High-Risk Groups or the origins of stigma
- The HIV/AIDS epidemic started in the US in the early 1980s, at the end of a period of marked rupture in the American society with respect to (amongst others) the right of sexual self-determination. Within this context, HIV/AIDS acquired unprecedented moral, social and political significance and was falsely identified with certain minority groups, like gay men and injecting drug users. Commonly, these groups are referred to as ‘high risk groups’.
- HIV is mainly a sexually transmitted virus and, as such, concerns every sexually active person. HIV does not discriminate against any group of people on account of their personality characteristics.
- The use of the term ‘high risk group’ is delusive, as it preserves the erroneous stereotype of HIV/AIDS as an exclusive disease of certain minority groups, at the same resting assured the rest of the population.
- It is preferable to talk about ‘high risk behaviors’, that is, behaviors that do increase the possibility of HIV transmission (e.g. condomless sex, sharing needles).
One of the most common misconceptions about HIV/AIDS is that it exclusively (or predominantly) concerns certain groups of people, primarily homosexual men, as well as injecting drug users, women in prostitution, transgender people, immigrants etc. The term “high-risk group” is commonly used to refer to these specific population groups. This perception is certainly false, it accompanies, however, the HIV/AIDS epidemic since its first appearance in the US, Europe and other countries around the world. Throughout the history of medicine, HIV infection is perhaps the most distinctive example of a physical illness, which, at least initially, became understood mainly in moral terms, rather than through medical science and, thus, was mistakenly associated (or identified) with specific population groups and “deviant”, socially unacceptable behaviors. The reason why this has happened does not really have to do with the nature of the illness, but mainly with the political and social context in which it occurred.
The HIV/AIDS epidemic started in the US in the early 1980s (see The history of the HIV/AIDS epidemic), marking the end of one of the most troubled times in the history of the country. During the past two decades, the American society had gradually been led to a state of deep division and acute (and often violent) dispute, due to a series of critical and urgent socio-political issues, such as the claim of equal rights by the African-American community, the Vietnam war, the feminist movement and the movements against homophobia (see Figures 1-4). It was a period of intense and widespread clash between the younger and older generation, a period of conflict between an emerging counterculture and the dominant ideology, which developed both in the US and in many other countries (e.g. May of 1968 in Paris, Prague Spring), promoting the need for social change and justice, global peace, more democracy, more individual freedom and the protection of human rights. Young people of the 1960s and 1970s demonstrated an intense anticomformism, challenging the traditional values of the post-war American society, such as dedication to hard work and profit, family, religious faith and love for your country, by adopting an unconventional and often provocative lifestyle, in which music, experimenting with drugs and sexual freedom prevailed. In this subversive atmosphere, the for decades oppressed and socially excluded homosexual community of the US requested the abolition of the various discriminations against it. On the other hand, the reaction of the conservative forces of the American society, institutional or not, was also fierce, aiming to maintain the status quo through repression and law enforcement. According to many historians, the rupture of the American society at that time can only be compared with that of the American civil war, and its impact on the years that followed was huge in almost all aspects of social life [1,2].
In this climate of intense controversy between the radical and conservative parts of the American society, the AIDS epidemic came to exert a catalytic effect and to escalate the controversy over the individual right of sexual self-determination and discrimination against homosexuals, favoring, however, this time the opponents of homosexuality. AIDS did mainly affect young homosexual men and, without anyone being able to explain why this was happening, the conditions for a new wave of homophobia were set. For the – adult then – young people of the ’60s and ’70s and especially for the gay community of the time, AIDS meant a significant retreat, bringing the carefree lifestyle of overcoming social restrictions and free sexuality to an end. Conservative and super-conservative circles welcomed AIDS as a confirmation of their belief, that accepting homosexuality and any other form of “unrestrained” freedom and ignoring traditional values of the US, “the laws of nature and god”, could only be followed by a heavy price and a harsh punishment . The AIDS threat triggered, within a few years, a widespread wave of terror and massive hysteria in a large part of the conservative American society and again stimulated its strong homophobic feelings (see The history of the HIV/AIDS epidemic > 1981-1994: From passiveness to massive panic). “AIDS is not just the punishment of god towards homosexuals. It is the punishment of god towards a society that tolerates homosexuals” proclaimed Jerry Falwell, a well-known demagogue and super-conservative activist of the time. Also, Ronald Reagan, a fierce opponent of student mobilizations, as governor of the California state in 1967-75, took no measures to control the epidemic as president of the US from 1981 to 1989, considering HIV/AIDS as only a disease of homosexuals and drug addicts [3,4]. For the activist movements, which, despite their internal contradictions, had achieved significant victories, such as the declassification of homosexuality as a mental disorder by the American Psychiatric Association in 1973, the AIDS epidemic meant, at least during its first years, a big setback.
Thus, from the very beginning, HIV/AIDS was not viewed just as an infection of the immune system, but as a disease, unprecedented in moral, social and political levels, precisely because it is closely linked to sexual behavior and because the diversity of human sexuality, the right of sexual self-determination and individual freedom had all in all been – and continued to be – an area of serious controversy. Although, already from 1981-82, several AIDS cases had been reported in women, newborn babies and multi-transfused patients, indicating that HIV does not distinguish people based on their sexual orientation, public speech about HIV/AIDS remained focused not much on the need for research and treatment of this incomprehensible and fatal disease, but more on whether homosexuality can be considered normal by society. For many years, reference to HIV and AIDS was a reference to homosexual men and other “deviant” population groups, so in this way the disease was identified with these specific groups of people in the public consciousness.
It took about a decade and several millions of deaths, worldwide, for HIV/AIDS to become understood not as a disease of certain minorities, but as a global threat, which resulted in an increase of funding for research and treatment. The progress made in HIV medical treatment since the mid-1990s has been impressive (see The history of the HIV/AIDS epidemic > 1995 and after: the era of HAART). However, no such progress was made in the way a large part of society perceived HIV/AIDS and the same distortions that originally accompanied the disease are still largely spread today, affecting not only many people’s behavior, but also their thinking regarding HIV/AIDS. A typical example is the term “high-risk group” often found in texts, as a reference to homosexual men, injecting drug users, women in prostitution, immigrants from countries with high HIV incidence etc., the use of which seems to have been developed and also maintain the myth that HIV is a disease of specific population groups.
The term “high-risk group” is a descriptive statistical term and refers to the frequency at which a specific disease occurs in population groups with specific characteristics, in comparison to the general population, as indicated by relevant epidemiological studies. However, it does not explain if these specific characteristics of the so-called “high-risk groups”, apart from often co-occurring with the disease, are somehow connected to it or even cause it. For instance, it is known that in the US and many European countries the incidence of HIV/AIDS among homosexual men is higher in comparison to heterosexual men [5,32]. Does this mean that being homosexual alone results in a higher probability of being infected by HIV? If, in contrast, someone is positive to HIV, does this mean that he is also gay? If so, how does homosexuality lead to HIV infection? And if someone is heterosexual, does this mean that he is not at risk of being infected with HIV? The “high-risk group” concept does not answer any of these questions. On the contrary, its use seems to set the conditions for many misconceptions.
