2. q Moderately

3. q Considerably

4. q Extremely
Veterans Health Administration 95

Appendices

26. How worried are you that you may have already been exposed 

to the HIV or AIDS virus?

0. q Not at all

1. q Slightly

2. q Moderately

3. q Considerably

4. q Extremely

27. How many times have you had a blood test for the AIDS virus 

(HIV)? (circle):

0 1 2 3 4 5 6 7 8 9 10 or more times

28. When were you last tested for HIV? On the lines below, please 

write the month and year of your most recent test.

/ 

MONTH YEAR

29. Were you ever told that you had the HIV, the AIDS virus?

0. q No

1. q Yes

2. q I never got the results

Thank You. 

Please let the staff person know that you have finished. 
96 Veterans Health Administration

Appendices

(Appendix D)

August 16, 2001 IL 10-2001-012

Under Secretary for Health’s information Letter

Access to Condoms as HIV Prevention

1. This Information Letter provides information on the use of condoms 

in the prevention of human immunodeficiency virus (HIV); provides 

guidance and further information on the Veterans Health Administration 

(VHA) existing policy on providing male and female condoms 

through the National Formulary; and provides recommendations on the 

prescribing of condoms.

2. Background

a. In the absence of a cure or preventive vaccine, consistent use of 

barrier methods, such as the condom, remains the single best method of 

preventing transmission of HIV. Multiple cohort studies, including those 

of serodiscordant couples, have demonstrated a strong protective effect 

of condom use against HIV infection. Consistent use of condoms has 

been found to reduce the risk of HIV transmission by 87 to 95 percent. 

Condoms also play an important role in the prevention of transmission 

of sexually transmitted diseases that are transmitted through genital 

secretions or genital ulcerative diseases when the ulcers or lesions occur 

in areas covered or protected by the condom. Finally, as the most recent 

data from the Centers of Disease Control and Prevention have suggested 

that 10 to 15 percent of cases of hepatitis C may be secondary to sexual 

transmission, condoms may also play a role in preventing transmission 

of hepatitis C.

b. Thus, education about risk reduction and access to condoms for male 

and female veterans is a key component of VHA’s program to prevent 

HIV, hepatitis C and sexually transmitted diseases (STDs) and their 

impact on veterans and VHA. As the nation’s largest single provider of 

HIV care, it is important that the Department of Veterans Affairs (VA) be 

a leader in the integration of HIV prevention into clinical care.

c. Findings from a recent national survey conducted by the Pharmacy 

Benefits Management Strategic Health Care Group suggest that while 

many pharmacies in the VA health care system routinely stock the 

male latex condom and the female polyurethane condom, they may be 

underutilized and are not routinely being prescribed to veterans with HIV, 

or those at high-risk for HIV.
Veterans Health Administration 97

Appendices

3. A Reminder of VA Policy on the National Formulary

a. Both male latex and the female polyurethane condoms are currently 

available on the VHA National Formulary and are classified as a medical 

supply (VA CLASS XA900). Male and female veterans can be prescribed 

any type of condom, as best suits their individual prevention needs.

b. As stated in VHA Directive 2001-044, “Items listed in the 

FORMULARY must be made available throughout the VA health care 

system and cannot be made non-formulary at the Veterans Integrated 

Service Network (VISN), or local level. Restrictions can be established 

at the national, VISN or local level for formulary items that require close 

monitoring to ensure appropriate use. Restrictions may include evidencebased guidelines and/or prescribing privileges for providers with certain 

expertise. Restrictions will not be based solely on economic issues and 

will not be so limited as to prevent patients with legitimate needs from 

receiving FORMULARY medications.”

4. Recommendations

a. The Public Health Strategic Health Care Group (PHSHG) and the 

Pharmacy Benefits Management (PMB) Strategic Health Care Group 

recommend that patients with HIV routinely be asked if they wish to 

receive a prescription for condoms in order to help prevent transmission 

of HIV to others through sexual contact. Condom use is to be strongly 

encouraged for veterans with HIV, as part of their routine care.

b. It is strongly recommended that condom use and the potential need for 

prescriptions be routinely discussed with patients who:

(1) Are not HIV positive, but who report high-risk activities such as 

unprotected sex with multiple sexual partners.

(2) Have been diagnosed with an STD.

(3) Have a history or current diagnosis of injection drug use or 

substance abuse.

(4) Have tested positive for hepatitis C or hepatitis B.

NOTE: It is also recommended that the potential need for condoms be 

discussed with veterans who are being evaluated or treated for impotence 

or erectile dysfunction if they also report high-risk sexual behaviors or 

multiple sexual partners.
98 Veterans Health Administration

Appendices

c. VA Pharmacy staff are encouraged to work closely with local providers 

to ensure that condoms are readily available to patients who require them. 