At this point, a very common logical mistake is observed: the relation of co-existence or co-occurrence of two characteristics (in this case homosexuality and HIV) is perceived as a causal one, in which one characteristic is considered as the cause or precondition of the other. In this way, many people mistakenly conclude that, since someone is HIV-positive, he is also gay and vice versa. Or that since someone is not homosexual, there is no reason for him to worry about HIV. This mistake is also facilitated by the ignorance regarding the nature of the virus and the ways of its transmission, as well as by pre-existing stereotypes and prejudice for homosexual men and other “high risk groups”.
This misconception has two critical consequences. The first is the further stigmatization of population groups that are, anyway, in many respects at a socially disadvantaged position. “High-risk groups” are easily perceived as “dangerous groups” and are treated by the rest with suspicion and fear. The second consequence is the complacency of other groups of the society, which do not belong to the so-called “high-risk groups” and which believe that HIV/AIDS does not concern them.
Linking or identifying HIV/AIDS with certain social groups is quite easily rejected if this simple fact is considered: HIV is a virus (see What is HIV?) and, as all viruses that can be transmitted to humans, it survives and replicates by infecting certain types of cells in our body (see Figure 9), without caring whether the human comprised by these cells is male or female, homosexual or heterosexual, young or old, Christian or Muslim, native or foreigner. In other words, HIV infects human cells, not human personalities and, in this sense does not – and could not – make distinctions. Under the microscope, in the microcosm of cells and viruses, all humans are the same and, therefore, equally susceptible to HIV.
In fact, HIV/AIDS, like any other sexually transmitted disease, concerns any sexually active person. In addition, if the epidemiological data regarding HIV incidence worldwide and not only in the western world are examined, it is realized that HIV equally affects men and women and that heterosexual intercourse is the most common way of HIV transmission (see The history of the HIV/AIDS epidemic > Epidemiological data).
However, specific behaviors can actually make HIV transmission more possible, either because they allow or facilitate – from a biological point of view – the entry of the virus inside the body (e.g. sexual intercourse without the use of condom), or because they make – from a psychological point of view – a person more prone to unsafe practices (e.g. sexual intercourse under the influence of psychotropic substances). So, instead of considering HIV as implicit to specific groups of people, the reason why its incidence appears to be proportionally higher among these groups in some countries should be examined, by focusing on such high-risk attitudes and practices. For example, it is known that anal sexual intercourse without the use of condom involves a much higher probability of HIV transmission, in comparison to vaginal intercourse (see Ways of HIV transmission and non-transmission) and this partly explains the higher HIV incidence among homosexual men. However, the vast majority of homosexual men are negative to HIV, precisely because they take the necessary precautions. Similarly, syringe sharing is the main way of HIV transmission among injecting drug users. And again, the vast majority of drug users are negative to HIV, just because they do not share the tools they use with others. It is, therefore, more appropriate to talk about “high-risk behaviors” and not “high-risk groups” (for more information, see below High-risk behaviors).
A series of behaviors or practices can increase the possibility of HIV transmission, either because they allow or facilitate – from a biological point of view – the entry of the virus inside the body, or because they make – from a psychological point of view – a person more prone to unsafe practices. These are:
- Sexual intercourse without the use of condom or with false use of condom
- Sexual intercourse under the influence of alcohol or other psychotropic substances
- Frequent change of sexual partners
- Sexual contact in the presence of another sexually transmitted disease
- Violent or traumatic sexual intercourse, ejaculation inside the receptive partner
- Sharing works for injecting psychotropic substances
- Pregnancy without HIV testing
- Medical or cosmetic procedures with non-sterilized equipment
HIV is a virus (see What is HIV?) that, like any other virus that can be transmitted to humans, survives and replicates by infecting specific types of cells in our body. In this sense, HIV does not – and could not -make distinctions (see above High-risk groups and the origins of stigma). All humans have the same cellular structure and, as a result, we all are, at least biologically, equally susceptible to HIV. However, specific behaviors or practices are likely to increase one’s probability of being exposed to HIV. These are usually referred to as “high-risk attitudes” and include:
Sexual intercourse without the use of condom
Condomless sex is by far the most common way of HIV transmission. The probability of HIV exposure is higher during anal intercourse, relatively lower during vaginal intercourse and much lower (but not zero) during oral intercourse  (see Ways of HIV transmission and non-transmission). During any kind of intercourse, the transmission probability is much higher for the receptive partner (the one penetrated), rather than for the insertive partner (the one that penetrates), especially if the later ejaculates inside the receptive partner and if the intercourse is traumatic (see below). This, of course, does not in any way suggest that the virus cannot be transmitted from the receptive to the insertive partner, too. A series of other factors also affect the transmission probability during sexual intercourse, such as the viral load of the HIV-positive partner and the presence of other sexually transmitted diseases in one or both partners (see Factors affecting the probability of HIV sexual transmission).
Sexual intercourse with false use of condom
Condoms are highly effective means of protection against HIV and most sexually transmitted diseases, as well as unwanted pregnancies, provided that they are used properly (see below The proper use of condom). Several studies show that a fairly high percentage of people often use condoms in the wrong way . Some of the most common mistakes are:
- using an expired condom
- keeping condoms in places with humidity or high temperature
- late placement or premature removal of the condom
- false condom placement to the penis (e.g. unwrapping before placement, air in the reservoir tip of the condom)
- use of lubricants not compatible with latex (e.g. vaseline)
- re-use of an already used condom
- damage of the condom by a sharp object (e.g. nails, teeth)
- removing the penis without holding the condom from its base
Ejaculation inside the receptive partner
HIV is found in amounts sufficient to cause infection in pre-seminal fluids. Its concentration is much higher in semen though. When the HIV-positive partner does not use a condom and ejaculates directly into the vagina, anus or mouth of his/her partner, a large amount of viral particles is released, which greatly increases the likelihood of HIV transmission (see HIV transmission process).
Violent or traumatic sexual intercourse
When sexual intercourse takes place in a violent way, it is more possible for the condom to be torn or slip. In addition, during violent intercourse, injuries are likely to be caused to the skin or genital mucosa. The rectum is much more susceptible to injuries, because it does not have the natural lubrication mechanisms available in the vagina and penis. If a condom is not used, these wounds are another possible entry point for HIV, as they offer the virus immediate access to the bloodstream (see The process of HIV transmission).
Sexual contact in the presence of another sexually transmitted disease
The presence of an active sexually transmitted disease, apart from HIV (e.g. genital herpes, syphilis, warts, gonorrhea, chlamydia etc.), in one of the two or both partners significantly increases the risk of HIV sexual transmission . Many sexually transmitted diseases cause ulcers or wounds to the skin or genital mucosa, creating additional points of possible exposure to the virus (see The process of HIV transmission). Also, inflammation caused in the genital area attracts a large number of immune cells and, in this way, HIV has more potential target-cells. Finally, sexually transmitted infections weaken the immune protection of the mucous membranes, making them more susceptible to a possible infection.