To help offset the cost of increased condom dispensing, the PBM and 

PHSHGs have arranged for the availability of male condoms through the 

Pharmaceutical Prime Vendor (PPV) at a greatly reduced cost. Lubricated 

male condoms are available through the VA PPV for $43.75 per 1,008. 

NOTE: The PPV Item Number for the reduced price condoms is 4190914.

5. References

a. Centers for Disease Control and Prevention. “Sexually Transmitted 

Disease Treatment Guidelines,” Morbidity and Mortality Weekly Report 

(MMWR). 1993; 42 (No. RR-14).

b. Centers for Disease Control and Prevention. Latex Condoms and STDs 

Prevention Messages, July 2001.

c. Wald, A., Langenberg, A.G.M., Link, K., Izu, A.E., Ashley, R., 

Warran, T., Tyring, S., Douglas, J.M., and Corey. L. Effect of Condoms 

Reducing the Transmission of Herpes Simplex Virus Type 2 from Men 

to Women,” Journal of the American Medical Association (JAMA), 2001; 

285:3100-3106.

d. Centers for Disease Control and Prevention. “Recommendations for 

Prevention and Control of Hepatitis C Virus (HCV) Infection and HCVRelated Chronic Disease” MMWR 1998; 47 (No. RR-19).

6. Questions may be referred to Kim Hamlett-Berry, Ph.D., Director 

of HIV and Hepatitis C Prevention Service, Public Health Strategic 

Health Care Group (13B), at (202) 273-8929, or Michael Valentino, R. 

Ph., MHSA, Associate Chief Consultant, Pharmacy Benefits Management 

Strategic Health Care Group, at (708) 786-7886.
Veterans Health Administration 99

Appendices

(Appendix E)

HIV Partner Counseling & Referral Services (HIV partner 

notification contact information) for Select States 

California

Catherine Baker

California Office of AIDS

Prevention Services

California Department of Health Services

916-327-3248

Florida

Partner Counseling and Referral Services

Florida Department of Health

850-245-4303

To obtain information on partner counseling and notification services 

available in Florida, contact the appropriate county health department or 

the telephone number above for contact information.

Georgia

Miguel Miranda

Prevention Services: STD/HIV Section

Georgia Dept. of Human Resources, Div. of Public Health

2 Peachtree Street, NW

Suite 12-255

Atlanta, GA 30303

404-657-3100

Illinois

Prevention Counseling Testing Referral/Partner Counseling Referral 

Program (PCTR/PCR)

HIV/AIDS Department

Illinois Department of Public Health

217-524-5983
100 Veterans Health Administration

Appendices

New Jersey

Notification Assistance Program

Department of Health and Senior Services

973-648-7500 (ask for notification assistance)

877-356-8312 (toll-free information line for individuals and providers)

New York

PartNer Assistance Program (for areas outside of NYC) 

1-800-541-AIDS or 1-800-872-2777

Contact Notification Assistance Program (for locales within NYC) 

212-693-1419 or 212-447-2489

http://www.health.state.ny.us/nysdoh/hivaids/hivpartner/infoprov.htm

Pennsylvania

Partner Counseling and Referrals Services

Division of HIV/AIDS 

Bureau of Communicable Disease

Pennsylvania Department of Health

717-783-0572

To obtain information on partner counseling and referral services 

available in Pennsylvania, contact the appropriate local health 

department or the telephone number above for contact information.

Texas

Texas HIV-STD Info. Line

Texas Department of Health

1-800-299-2437

To obtain information on partner counseling and referral services 

available in Texas, contact the appropriate local health department or the 

telephone number above for contact information.
Veterans Health Administration 101

Appendices

(Appendix F)

July 18, 2001 ............................................................IL 10-2001-011

Under Secretary for Health’s Information Letter

GUIDELINES FOR HIV TESTING IN VA FACILITIES 

FOLLOWING OCCUPATIONAL EXPOSURES

1. This information letter provides guidance concerning Human 

Immunodeficiency Virus (HIV) testing in occupational exposure situations; 

clarifies Department of Veterans Affairs (VA) policy about testing for HIV, 

and includes a collection of consensus recommendations of a Committee 

(see subpar. 2b) that included experts in the field of HIV, Acquired Immune 

Deficiency Syndrome (AIDS), and occupational safety.

2. Background

a. Considerable progress has occurred toward the development of 

therapeutic agents used to treat HIV infected individuals and significant 

technical advancement has been made in diagnostic techniques to detect 

HIV. These recent advancements necessitated a re-examination of VA 

policies and procedures as related to testing for HIV within the context of 

potential occupational exposure.

b. A committee was established to review existing VA policies on HIV 

testing in situations of potential occupational exposure. The Committee 

was composed of front-line HIV care providers including infectious 

disease experts, infection control and occupational health experts both 

from VA Central Office and the field; VA General Counsel’s Office; the 

National Center for Ethics; and a union representative.

c. The guidelines contained in this Information Letter represent a 

collection of recommendations of the Committee and provide reference 

to the United States (U.S.) Public Health Service (PHS) guidelines for 

management of occupational exposures and post-exposure prophylaxis 

to HIV.

d. The Committee addressed six specific areas. These include:

(1) VA HIV testing policy in occupational exposures in general;

(2) Situations where the source patient refuses or is incapable of giving 

consent or an appropriate authorized surrogate refuses consent;
102 Veterans Health Administration

Appendices

(3) Confidentiality issues related to exposed employees’ records;

(4) Exposures during off-duty hours;

(5) Availability of state-of-the-art diagnostic technologies to detect 

HIV; and

(6) Process integrity issues.

3. General Guidance for VA Facilities

a. The U.S. PHS has developed guidelines for the management of 

occupational exposures to HIV and made recommendations for postexposure prophylaxis (see subpar. 9a). This information, designed as 

general guidance, can be used by all VA health care facilities in 

establishing appropriate programs for the management of health care 

workers (HCWs) who have occupational exposure to blood and other 

potentially infectious materials, and for post-exposure prophylaxis. This 

document is accessible on the web site: http://www.cdc.gov/mmwr/

preview/mmwrhtml/rr5011a1.htm.

4. A Reminder of VA Policy on HIV Testing

a. VA policy provides that every patient has the right to informed 

participation in the patient’s health care decisions (see subpar. 9b, VHA 

Handbook 1104.1, and Title 38 Code of Federal Regulations (CFR) 

§17.32, regarding Informed Consent). Public Law 100-322 Section 124, 

as amended, specifies that testing for HIV must be voluntary and requires 

specific written consent by the patient to be tested (see subpar. 9c). The 

law also provides that HIV testing be accompanied by documented preand post-test counseling.

b. This Information Letter further clarifies VA policy about testing for HIV. 

A common query is whether specimen left over from other diagnostic or 

therapeutic tests may be tested for HIV when the source patient cannot 

be located, is incapacitated, or refuses the HIV test. Current law mandates 

that VA may administer a test to a patient that would lead to the diagnosis 

of HIV infection only with the prior written consent of the patient, or of 

an authorized surrogate in accordance with applicable law and regulations. 

This includes circumstances where occupational exposures have occurred.

c. In situations of occupational exposures, there are instances where testing 

of the source patient is difficult or impossible. These situations include:
Veterans Health Administration 103

Appendices

(1) Source patient or appropriate authorized surrogate refuses consent 

for HIV test.

Recommendation: Offer exposed employee post-exposure management 

and anti-retroviral prophylaxis, as warranted by PHS guidelines. The 

patient, or appropriate authorized surrogate may be re-approached by a 

different provider, e.g., a counselor, an attending physician or a nurse who 

is not involved in or affected by the exposure event. Careful attention needs 

to be taken to ensure that coercion is neither applied nor perceived when 

a person who initially declined testing is re-approached. If the patient, 

or appropriate authorized surrogate, still declines, testing may not be 

performed, even on available residual specimens.

(2) Source patient left VA medical center before consent was obtained.

Recommendation: Offer exposed employee post-exposure management 

and anti-retroviral prophylaxis, as warranted according to PHS 

guidelines. Follow-up with the patient to obtain consent. The source 

patient’s written consent on VA Form 10-5345, Request for and Consent 

to Release of Medical Records Protected by 38 U.S.C. § 7332, (see 

subpar. 9d) is also required to disclose the HIV test results to the exposed 

employee. Provide assistance or support where possible to maximize 

patient’s convenience in the consenting and testing process. A specimen 

previously collected for other purposes cannot be used for HIV testing 

without appropriate consent.

(3) Source patient cannot be located.

Recommendation: Offer exposed employee post-exposure management 

and anti-retroviral prophylaxis, as warranted according to PHS 

guidelines. Specimen previously collected for other purposes cannot be 

used for HIV testing without appropriate prior consent.

(4) Source patient is incapacitated, incompetent or comatose.

Recommendation: Offer exposed employee post-exposure management 

and anti-retroviral prophylaxis, as warranted according to PHS 

guidelines. VA regulations limit diagnostic testing of HIV and the 

disclosure of information related to HIV infection, when the patient lacks 

the decision-making capacity (incapacitated, incompetent, or comatose). 