Frequent change of sexual partners
The more sexual partners one has, the more likely he or she is to be exposed to HIV and other sexually transmitted diseases. In fact, the probability of HIV exposure is increased almost exponentially, depending on the number of sexual partners, if we also take into consideration that each partner alone had a number of sexual partners in the past, who also had a number of sexual partners and so on (see Figure 1). In a sense, when we have sexual contact with someone, it is like coming in contact with all his or her previous partners and all the other partners they had and so on. For this reason, maintaining faithful, monogamous relationships, in which both partners have checked their sexual health, is considered as one of the main ways for preventing HIV and other sexually transmitted diseases (see Preventing HIV sexual transmission).
Sexual intercourse under the influence of alcohol or other psychotropic substances
All psychotropic substances, legal or illegal, restrict less or more the ability of movement, thinking and judgment and, finally, the ability of self-control. Being under the influence of such substances makes someone more prone to unsafe behaviors and practices, such as having an intercourse without using a condom or using it in the wrong way. Specifically the use of poppers, a group of stimulants, doubles the likelihood of HIV transmission to the passive partner during anal intercourse, as it increases the blood flow through the vessels of the area [11,12] (see Factors affecting the probability of HIV sexual transmission).
Sharing tools for injecting psychotropic substances
Sharing syringes and other tools is the most common way of HIV transmission, as well as transmission of other viral infections (e.g. hepatitis B and C) among people that inject psychotropic substances (intravenously, subcutaneously or intramuscularly). As someone draws blood in order to check if the needle is in a vein, small (and usually not visible) blood quantities remain in the syringe barrel after the injection. If the blood residue is HIV-positive and if the same syringe is later used by another person, it is likely for HIV to enter directly into the bloodstream  (see Ways of HIV transmission and non-transmission). There is also a possibility of transmission, if sharing other tools, such as spoons, containers, swabs, solvents etc., which may also carry blood residues.
Pregnancy without HIV testing
If no protective measures are taken, the likelihood of HIV transmission from mother to fetus or infant, during pregnancy, childbirth or breastfeeding is high (estimated at 25-45%)  (see Ways of HIV transmission and non-transmission). However, if a series of preventive measures are taken, such as prompt administration of antiretroviral treatment to the mother and – for a 4-week period – to the infant, the transmission probability is less than 1% . For this reason, any woman that is or intends to get pregnant needs to do an HIV antibody test as soon as possible, so that, in case the test is positive, she has time to take the appropriate measures, always according to her doctor, in order to minimize the probability of transmission to her baby.
Medical or cosmetic procedures with non-sterilized equipment
Any item or tool that comes in contact with blood, either used for medical operations (e.g. blood sampling syringes, surgical or dental tools), or cosmetic procedures (e.g. tattoo or body-piercing needles) should be sterile or for single use only. If this equipment carries residues of fresh blood infected by HIV and if used within a short time to another person, there is a possibility of HIV transmission (see Ways of HIV transmission and non-transmission).
Sharing sharp objects and items of personal hygiene
Sharing sharp objects, like toothbrushes, nail scissors, razors etc., which can cause mild injuries and carry blood residues (often not visible), should in general be avoided. Every person should use his/her own items for personal hygiene. The probability of HIV transmission is, of course, in this case extremely low (slightly less than 0.3%), but the personal use of such items for reasons of general hygiene is still highly recommended (see Ways of HIV transmission and non-transmission).
Preventing HIV sexual transmission
- Besides abstinence from any sexual activity and having a mutually faithful monogamous relationship, the use of condom is the most effective way of preventing HIV and many other STIs, as long as it is being used in every single intercourse, during its whole duration and in the right way. The use of lubricants together with condoms can provide additional protection.
- It is recommended to avoid high risk behaviors, such as having sex under the influence of alcohol or other psychotropic substances or in the presence of another sexually transmitted disease, having violent or prolonged sexual intercourse or ejaculating inside the receptive partner.
- There is strong evidence that circumcision can reduce up to 60% the chance of woman to man HIV transmission during vaginal sexual intercourse.
The most effective way of avoiding HIV sexual transmission or the transmission of any other sexually transmitted disease is either the total abstinence from any kind of sexual activity, or limiting sexual life exclusively within a mutually faithful monogamous relationship, in which both partners have been tested and are aware they are sexually healthy and in which it is ensured that none of them has sex with a third person. However, many people choose neither to limit their sexuality to a single affair, nor to be completely deprived of it. This is completely understood and acceptable. Sexuality is a particularly rich and enjoyable part of life and relationships. However, it still involves the risk of exposure to HIV and other sexually transmitted diseases. Thus, in order for sexuality to be – and remain – a pleasant part in the life and relationships of an individual, it should be accompanied by the assumption of responsibility for the protection of his/her health.
Apart from sexual abstinence and a mutually faithful monogamous relationship, the use of condom is the most effective way for prophylaxis from HIV and most sexually transmitted diseases (as well as from unwanted pregnancies). Certified, laboratory-tested condoms are impervious to any microorganism, including all viruses. However, the protection offered by a condom does not only depend on the condom itself, but also on the frequency and the way it is used, i.e. whether it is used in every sexual intercourse and in the proper way.
The protection level offered by the condom against HIV during vaginal intercourse, provided it is used in each and every intercourse, is estimated at 80-85% [16,17]. That is, for every 100 cases of HIV transmission that would occur, if the condom was not used, 15 to 20 will occur if it is systematically used. The few studies that have researched if this is also applies when it comes to anal intercourse, indicate a slightly lower level of protection of around 70-76% , due to the anyway higher probability of HIV transmission during anal intercourse. The residual rates are mainly due to the false use of the condom and, much more rarely, to manufacturing defects. The possibility for a condom to break, if not used or fitted properly, is estimated at 2% and 4% for vaginal and anal intercourse, respectively. The possibility, though, for it to slip off is estimated at 13% and to come off completely at 3-5% [19,20]. So, for maximum protection, the condom should be used not only in every single intercourse, but also in the correct way (see below The proper use of condom).
The use of lubricants together with a condom may offer additional protection in several cases. That is particularly true when it comes to anal sex, as the rectum does not have sufficient lubrication mechanisms of its own. However, the lubrication of the female vagina is also likely to be disturbed by various factors (e.g. menstrual phase, menopause, breastfeeding etc.) and vaginal dryness can occur. The increased friction developed during sexual intercourse in these cases leads to a higher probability of an internal injury or of the condom slipping off or tearing and, thus, the transmission probability of HIV and other sexually transmitted diseases is higher. Attention is also needed when choosing the lubricant that is to be used, as this must be compatible with latex (e.g. water-based; vaseline and other oil-based substances should not be used as lubricants) (see below The proper use of condom).