Testing for HIV, like any other diagnostic or therapeutic procedure, 

typically requires the patient’s (or appropriate authorized surrogate’s) 

informed consent. When the purpose of the test is to confirm the patient’s 
104 Veterans Health Administration

Appendices

HIV status following an occupational exposure, a written consent allowing 

the test for HIV is required. Furthermore, disclosure of the test results 

to the exposed employee also requires written consent from the patient, 

or from the patient’s legal guardian in instances where the patient lacks 

the decision-making capacity. Such disclosures require the specific written 

consent of the patient’s court appointed legal guardian on VA Form 

10-5345. If the patient is incompetent and there is no consenting court 

appointed legal guardian, HIV testing and disclosure of the HIV test results 

are not permitted.

(5) Source patient is deceased.

Recommendation: Offer exposed employee post-exposure management 

and anti-retroviral prophylaxis, as warranted according to PHS guidelines. 

If the purpose of testing at autopsy is to establish the diagnosis of HIV, then 

specific consent of the deceased’s next-of-kin, or appropriate authorized 

surrogate, would be required (see subpar. 9e).

5. Employee Confidentiality and Record Keeping

a. Confidentiality of medical information pertaining to both HCWs and 

patients is essential. Employee health records should not be accessed 

by anyone other than Employee Health staff and others who are 

involved in providing health care to the exposed HCW without the 

prior written consent of the worker or as otherwise authorized by law. 

Appropriate security measures and sanctions must be in place to assure the 

confidentiality of all employees’ health records.

b. Medical records and HIV test results of patients who are identified as 

the potential source of exposure of blood and/or body fluids are subject to 

confidentiality protections imposed by law (see subpar. 9f). Test results or 

other information concerning a patient’s HIV status may not be disclosed, 

in most instances, without the patient’s specific prior written consent. The 

source patient’s identity and HIV status must not be recorded or reported in 

HCW’s records unless appropriate written permission is obtained.

6. Exposure Management During Non-administrative Work 

Hours

a. A person can be designated within the facility to deal with issues on 

occupational exposure to blood and body fluids with coverage provided 

for off-duty hours.
Veterans Health Administration 105

Appendices

b. A number of the exposures to blood and body fluids occur off-shifts 

and during non-administrative hours. The written policies and procedures 

on the management of the HCW exposed during off-shift and nonadministrative duty hours should be uniformly in accordance with 

the Exposure Control Program of the Occupational Safety and Health 

Administration (OSHA) (see subpar. 9g).

7. Availability of Most Advanced HIV Testing Technologies

a. The PHS guidelines on evaluation and testing of exposure source should 

be followed when evaluating for possible HIV infection (see subpar. 9a).

b. The most advanced and rapid HIV detection technologies should be 

made available (see subpar. 9h). Consideration should be given to using 

rapid HIV detection tests so that source patients’ HIV status can be 

determined as quickly as possible.

c. In addition to the HIV antibody blood test, the direct HIV detection test, 

as well as the rapid tests such as urine antibody and oral tests that have 

the highest degree of sensitivity and specificity, should be made available 

in appropriate situations along with appropriately trained technicians to 

perform the test(s).

8. Process Integrity Issues

a. The exposed HCW should never be the one to approach or counsel the 

source patient about HIV testing.

b. An appropriately trained person should obtain the consent for HIV 

testing of the source patient, or the HCW, and conduct the counseling 

and post-exposure management of the exposed HCW. The post-exposure 

prophylaxis, management and treatment of the exposed HCW, may best be 

directed by a multidisciplinary team of VA providers who are trained in 

issues dealing with occupational exposures.

c. A facility multidisciplinary team should be available for consultation 

during the off-shiftsand non-administrative hours.

9. References

a. Updated U.S. Public Health Service Guidelines for the Management of 

Occupational Exposures to Hepatitis B Virus (HBV), Hepatitis 
106 Veterans Health Administration

Appendices

C Virus (HCV), and HIV and Recommendations for Post-exposure 

Prophylaxis. Morbity and Mortality Weekly Report (MMWR) 2001;50 

(No. RR-11):1-43. (Web address: http://www.cdc.gov/mmwr/preview/

mmwrhtml/rr5011a1.htm)

b. VHA Handbook 1004.1.

c. Title 38 CFR Section 17.32

d. Veterans’ Benefits and Services Act of 1988, Public Law No. 100-322, 

Section 124, 102 Stat. 487 (1988) (38 U.S.C. Section 7333).

e. Title 38 CFR Section 1.460-1.496.

f. Title 38 U.S.C. Section 7332.

g. Office of General Counsel Advisory Opinion VADIGOP 6-8-88. 

Informed Consent for Testing and Autopsies for AIDS. June 8, 1988.

h. VHA Manual M-1, Part 1, Chapter 9, Release of Medical Information.

g. Occupational Safety and Health Administration’s Regulation on 

Bloodborne Pathogens. (29 CFR Section 1910.1030, Bloodborne 

pathogens).

h. Holodniy M. “Establishing the Diagnosis of HIV Infection” AIDS 

Therapy. Dolin, Masur & Saag Eds. Churchill Livingstone Publisher, 

1999.

10. Questions may be referred to Abid Rahman, Director, Government 

Liaison, with the Public Health Strategic Health Care Group (132/13B), 

at 202-273-8468 or e-mail to: abid.rahman@mail.va.gov.
Veterans Health Administration 107

Appendices

 (Appendix G)

VA HIV/AIDS-related Circulars, Directives & Informational Letters

Circulars

Public Law 100-322, Section 124: Testing for HIV (Human 

Immunodeficiency Virus) and Informed Consent (Circular 10-88-151, 

December 14, 1988)

Questions Related to Testing for HIV (Human Immunodeficiency Virus), 

Informed Consent and Case Reporting in VHS & RA (Veterans Health 

Services and Research Administration) (Circular 10-88-151, Supplement 

No. 1, October 18, 1989)

Directives

National Hepatitis C Program (VHA Directive 2001-009, 

February 27, 2001) 

http://vaww.va.gov/publ/direc/health/direct/12001009.pdf

Information Letters

Case Reporting of Human Immunodeficiency Virus (HIV) to State and 

Local Health Authorities by VA Facilities and Providers (IL-10-2001-002, 

February 13, 2001)

http://vaww.va.gov/publ/direc/health/infolet/10200102.pdf

Access to Condoms as HIV Prevention (IL-10-2001-012, August 16, 2001)

Guidelines for HIV Testing in VA Facilities Following Occupational 

Exposures (IL-10-2001-011, July 18, 2001) 

http://vaww.va.gov/publ/direc/health/infolet/10200111.pdf

Hepatitis C Testing and Prevention Counseling Guidelines for VA Health 

Care Practitioners (IL 10-2001-009, June 12, 2001)

http://www.va.gov/publ/direc/health/infolet/10200109.pdf

Recommendations for Prevention and Treatment of Opportunistic 

Infections in HIV and AIDS Patients (IL 10-97-015, March 24, 1997)

http://vaww.va.gov/publ/direc/health/infolet/109715.doc

Update On Use of Viral Load Assays, Resistance Assays, and 

Antiretroviral Agents in HIV Disease (IL 10-98-019, September 9, 1998)

http://vaww.va.gov/publ/direc/health/infolet/109819.htm
108 Veterans Health Administration

Appendices

(Appendix H)

HIV/AIDS Information Resources

American Foundation for AIDS Research (amFAR) 

HIV/AIDS Treatment Directory

http://www.amfar.org/

amfAR’s HIV/AIDS Treatment Directory is a comprehensive, continuously 

updated, searchable database of clinical results for approved and 

experimental treatments and actively recruiting HIV/AIDS clinical trials. 

This respected resource includes feature articles, conference reports, and 

news and analysis on the latest developments in HIV/AIDS research and 

clinical practice.

The Body

http://www.thebody.com/index.shtml

The mission of The Body web site is to use the web to lower barriers 

between patients and clinicians, demystify HIV/AIDS and its treatment, 

improve patients’ quality of life, and foster community through human 

connection. 

Center for AIDS Prevention Studies

74 New Montgomery, Suite 600 

San Francisco, CA 94105 

(415) 597-9100; (415) 597-9213 - fax 

CAPSWeb@psg.ucsf.edu 

http://www.caps.ucsf.edu/capsweb/FSindex.html

This web site contains concise, science-supported HIV prevention fact 

sheets for practitioners and the public in English, Spanish, and Kiswahili 

(selected sheets).

CDC National Prevention Information Network

http://www.cdcnpin.org

This web site is part of the CDC’s National Center for HIV, STD, and 

TB Prevention. It examines the connections among these diseases and 

provides multiple documents to download and links to related web sites.
Veterans Health Administration 109

Appendices

ClinicalTrials.gov

http://www.clinicaltrials.gov/

The U.S. National Institutes of Health, through its National Library of 

Medicine, has developed ClinicalTrials.gov to provide patients, family 

members and members of the public current information about clinical 

research studies. These trials include diseases affecting the immune 

system such as HIV/AIDS.

HIV/AIDS Treatment Information Services (ATIS)

http://www.hivatis.org/

ATIS is the central resource for federally-approved treatment guidelines 

for HIV and AIDS. You can download current and archived guidelines 

from this web site. 