Apart from the above, a series of behaviors and practices during sexual intercourse are likely to increase the transmission probability of HIV and other sexually transmitted diseases (see above High-risk behaviors). For instance, when sexual intercourse takes place in a violent way, the possibility of an injury of the genital area, as well as the possibility of the condom coming off or tearing, is obviously greater. This is also the case when the intercourse is prolonged (it is recommended to use a new condom after 30 minutes). The transmission probability is also increased, if the insertive partner does not use a condom and ejaculates inside the receptive one. In some cases, sexual intercourse is preferable or necessary to be completely avoided, if one or both partners have some other active sexually transmitted disease, until this is properly treated. Finally, sexual intercourse is better to be avoided under the influence of alcohol or other substances that limit the judgment and self-control ability of a person, as the possibility of engaging to unsafe behaviors or practices is greater.
One last and not particularly well-known way of prophylaxis in the case of men is circumcision, that is, the surgical removal of the foreskin that covers the tip of the penis. There is strong evidence that circumcision reduces HIV transmission probability from a woman to a man during vaginal intercourse by 50% to 60% [21,22,23]. The World Health Organization recommends circumcision as a key measure for preventing HIV infection, especially in African countries, where heterosexual intercourse is the most common way of HIV transmission . There is no evidence that circumcision has the same protective effect for men who have sex with men. This drastic reduction of the likelihood of transmission is due to the fact that in the foreskin of the penis a large number of dendritic cells (Langerhans cells) are located. These cells are usually the first to be infected by HIV during sexual intercourse and through which HIV is transferred to the lymph nodes  (see The process of HIV transmission).
Prophylaxis from HIV when using addictive substances
- Globally, it is estimated that about 13% of people using drugs intravenously are HIV positive, although this percentage greatly deviates amongst countries. For each instance of sharing a needle for drug use, the chance of HIV transmission is considered to range from 0.63 to 2.4%.
- The most common way of HIV transmission between people that inject drugs is through sharing needles and other works. In addition, all psychotropic substances limit a person’s self-control, thus making it more possible for him or her to be involved in high risk behaviors.
- If an injecting drug user is not ready to discontinue drug use or at least intravenous drug use, he or she should use his or her own works exclusively and not share it with anybody.
In many ways, the use of addictive psychoactive substances makes the likelihood of someone engaging to high-risk behaviors greater, increasing therefore, the possibility of exposure to HIV or other infectious diseases (e.g. hepatitis B and C). In fact, the prevalence of HIV infection among people that inject drugs is higher compared to that of the general population. It is estimated that, worldwide, about 13% of the people using intravenously addictive substances are positive to HIV, although this percentage varies greatly from country to country . Typically, however, when injecting drug use increases in a community, it is soon followed by a respective increase in HIV incidence . This specifically has occurred in the recent years in our country as well.
During the years of 2011-2015, 1,201 new cases of HIV infection related to the use of addictive substances (34.68% of the total new HIV diagnoses of this period, for which the mode of transmission is known) were recorded in Greece [27,28,29,30,31]. The incidence of HIV infection among people that use addictive substances hugely increased in 2011 (241 new cases or 32.8% of the total new cases, with the way of transmission being known) and in 2012 (522 or 54.6% respectively) and was gradually limited during the following years (the respective percentage for 2016 is 16.7%) . From the total cases of HIV diagnosis in Greece, from the beginning of the epidemic until the end of 2016, for which the way of transmission is known, 13.51% of them (1,774 people) are related to injecting drug use .
The most common way of HIV transmission among people who inject addictive substances is syringe sharing. During intravenous drug use, the person first suctions a small amount of blood, in order to make sure that the needle of the syringe is inside a vein. After the infusion of the substance, a small (and usually not visible) amount of blood remains in the syringe barrel. If this blood residue is positive to HIV and if the same syringe is later used by another person, it is possible for the virus to directly enter the bloodstream (see Ways of HIV transmission and non-transmission). This also occurs when the substance is administered intramuscularly or subcutaneously. In addition, although HIV does not easily survive in the external environment, it can survive for up to a few weeks in the sealed from the external environment syringe. It should also be noted that a transmission probability exists when sharing other works for injection, such as spoons, containers, cotton, solvents etc., which may also have come in contact with a used syringe and carry blood residues.
For each incidence of syringe sharing between an HIV-positive and an HIV-negative person, the likelihood of HIV transmission is estimated at 0.63 to 2.4%, depending on the amount of blood left in the barrel and the amount of viral load in it . Obviously, the more often one shares syringes and other works and with more people, the higher the probability of exposure to HIV is.
In addition, the use of drugs increases the probability of HIV exposure in indirect ways as well. All addictive psychoactive substances, legal or illegal, more or less weaken the ability of thinking, judgment and self-control, so that a person is more likely to engage in unsafe practices, such as condomless sexual intercourse. Indeed, many studies have shown that the use of condom among people who use addictive substances is generally limited, while it is estimated that about one out of three never uses a condom . In addition, some stimulants, such as cocaine and crack, increase sexual desire, leading to more sexual intercourses with more partners (the incidence of HIV for cocaine-dependent people is almost twice as high as it is for heroin-dependent people). Also, for some drug users, offering sex is a way of making money or other exchanges.
When it comes to preventing the risk of HIV exposure related to the use of addictive substances, the best someone can do is, obviously, stop using drugs, often with the necessary support of a drug rehabilitation program. If this is not possible, the next option is discontinuing injecting use and opting for a safer way of administration. If this is also impossible, the user should make sure to always use personal equipment and not share it with others, even if they are familiar or intimates (they may be HIV-positive without knowing it). This also applies for syringes, as well as any other object used during the preparation of the substance and may come in contact with blood. Especially cotton or anything else that can be used as a filter provides the ideal environment for the survival of viruses and other microbes.
Each syringe should be used only once and then be disposed of in a safe place. For each subsequent use, a new, packaged and sterile syringe should be used, which has been purchased from a pharmacy and not from another, unreliable source. If this is not possible and the same syringe is to be used by the same person, it should be carefully cleaned and disinfected as described in the following steps [34,35]:
- Fill the syringe from the needle by suctioning cold (not hot), clean water and empty it by pushing the plunger. Repeat the same process several times, until the inside of the syringe is clean from any visible residue.
- Fill the syringe from the needle with insoluble household bleach and shake it or lightly tap it with your finger for at least 30 seconds (the more, the better). Then, empty the syringe by pushing the plunger.
- Refill the syringe from the needle with cold, clean water and empty it by pushing the plunger. Repeat the process a few more times.
It should be emphasized that a disinfected syringe can never be considered as safe as a sterile one. Plastic syringes, usually used for injecting psychotropic substances, are designed for one single use. The process described above reduces the transmission probability of HIV and hepatitis B and C viruses, but does not guarantee that all viral particles have been eliminated or that other microbes do not still survive inside the syringe. In any case, the use of a new, sterile syringe should always be preferred and the above procedure should only be applied in exceptional cases.