HIV InSite

http://hivinsite.ucsf.edu/InSite.jsp

This web site provides comprehensive, up-to-date information on HIV 

treatment, prevention, and policy. HIV InSite is a collaborative project 

of the San Francisco Veterans Affairs Medical Center, the Positive Health 

Program at San Francisco General Hospital, and the Center for AIDS 

Prevention Studies.

HIV/AIDS Bureau (HAB)

Health Resources and Services Administration (HRSA)

http://hab.hrsa.gov/

HAB, one of four bureaus of HRSA, is the largest single source, next to the 

Medicaid and Medicare programs, of federal funding for HIV/AIDS care 

for low-income, and un- and underinsured individuals. HRSA administers 

the Ryan White Comprehensive AIDS Resources Emergency (CARE) Act.

National Association of State and Territorial AIDS Directors 

(NASTAD)

444 North Capitol Street, NW

Suite 339

Washington D.C. 20001

202-434-8090 

http://www.nastad.org
110 Veterans Health Administration

Appendices

NASTAD is a non-profit national association of state health department 

HIV/AIDS program directors who have programmatic responsibility 

for administering HIV/AIDS health care, prevention, education, and 

supportive services programs funded by state and federal governments.

Office of AIDS Research (OAR)

National Institutes of Health (NIH)

http://www.nih.gov/od/oar/

OAR is located within the Office of the Director of NIH and is responsible 

for the scientific, budgetary, legislative, and policy elements of the NIH 

AIDS research program.

Congress has provided broad authority to the OAR to plan, coordinate, 

evaluate, and fund all NIH AIDS research. The OAR is responsible for 

the development of an annual comprehensive plan and budget for all NIH 

AIDS research. 

The Substance Abuse and Mental Health Services Administration 

(SAMHSA)

5600 Fishers Lane

Rockville, MD 20857

info@samhsa.gov

http://www.samhsa.gov/

SAMHSA is the federal agency charged with improving the quality and 

availability of prevention, treatment, and rehabilitative services in order 

to reduce illness, death, disability, and cost to society resulting from 

substance abuse and mental illnesses. SAMHSA addresses HIV/AIDS 

issues in the context of substance abuse and mental illness issues.

VA AIDS Information Newsletter

AIDS Information Center

Director, J. Michael Howe, MSLS

Department of Veterans Affairs (13B)

810 Vermont Avenue, NW

Washington, DC 20420

202-273-9206

202-273-6243 (fax)

j.michael.howe@hq.med.va.gov
Veterans Health Administration 111

Appendices

The AIDS Information Newsletter is a biweekly, electronic resource that 

provides current information to ensure that VA personnel are informed 

about the latest developments regarding the care of veterans with HIV 

infection.

VHA Public Health Strategic Health Care Group

Lawrence R. Deyton, MSPH, MD

Chief Consultant

Department of Veterans Affairs (13B)

810 Vermont Avenue, NW

Washington, DC 20420

202-273-8567

202-273-6243 (fax)

http://vhacoweb1/aidsservice/

113

HIV Prevention Handbook

Veterans Health Administration

INDEX

Veterans Health Administration 115

Index

INDEX
116 Veterans Health Administration

Index

INDEX

AIDS-defining conditions, 19, 84

African Americans

Effects of HIV/AIDS epidemic, 7, 21-22

Amniotic fluid, see Transmission

Anonymous HIV testing and counseling

Guidance, 55

Resources, 55

Assessment, conducting HIV risk assessment of VA patient, 24-30

Assessment tools

HIV risk, 24,33-34, 85-95

Hepatitis C, see Hepatitis C Testing and Prevention Counseling 

 Guidelines for VA Health Care Practitioners (IL 10-2001-009), 107

Infectious disease risk for use in a substance abuse service setting, 33-34

Barrier methods

Dental dams, use of, 52

Female condoms, use of, 51

Male condoms, use of, 50

Negotiation skills, use of, 53

Behavior change counseling, 39-41

Assessing patient’s level of HIV awareness and concern, questions 

 for bringing about desired change, 36, 39-40

Determine the patient’s readiness for change, 40 

Goals of, 39-40

Behaviors, risk for HIV transmission, 16

Bodily fluids, 16

CDC, Serostatus Approach to Fighting the Epidemic, 6

Case reporting to state and local health authorities, HIV-positive 

 test results, 65

Casual contact, see Transmission, 17

Cerebrospinal fluid, see Transmission, 16

Conditions that suggest HIV infection, 19

Condoms

Effectiveness of , 47, 96

Dental dams see Barrier methods

Female condoms, use of, 51

Male condoms, use of, 50

Negotiation skills, 53

Nonoxynol-9, 48-49

Prescribing to VA patients, 14, 48, 97
Veterans Health Administration 117

Index

VHA National Formulary, 14, 48, 97

Confidentiality

Circumstances under which confidentiality can be broken in the 

 VA system, 10

Discussions in inappropriate VA settings, 11-12

Notations in VA patient records, 11

Penalties for unauthorized VA disclosures, 11

Written Consent for Medical Record Release (10-5345), 11

Contact tracing; see Partner notification and referral services

Demographics, HIV/AIDS in the United States

AIDS cases, 6

AIDS deaths, 6

African Americans, 7

Females, 8

HIV cases, 6-7

Heterosexuals, 7, 20-21

Hispanics, 7

Men who have sex with men, 7, 21

United States, 6-8

Veterans, 52

Dental dams, see Barrier Methods

Disclosure

HIV test results, 11, 63-64 

Lack of patient informed consent, 55-56, 63-64

Penalties for unauthorized disclosure of medical record

 information, 11

Domestic violence

Resources, 63

Screening for during post-test counseling, 61-63

Drug use history, taking a patient’s

Assessment tool for determining infectious disease risk (for use in 

 substance abuse service setting), 33-34

Emergency room setting, HIV prevention in the, 37-38

Harm reduction, definition of, 41

Health care provider

Frustration and burnout, 68-69

Occupational exposure to HIV, 67-68

Hepatitis C

Hepatitis C Testing and Prevention Counseling Guidelines for VA 

 Health Care Practitioners (IL 10-2001-009), 107
118 Veterans Health Administration

Index

Injection drug use transmission, 28, 30

Resources, see Hepatitis C Testing and Prevention Counseling 

 Guidelines for VA Health Care Practitioners (IL 10-2001-009)

Herpes zoster, 19

HIV infection, conditions that suggest, 19, 84

HIV prevention

Evidence of effectiveness, 4-5

Primary, 13-15

Secondary, 13-15

HIV prevention approaches and strategies

Behavior change counseling, 39-41

Partnership for Health intervention for HIV-positive patients, 46-47

Primary prevention, 13-14

Transtheoretical Model of the Stages of Change Theory, 42-46

Secondary prevention, 13-14

HIV pre- and post-testing counseling and testing

Anonymous counseling and testing guidance, 55

Anonymous testing counseling and testing resources, 55

Approaching HIV testing and counseling with patients, cues for, 58

 Benefits of HIV testing and counseling, 59

Case reporting to state and local health authorities, 65

Confidential counseling and testing, VA policy, 10-11, 65

Domestic violence, screening for during post-test counseling, 61-63

Domestic violence, resources, 63

Informed consent, 55-56

Partner notification and referral services, guidance, 63-64

Pretest counseling, VA requirements, 60-61

Pretest counseling documentation, VA requirements, 60-61

Post-test counseling, VA requirements, 61

Post-test couseling documentation, VA requirements, 61

Referrals from VA health care providers, 65-66

Testing technology, 57

VA staff who can provide pre- and post-test counseling, 57

Homeless veterans

Mental health service providers, guidance for, 37

VA Stand Downs, 37-38

Homosexuality, see Men who have sex with men or Lesbians

ICR, see Immunology Case Registry

Immunology Case Registry, 9

Informed consent
Veterans Health Administration 119

Index

Federal regulations, 55

HIV testing and counseling, 54-56

Legal guardian, consent provided by, 56

Mental status questions, 56

Next of kin, 56

Patients unable to provide informed consent, 56

VA Consent for HIV Antibody Testing form (10-012), 55

Injection drug use paraphernalia, risk reduction activities, 28, 31

Injection drug users, risk for HIV transmission, 7-8, 21

Injection drug use risk reduction activities, 4

Risk for hepatitis C, 30

Infectious disease assessment tool, 33-34

Kissing

Cheek, on the, see Transmission, 17

Open mouth, see Transmission, 17-18

Medical conditions, may suggest HIV infection, 19

Medical records

Notations, 11, 54, 61

Written Consent for Medical Record Release (10-5345), 10-11, 63

Men who have sex with men, 7, 20-21

Mental health service providers, guidance for, 35-36

Condom availability, 36

Homeless veterans, 37

Post-traumatic stress disorder (PTSD), 35

Seriously and persistently mentally ill, 35

Negotiation skills, condom use, 53

National Formulary, VHA

Availability of male and female condoms, 48, 97

Nonoxynol-9, 48-49

Nutrition services, referrals for, 65

Obstacles to prevention, 14

Occupational exposure

Guidelines for HIV Testing in VA Facilities Following Occupations 

 Exposure (IL 10-2001-011), 67, 101-106

VA health care providers, 67-68

Older adults, risk for HIV transmission, 22-23

Open wounds, see Transmission, 17

PTSD, see Post-traumatic stress disorder

Partner notification and referral services, guidance

VA policy on notification to partners at risk, 63-64
120 Veterans Health Administration