Regarding prophylaxis from HIV sexual transmission, see above Preventing HIV sexual transmission.
HIV prevention in everyday life and workplace
- HIV transmission during every day human interaction is extremely rare and mainly concerns cases where the blood of an HIV positive person comes into contact with an open wound or mucus membrane of another person. The chance of HIV transmission in such cases is estimated at 0.1 to 0.3%.
- Taking a few basic measures of protection and personal hygiene is considered adequate to rule out even this quite small chance of transmission.
- If someone thinks that he or she may have somehow been exposed to HIV, he or she can immediately address to a hospital emergency department, where a specialized physician will assess whether or not administration of post-exposure prophylaxis (PEP) is needed.
HIV is, in general, a virus with low transmissibility (see The process of HIV transmission). It is estimated that the transmission probability of the hepatitis B and C viruses is up to 100 and 10 times greater, respectively . It is also known that HIV is a rather fragile virus, with limited ability of survival in the external environment, outside the human body. The ways in which HIV can be transmitted from person to person are well-understood and verified for over 30 years now (see Ways of HIV transmission and non-transmission) and these do not include any of the usual forms of daily social interaction. Intact skin is a protective barrier, impervious to HIV. HIV is not transmitted through the air and is not contained in infectious amounts in saliva, sweat, tears, urine or feces. Thus, transmission is biologically impossible and statistically unlikely through simple physical contact (e.g. touching, shaking hands, hugs), kissing (even deep, prolonged kissing), food or water, insect bites or animal bites, sharing of a toilet or other everyday items (e.g. furniture, cutlery, glasses, bedding, knobs, switches, keyboards) (see HIV transmission > Improbable ways of transmission). Also, for an HIV-positive person that receives systematic antiretroviral treatment (see Treatment of HIV infection) and, as a result, has an undetectable viral load, transmitting the virus in any way is quite unlikely.
All these indicate that every person that may associate, live or work with an HIV-positive person has no reason to worry about a possible transmission. The only – and extremely rare – possibility of HIV transmission during day-to-day (non-sexual) interaction exists, if an HIV-positive person bleeds and an adequate amount of blood comes in direct contact with:
(a) an injury, wound or any other kind of skin discontinuity of another person
In this case, the virus has direct access to the bloodstream through the exposed vessels. The actual HIV transmission probability in this case is very low (estimated at 0.1 to 0.3%), it depends, though, on series of factors, such as the amount of blood with which someone comes in contact, the amount of viral load in it and the depth of the wound .
(b) the ocular or oral mucosa of another person
Transmission in this way is in theory possible, but in practice extremely difficult to occur (the corresponding probability is considered to be less than 0.1%) . Unlike the vaginal, preputial or rectal mucosa, the oral and ocular mucosa is much less susceptible to HIV, as long as there is no other injury or wound. Very few such cases of transmission have been recorded worldwide, over the years.
However, in order for even this extremely low probability of HIV transmission during day-to-day contact to be excluded, taking basic protective measures and caring for personal hygiene, which actually protects people from many other (and much more easily transmittable) infectious diseases and not just from HIV, is sufficient. These are [37,38]:
Do not share items used for personal hygiene (e.g. razors, scissors, toothbrushes), which may cause slight injuries and carry blood residues.
If you are about to go through a medical (e.g. dental or surgical) or cosmetic (e.g. tattooing, body-piercing) procedure, make sure that sterile or disposal equipment is being used.
When providing first aid to someone bleeding:
Make sure to cover your hands by wearing latex gloves and lowering our sleeves, especially if you have wounds or any other skin condition.
In case of a risk of blood being spilled on your face, cover your mouth with a mask and your eyes with glasses.
If you need to exert pressure on a bleeding wound, use a clean cloth as an in-between barrier.
If you are to perform cardiopulmonary resuscitation to a person bleeding from the mouth, use a special mask, if available, or firstly remove as much blood as possible with a clean cloth. First aid administration should in no case be delayed due to fear of contact with the victim’s blood (no case of HIV transmission during CPR has ever been reported).
After providing first aid, wash your hands as soon as possible with plenty of cool (not hot) water and soap, being careful of not touching your eyes.
Cleaning objects and surfaces from blood
Items dirty with blood are fine if washed well, with plenty of cool (not hot) water and soap. If these are sharp objects, be careful not to get injured when handling them.
Blood stained clothes are fine if washed with a standard household detergent at 70oC for at least 25′ or with a detergent, suitable for cold washing at a lower temperature.
- If blood is spilt on the floor or any other surface, it should, first of all, be absorbed by some absorbent material (e.g. paper towels, kitchen towels or other fabrics). Then the surface should be washed with common household bleach dissolved in water, which should be left to act for 10-15′ (alternatively, hydrogen peroxide can also be used).
In case of coming in contact with blood that is (or you do not know if it is) HIV-positive:
If the exposure has occurred through a skin injury, let the trauma mildly bleed without pressing or rubbing it.
Wash the exposed part (wound or mucosa) with plenty of cool (not hot) water and soap, without rubbing it hard or pressing it.
Do not apply antiseptics (their effect on the local immune mechanisms is not known).
If blood has come in contact with your eyes, allow plenty of water to run directly on the eye. If you wear contact lenses, again let plenty of water run before and after removing them.
Prophylactic treatment following HIV exposure
If you believe that there is a strong chance that you have been exposed to HIV, you should contact the emergency department of a hospital as soon as possible (ideally within 2-4 hours and not later than 72 hours), so that a specialist can assess the probability of exposure and, if necessary, provide post-exposure prophylactic treatment (PEP), which can prevent the virus from settling in your body (see below Post-exposure prophylaxis).
The proper use of condom
The use of condom during sexual intercourse is a very effective means of prevention against HIV and most sexually transmitted diseases, as well as a very effective method of contraception. However, the protection offered by a condom depends not only on the condom itself, but also on the way it is used. In other words, in order for the protection offered by the condom to be maximized, it should be used in every sexual intercourse and in the right way. The following is a series of practical rules and tips on the proper use of condom.
Where to pay attention when buying condoms?
Regardless of the brand or type of condoms you prefer, make sure that the condoms have the “CE-mark”, which indicates that they have been manufactured and checked according to the procedures determined by the EU legislation. Otherwise, their safety is not guaranteed.
The use of condoms is safe for a period of 3 to 5 years after they have been released on the market, depending on the manufacturing company. Always check the expiration date on the packaging – the farther it is, the better. Do not use condoms after their expiration date and avoid using condoms that are about to expire.
Prolonged exposure to sunlight or extreme environmental conditions (cold or heat, drought or humidity) alters condom materials, making them less secure. Prefer buying condoms from points of sale, where they are kept in proper conditions (e.g. pharmacies, shops) and not from kiosks or vending machines.
Check the packaging of the condoms and make sure they are intact. If it seems faded, creased, damaged, torn or for any other reason “tainted”, prefer another one.
Conventional broad-line condoms fit most men fine. If, however, they do not cover the entire penis, to its base, or are too narrow, you can look for condoms of bigger size.
A very small percentage of people is allergic to latex, the material of which most condoms are made. For these people, an equally safe alternative are polyisoprene or polyurethane condoms, which are, though, more expensive and more difficult to find.
Where to keep your condoms?
Avoid putting condoms in places where they might be pressed or creased (for example, in tight pant pockets, in the wallet) or leaving them in places where they might be exposed to sunlight, humidity and very high or low temperatures (e.g. inside the glove compartment).
Keep your condoms in places with a relatively steady, cool temperature, away from sunlight, sources of moisture or heat.
Keep condoms available in a place (or places) where they are more likely to be used, so that they can be easily accessible and there would be no need for the sexual act to be disrupted. Also, make sure you have a sufficient supply of condoms, since you may need more than one.
How to put on a condom?
The condom should be used throughout the whole sexual intercourse, so that the exchange of sexual fluids between the two partners can be prevented. The condom must be put on as soon as the penis comes to an erection (not earlier) and before it comes in contact with the partner’s genitals. Respectively, the condom must be removed soon after ejaculation, before the penis relaxes.
Open the condom by gently and carefully tearing the one of the two jagged sides of the wrapper (the straight sides are more difficult to tear and you may damage the condom) (see Figure 1a). Do not use nails, teeth, scissors or anything that can tear the condom.
Before placing the condom on the penis, find the right side of placement from which it is unfolded. If you have any difficulty, you can try unfolding it a little bit before you wear it or lightly blowing inside it. If, however, you have placed it upside down and it has been unfolded with difficulty to a point, remove it and use a new one.
In order to wear the condom, pull the foreskin of the penis back (the skin covering the glans) and place it on the penis (see Figure 1b). Using your index finger and thumb, squeeze the tip of the condom, so that no air remains in the reservoir. This part should have no air, in order to receive the semen after ejaculation. Otherwise, there is a risk for the condom to break (see Figure 1c). Then, gently unfold the condom downwards with your other hand, until it covers the entire penis to its base (see Figure 1d).
If you want to use a lubricant, make sure it is compatible with latex, i.e. it is water-based or silicone-based. Substances that contain oils (e.g. vaseline, baby oil, moisturizing creams) quickly damage latex, causing small and not visible holes.
Never use two condoms at the same time. The friction developing between them may cause splits.
Remove sharp objects you may be wearing that can damage the condom during intercourse, such as jewelry or watches.
If, during intercourse, the penis loses its erection, remove the condom and place a new one when the erection comes back. Similarly, if during intercourse the condom slides or tears, remove it immediately and place a new one.
If penetration lasts for long, the condom is recommended to be replaced with a new one after 30 minutes of use.
How is the condom removed?
After ejaculation and before the penis relaxes, gently withdraw from your partner by holding the base of the condom. If the penis relaxes, while you are still inside your partner, the condom may slip and the semen leak (see Figure 1e).
Remove the condom from the penis with a tissue, so that your hand does not touch the fluids on its outer surface. Then wrap it with the tissue, throw it in a bin (not in the toilet bowl) (see Figure 1f) and wash your hands with soap. Each condom is strictly for one use only.
- Use the condom in every sexual intercourse.
- Use the condom from the beginning of the intercourse until the end.
- Use the condom for any kind of sexual intercourse (vaginal, anal or oral)
- The condom is not a male accessory. Responsibility for its use belongs to both partners.
- The condom is not necessarily a “discord” during the sexual intercourse. Use your imagination to make it a fun and enjoyable part of sexual foreplay.
- If you do not feel familiarized with using a condom, a good idea is to sometimes try and use it on your own, before using it with a partner.
- If you realize the condom has broken or come off during sexual intercourse with someone that is (or does not know if he/she is) HIV-positive, you should as soon as possible contact the emergency department of a hospital, so that a doctor can evaluate if prophylactic treatment is needed (see below Post-exposure prophylaxis).
Testing for HIV
5.1. When and why should I get tested for HIV?
- Every sexually active person should regularly get tested for HIV and other STDs. People that are involved in high-risk behaviors should get tested at least once every year or even more frequently.
- Prompt diagnosis of HIV is crucial both for personal and public health.
- A significant percentage of people living with HIV remain undiagnosed for a long time or are diagnosed at an advanced stage of the disease.
In most cases, HIV infection causes no obvious symptoms for a long period of time, which on average lasts for 8 to 10 years (see The stages of HIV infection). During this time, there is no way for someone to know that he/she is HIV positive, apart from going through a special HIV test. During this same period, though, HIV gradually weakens the immune system, making an individual more and more susceptible to various diseases (see How does HIV affects the immune system?). Moreover, if the same person engages in high-risk behaviors (e.g. condomless sexual intercourse), he or she can transmit the virus to other people.
Early diagnosis of HIV infection is, therefore, critical for both personal and public health. An early diagnosis allows a person to receive antiretroviral treatment on time, before a severe damage is caused to the immune system. In this way, the health of the individual is protected, the life expectancy and quality is improved and the transmission probability of the virus is greatly reduced. In addition, being aware of his/her seropositivity, allows someone to take the necessary precautions in order to avoid passing on HIV to other people.
However, the number of people in the countries of the EU that are diagnosed lately (that is, several years after the infection and at an advanced stage of infection) remains high. 47% of people diagnosed with HIV in 2015 had less than 350 CD4/mm3 cells and 28% less than 200 CD4/mm3 cells  (see Important medical tests). In Greece, 57.9% and 37.2% of people diagnosed with HIV in 2016 had less than 350 and 200 CD4/mm3 cells, respectively .
According to a 2015 US study, it is estimated that 18.1% of people living with HIV in the US is unaware of their seropositivity. It is also estimated that about 30% of all new HIV infections come from this undiagnosed population group. In the countries of the EU, about 15% of the HIV-positive population is considered to be undiagnosed .
Every sexually active person should be regularly tested for HIV (as well as for other sexually transmitted diseases). HIV does not distinguish people and can infect anyone, regardless of gender, age, profession religion, race, ethnicity, sexual orientation or any other personality feature (see above “High-risk groups” and the origins of stigma).
Especially for people who may be involved in high-risk behaviors, European  and Greek  guidelines recommend that testing should take place at least once a year or more frequently (every 6 or 3 months), depending on a person’s degree of possible exposure to HIV. In particular, an HIV screening test is recommended in the following cases:
- to people that believe they may have been somehow exposed to HIV
- to any woman who is or is planning to get pregnant
- to people that have had sexual intercourses (rectal or vaginal) without the use of condom
- to people who inject addictive substances
- to people that have a history of any other sexually transmitted disease (e.g. syphilis, hepatitis B or C), tuberculosis or lymphoma
- to people with an HIV-positive partner
- to people with symptoms similar to those of acute HIV infection
- to victims of rape, sexual abuse, trafficking
- to people coming from countries with high HIV incidence
- to people who have sexual contacts while staying in countries with high HIV incidence or with people coming from countries with high HIV incidence
5.2. How is HIV testing carried out?
- The diagnosis of HIV infection can be made through various laboratory exams that detect the presence of certain biological markers of the virus in the blood serum.