Index

Partnership for Health intervention for HIV-positive patients, 46-47

Patient-centered interviews, 14

Post-test counseling 

Post-test counseling, VA requirements, 61

Post-test couseling documentation, VA requirements, 61

Post-traumatic stress disorder, 35

Pre-testing counseling 

Pretest counseling, VA requirements, 60-61

Pretest counseling documentation, VA requirements, 61

Prevention, evidence of effectiveness, 4-5

Primary HIV prevention

Activities, 13-14

Definition, 13

Public health departments

Partner notification and referral services, guidance, 63-64

Reporting of VA patient HIV test results, 65

Referrals from VA health care providers, 65-66

Release of VA medical records see Written consent for medical 

 record release

Reporting of VA patient HIV test results, public health departments, 64

Risk assessment tool, HIV, 23-24

SAFE, see Serostatus Approach to Fighting the Epidemic

SAMHSA, see Substance Abuse Mental Health Services Administration, 

 infectious disease assessment tool

Salivia, see Transmission

Secondary HIV prevention, 13-14

Activities, 13-14

Definition, 13

Seriously and persistently mentally ill, 35, 37

Serostatus Approach to Fighting the Epidemic, CDC, 6

Sexual activities, degree of risk for HIV transmission (chart), 27

Sexual history, taking a patient’s

Guidance, 25-26, 36

Questions to use with patients (cues), 25-26

Risk of transmission through various sexual activities (chart), 27

Sexually transmitted diseases, 5

Increased risk for HIV transmission, 5 14, 19, 47

Stages of Change Theory, 42-45

Stand Downs, see VA Stand Downs

Substance abuse 
Veterans Health Administration 121

Index

History Taking, 28-30

Substance Abuse Mental Health Services Administration (SAMHSA)

 infectious disease assessment tool, 33-34

Substance abuse service provider, guidance for, 31-32

Assessment tool for infectious disease for use in a substance abuse 

 service setting, 33-34

Counseling for HIV, 28-31

Treatment as prevention, 30-31

Testing and Counseling see HIV testing and counseling

Testing technology, 57, 105,

Transmission of HIV

aerosal, 18

amniotic fluid, 16

bodily fluids, 16

casual contact, 17

cerebrospinal fluid, 16

hugging, 17

kissing, 17-18

mosquitoes, 17

open wounds, 17

resources, 18

saliva, 17

sexual activities, 16

sexually transmitted diseases, 5, 14, 19, 47

shaking hands, 17

sneezing, 17

sweat, 17

swimming pool, 18

synovial fluid, 17

tears, 17

Transtheoretical Model of the Stages of Change Theory, 39, 42-43

Action stage, 42, 45

Chart, reponses to risk-behavior questions, corresponding stages of 

 behavior change, and possible interventions, 44-45

Contemplation stage, 42, 44

Maintenance stage, 42-43, 45

Precomptemplation stage, 42

Preparation stage, 42, 44

Relapse, 43, 45

Termination state, 43
122 Veterans Health Administration

Index

VA Stand Downs, 37-38

VA Forms

Consent for HIV Antibody Testing (10-012), 55

Written Consent for Medical Record Release (10-5345), 10-11, 103

VA policy

Case reporting of Human Immunodeficiency Virus (HIV) to State and 

 Local Health Authorities by VA Facilities and Providers 

(IL 10-2001-002), 65

Disclosure of patient’s serostatus without patient informed consent 

 (38 U.S.C. Section 7332), 10-11

Guidelines for HIV Testing in VA Facilities Following Occupations

 Exposure (IL 10-2001-011), 101-106

Hepatitis C Testing and Prevention Counseling Guidelines for VA 

 Health Care Practitioners (IL 10-2001-009)

VA staff who can provide pre- and post-test counseling, 57

Vaginal candidiasis, 19

Veterans 

Demographics, at risk or with HIV/AIDS, 3, 9, 37

Veterans Health Administration

Availability of male and female condoms, 48, 97

Weight loss, 19

Women, 8

Written consent for medical record release, 10-11
VETERANS HEALTH ADMINISTRATION

PUBLIC HEALTH STRATEGIC HEALTH CARE GROUP (13B)

HIV & HEPATITIS C PREVENTION

810 VERMONT AVENUE, N.W.

WASHINGTON, DC 20420

IB 10-91

P95644

JANUARY 2002