- Most commonly, the initial diagnosis of HIV is made by an ELISA test or a rapid test, both of which detect HIV antibodies in the blood. Every positive initial result must be confirmed by a more specialized screening test (i.e. Western blot, PCR), before an HIV diagnosis is considered definite.
- Each diagnostic test for HIV can detect the presence of the virus in the blood after a certain period of time since the virus’s transmission. This period is usually referred to as “window period”.
The diagnosis of HIV infection is based on the detection of specific biological markers of the virus in body fluids, typically, in the blood serum .
These markers are:
- HIV antibodies (IgG and IgM): these are specific proteins produced by the human immune system in order to fight HIV. Antibodies have the ability to bind to proteins of the virus (the so-called antigens) and to deactivate or decompose them. Antibodies against HIV are produced in increasing quantities already from the first few weeks after infection and remain in the blood for the entire life of the individual. However, their presence can be detected from 3 to 8 weeks after HIV transmission.
- HIV genetic material (RNA): the HIV genome (RNA molecules), the first biomarker that can be detected in the blood, about 9 to 14 days after HIV transmission.
- p24 antigen: it is one of the proteins that form the HIV core (capsid). The concentration of p24 in the blood is, typically, very high during the first weeks after HIV transmission and later decreases to undetectable levels, as the immune system produces antibodies that deactivate it. Thus, p24 antigen is a useful indicator for the diagnosis of recent HIV infection.
There are several available laboratory tests and each of them can detect one or more of the above-mentioned HIV biological markers. However, these biomarkers do not appear in detectable quantities directly after the transmission of the virus. There is always a certain time period between the moment HIV is transmitted to someone and the point when the virus’s presence can be detected in the blood. This is referred to as the “window period”. So, if someone is tested for HIV a few days after transmission (within the window period), it is very likely that the test will be (falsely) negative. If the same test is repeated at a later time (after the window period), it will be (correctly) positive. Depending on which biomarkers are detected by an HIV screening test, there is a respective window period (see below).
The main HIV screening tests are the following:
The HIV immunoassay test, also known as ELISA (enzyme-linked immunosorbent assay), is usually the standard test used for HIV detection in the blood serum. The first generation of ELISA tests, which was essentially the first HIV test to ever be used, was released in 1985. Since then, three more generations of the same test have been developed, with an increasing sensitivity (the probability of the test being positive, if the person is indeed positive to HIV) and specificity (the probability of a test being negative, if the person is indeed negative to HIV).
The 3rd generation ELISA immunoassays can detect the IgG and IgM antibodies that are produced by our immune system against HIV. These can be detected in the blood about 3 to 8 weeks after HIV transmission. The 3rd generation ELISA tests have 100% sensitivity (null probability of a falsely negative result), while their specificity is estimated at 99.8% (0.2% probability of a falsely positive result) .
The 4th generation ELISA immunoassays, which tend to replace the older ones, can detect the p24 antigen, in addition to the IgG and IgM antibodies. This reduces the window period to 2 to 4 weeks after HIV exposure. They have 100% sensitivity and at least 99.7% specificity .
A positive ELISA test always needs to be confirmed by a second test using the Western blot method or, in special cases, molecular techniques for detecting the genetic material of the virus. In Greece, confirmatory tests are only carried out at an AIDS Reference Center (see below). If the result of the ELISA test is negative, it is considered that the person has not been exposed to HIV, unless he/she presents symptoms of acute HIV infection or has a history of recent (less than 8 weeks time before testing) exposure to HIV. These cases should be assessed by an HIV specialist who is in position to recommend if and when a retest should take place. This also applies in the rare cases when the initial test’s result is unclear or weakly positive.
Rapid HIV tests can be used as an initial check for HIV infection, alternative to the ELISA immunoassay. In this case, too, a positive result should always be followed by a confirmatory Western blot test in order for a diagnosis to be made.
The test is carried out by receiving blood from the fingertip, or, more rarely, smear from the gum area. The result is available within a few minutes (less than 20-30′). Rapid tests detect only antibodies against HIV and, thus, just like the 3rd generation ELISA tests, they have a window period lasting for up to 6-8 weeks. Their sensitivity ranges from 99.3% to 100% and their specificity from 99.7% to 99.9% .
Western blot confirmatory test
Any positive ELISA or Rapid Test result should be verified by the Western blot method, before the diagnosis is confirmed . This confirmatory check is carried out only at the specialized National AIDS Referral Centers (see Where can Ι get tested?) and its window period is 5 weeks. The Western blot method is a little bit less sensitive when the exposure to HIV is relatively recent. If it suspected that this is the case (e.g. history of recent exposure or positive 4th generation ELISA test) and the confirmatory test is negative, it can be repeated after 2-3 weeks .
The nucleic acid amplification test (NAT) detects the virus’s genetic material (RNA) in the blood. The most commonly used molecular control method is PCR (polymerase chain reaction). HIV RNA is the earliest presented biomarker of the virus in the blood and, thus, molecular tests have the shortest window period (from 9 to 14 days) . However, they are used for the initial HIV diagnosis only under certain circumstances (e.g. uncertain results of other HIV tests, blood donation, newborns of HIV-positive mothers) because of their high-cost and technical difficulty and their relatively low sensitivity . Molecular testing for HIV is carried out only in specialized AIDS Referral Centers (see Where can I get tested?). The same test is also used for the estimation of the viral load, as part of the standard health check and treatment of people that have been diagnosed with HIV (see Important medical tests).
5.3. Where can I get tested?
Tests for HIV-antibody detection can be carried out free of any charge and anonymously with a simple blood sampling at all national AIDS Reference Centers (see Table 1). Examinations are also available in most public hospitals free of charge or at a low cost, depending on each person’s insurance and the legislation in force. Finally, tests can also be carried out in private hospitals or microbiological laboratories at the expense of the individual.
Anonymous rapid tests are provided for free by various non-governmental organizations, such as Praksis (www.praksis.gr), Checkpoint (www.mycheckpoint.gr) and Doctors of the World (www.mdmgreece.gr).
In case of a positive initial result, a confirmatory test using the Western blot method is required. This is offered only at the National AIDS Reference and Control Centers.
Table 1. AIDS Reference and Control Centers
|AIDS – Cellular Immunity Reference Center||General Hospital of Athens “Evangelismos”, Department of Immunology and Histocompatibility||
|National Center for Sexually Transmitted Diseases & AIDS||Hospital of Cutaneous & Venereal Diseases ‘A. Syggros’||2107249025
|National Retrovirus Reference Center||Medical School of Athens University, Laboratory of Hygiene, Epidemiology & Medical Statistics||
|National AIDS Reference Center of Southern Greece||National School of Public Health, Department of Epidemiology and Biostatistics||
|National AIDS Reference Center of Northern Greece||Medical School of Aristotle University of Thessaloniki, Laboratory of Microbiology||
|AIDS Reference Center||University Hospital of Alexandroupolis, Blood Donation Center||
|National AIDS Reference Center of Southwestern Greece||General Hospital of Patras “Agios Andreas”||
|National AIDS Reference Center of Crete||General Hospital of Heraklion, “Venizelio – Pananio”||
5.4. Information, consent, anonymity and confidentiality
Like any kind of medical act or intervention, HIV-testing is subject to a specific legal framework, which states that:
HIV-testing is voluntary (L.2071/1992, art. 47 and L.3418/2005, art. 12)
No one can be forced into HIV-testing without his/her previous explicit and informed consent.
The only exception is the case in which there is a serious medical indication (i.e. the examination is necessary for the patient’s diagnosis and/or treatment) and urgent need for the examination and the patient is unable to consent.
HIV-testing is mandatory – only after the individual’s informed consent – in case someone wishes to donate blood, sperm, organs or other tissues.
HIV-testing can be anonymous (L.2472/1997)
The test can be anonymous, if the person to be tested wishes so. In this case, no identification documents are required. Only the person’s initials and date of birth are reported in the results documents or some other form of coding is used.
HIV-testing is confidential (L.3418/2005 art. 13 and PC371)
The result of the examination is announced exclusively to the individual tested. Announcement of the result through a letter or e-mail is forbidden.
Health professionals and all staff of the organization that carries out the examination ought to preserve confidentiality of the patient’s medical and sensitive data and reveal no information to any other person that is not involved with the examination and the subsequent treatment.
The doctor avoids, as much as possible, mentioning the diagnosis in various certificates.
Post-exposure prophylaxis (PEP)
- Post-exposure prophylaxis (PEP) is an urgent form of treatment that can prevent HIV transmission to an individual that may have accidentally been exposed to the virus. It includes the administration of an antiretroviral drugs combination for a 4-week period.
- PEP should be administered within 72 hours at the most after the suspected exposure to HIV, ideally, within 2 to 4 hours. Available research data suggest that PEP, if promptly received, can reduce the chance of HIV transmission up to 80-83%.
- The need for PEP administration is always assessed by a specialized physician at a hospital Emergency Department or a Special Infections Unit.
“Post-exposure treatment” or “post-exposure prophylaxis” (PEP) is a form of emergency treatment that can prevent HIV transmission to a person, who might have been exposed to the virus (e.g. if the condom has broken during sexual intercourse or if an injury by an infected object has occurred). The “emergency” definition refers to the fact that this kind of treatment, in order to be effective, should be received as soon as possible after a possible HIV exposure.
Post-exposure prophylaxis is also used in newborn babies of HIV-positive mothers (infant PEP), apart from a series of other preventive measures that are taken, in order to minimize the possibility of the virus being passed on from mother to child.
PEP involves the administration of a combination of antiretroviral drugs for a 4-week period . These drugs can directly block HIV replication mechanisms (see What is antiretroviral treatment?), thus, drastically reducing the ability of HIV to spread from the point of initial infection and systematically settle to other body cells and tissues.
The most significant factor regarding the effectiveness of PEP is timing: the shorter the interval from the time of possible infection to the beginning of treatment, the greater the chance of preventing HIV infection. Ideally, PEP should be administered within 4 hours after possible exposure and certainly not after 72 hours have passed . Within 72 hours at the most, HIV is considered to have infected several CD4 cells in the lymph nodes already and, therefore, to have settled in the body permanently (see The process of HIV transmission).
The research data supporting the clinical efficacy of PEP basically derive from studies on experimental animals [48,49,50] and studies on pregnant women with HIV . Far less studies have been made on occupational exposure to HIV  and even less on sexual exposure or exposure during the use of addictive substances [55,56,57]. Although they are not sufficient in order to draw any firm conclusion, especially regarding sexual exposure or exposure during drug use, the so-far-data indicate that PEP reduces the likelihood of HIV transmission up to 80-83%. On the other hand, cases of seroconversion have been reported, despite PEP administration [58,59,60].
Based on the revised guidelines of the Hellenic Center for Disease Control and Prevention , PEP administration is recommended in the following cases:
Subcutaneous or intramuscular injury by an intravenous or intramuscular needle or some other intravascular device, previously used by an HIV-positive person or a person whose HIV status is unknown ad high-risk factors of HIV infection are present.
Skin injury by a sharp object (e.g. scalpel, needle) that has been previously used on an HIV-positive person.
Simple contact lasting more than 15 minutes of a mucosa or injured skin with a sharp object (e.g. scalpel, needle) that has been previously used on an HIV-positive person.
Anal or vaginal sexual intercourse with an HIV-positive person that has detectable viral load or with a person whose HIV status is unknown but high-risk factors for HIV infection are present.
Receptive oral sex and ejaculation inside the mouth with an HIV-positive person that has detectable viral load.
For intravenous drug users, sharing a syringe, needle and any other work with an HIV-positive person.
In any case, the assessment of the possibility of exposure to HIV and the need for PEP administration should always be made by a specialized physician. So, if someone believes there is a good chance he or she has somehow been exposed to HIV, he/she should immediately contact the emergency department of a hospital, where a doctor will assess the likelihood of HIV exposure and, if necessary, provide an initial PEP scheme (usually less than 3 days long). The person will then be referred to an Infectious Disease Unit as soon as possible, where an HIV specialist will reevaluate the situation and be responsible for the rest of the treatment.
The doctor will consider several factors during the initial assessment of HIV exposure probability and the need for PEP administration, including a detailed description of the way the exposure occurred. It is particularly helpful, if the person believed to have passed on HIV also participates in this initial assessment, so that his or her HIV status can be confirmed and, if HIV-positive indeed, his or her viral load can be measured (if the viral load is undetectable, PEP is usually not recommended) and a genotypic resistance test can be carried out, which will indicate which kind of antiretroviral drugs should be administered, without a the risk of resistance development (see HIV resistance to antiretroviral drugs and HAART). The person who is to receive PEP is immediately subjected to serological testing for HIV (so that the probability of already being HIV-positive without knowing it can be excluded), as well as after 2 and 4 months (so that PEP effectiveness can be determined). In addition, the person is typically tested for other sexually transmitted diseases, such as hepatitis B and C. A pregnancy test is carried out as well in women .
Like almost all drugs, PEP can cause side effects. These usually involve gastrointestinal symptoms, such as nausea, vomiting and diarrhea. Fatigue and weakness can also occur and, much more rarely, changes in liver enzymes values and increased blood lipids (see Possible side effects of antiretroviral treatment).
Finally, it should be mentioned that PEP is an emergency treatment, not a means of prevention on which someone can systematically rely. Under no circumstances should PEP replace other preventive measures and, mainly, the proper use of condom during any sexual intercourse (see above Preventing HIV sexual transmission).
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