HIV Infection - Risk Factors and Prevention Strategies - UpToDate

26/7/2017 HIV infection: Risk factors and prevention strategies - UpToDate
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HIV infection: Risk factors and prevention strategies
Author: Myron S Cohen, MD

Section Editor: John G Bartlett, MD
Deputy Editor: Allyson Bloom, MD
All topics are updated as new evidence becomes available and our peer review process is complete.
Literature review current through: Jun 2017. | This topic last updated: Jun 08, 2017.
INTRODUCTION — Although the incidence of HIV has dropped considerably since the height of the
epidemic, millions of new HIV infections occur globally each year. An understanding of the risk factors for HIV
infection lies at the foundation of successful preventive strategies, which should combine both behavioral and
biomedical interventions to reduce HIV infection risk.
This topic reviews these risk factors and prevention strategies. More detailed discussion on particular
prevention strategies, including pre- and post-exposure prophylaxis for HIV, and prevention of mother-to-child
transmission of HIV are found elsewhere. (See "Pre-exposure prophylaxis against HIV infection" and
"Management of nonoccupational exposures to HIV and hepatitis B and C in adults" and "Management of
healthcare personnel exposed to HIV" and "Antiretroviral and intrapartum management of pregnant HIV-
infected women and their infants in resource-rich settings" and "Prevention of mother-to-child HIV
transmission in resource-limited settings".)
MODES OF ACQUISITION — HIV infection is acquired through sexual intercourse, exposure to infected
blood, or perinatal transmission. The distribution of the modes of transmission of HIV infection varies in
different countries. In the United States, male-to-male sexual contact and injection drug use (IDU) account for
more than half of cases [1]. The estimated lifetime risk of an HIV diagnosis in the United States is 1 in 6 for
men who have sex with men (MSM), 1 in 23 for women with IDU, and 1 in 36 for men with IDU, in contrast to
1 in 241 and 1 in 473 for heterosexual women and men, respectively [2,3].
In contrast, in resource-limited areas, penile-vaginal intercourse is responsible for 70 to 80 percent of HIV

infections, perinatal transmission and IDU account for 5 to 10 percent each, and a smaller but growing
proportion of cases are among MSM [4,5]. Since stigma remains a major problem hindering the study of
MSM in resource-constrained countries, it seems clear that the incidence and prevalence of HIV in MSM in
these settings needs far greater attention. (See "Global epidemiology of HIV infection", section on 'Modes of
transmission driving the epidemic'.)
RISK FACTORS FOR INFECTION — Risk of HIV infection varies by type of sexual or parenteral exposure
(table 1). However, estimates of risk are mostly based on observational studies and are difficult to quantify
since transmission risk also depends on other cofactors that greatly enhance (and occasionally reduce) the
probability of infection [6-8]. As an example, risk factors for HIV transmission include high viral load in the
source patient, and risk factors for HIV acquisition after exposure include sexually transmitted infections
(STIs), and lack of circumcision, as well as certain host and genetic factors [9-11].
Infectiousness of source
Viremia in the source individual — For all modes of transmission, a higher viral load in the HIV-infected
source individual is associated with a greater risk of transmission. Viral load depends on several factors, most
importantly whether the individual is taking antiretroviral therapy (ART) and the stage of HIV disease
[6,12,13]. Individuals with viral suppression on ART rarely if ever transmit infection [12,14,15], whereas the
risk of transmission appears higher during acute than chronic infection in untreated people [6,16].
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In studies of heterosexual couples, those who transmit HIV have higher levels of HIV RNA than those who do
not transmit HIV [6,9,17,18]. As an example, in a study of 415 HIV-serodiscordant couples in Uganda, the
baseline serum viral load was higher among transmitting partners than non-transmitting partners (90,000
versus 38,000 copies/mL, respectively) [9]. For each log increase in viral load, there was a 2.5-fold increase
in the risk of transmission. In contrast, there were no HIV transmission events from HIV-infected partners
whose baseline viral load was <1500 copies/mL, suggesting a threshold viral level for transmission [9].
Accordingly, higher viral load in the genital secretions also increases the probability of HIV transmission [17].
Similar findings have been described for perinatal HIV transmission. (See "Antiretroviral and intrapartum
management of pregnant HIV-infected women and their infants in resource-rich settings", section on 'HIV
viremia and risk of infant infection'.)
The viral load can be very high in patients with acute HIV infection or in those with advanced untreated AIDS
[19]. Acute infection is also associated with increased viral shedding in genital secretions for several weeks
after infection compared with the stable lower levels seen in chronic infection [20]. Accordingly, in several
studies, the risk of transmission of HIV appears highest from patients with acute HIV infection and higher
from patients with late-stage disease (ie, AIDS) compared with chronic infection [19,21-25]. One modeling
study estimated that 38 percent of all HIV transmissions in Malawi were attributable to sexual contact with
acutely infected individuals [21]. A phylogenetic analysis of patients with acute and early HIV infection,
including mostly men who have sex with men, was similarly suggestive of transmission networks during early
infection, with evidence of infection with viruses that could be grouped into closely related clusters [22,23].
Additionally, some animal data also support an increase in viral infectivity during newly-acquired infection
[26].
Virus in genital fluids — In general, lower levels of blood plasma HIV RNA are associated with
decreased genital HIV RNA levels [17]. However, several studies have shown that HIV can still be
intermittently detected in seminal fluid of some HIV-infected men, despite suppression of HIV viremia with
ART [27-31]. HIV can often be detected in the vaginal secretions of women despite the use of ART that
suppresses replication in blood [32,33]. Among men, detectable HIV in the semen despite undetectable
plasma HIV levels has been associated with a concurrent STI or urethritis [30]. However, it is unclear whether
detectable virus in the genital fluid when plasma virus is undetectable poses a significant transmission risk in
serodiscordant couples. A meta-analysis in 5021 heterosexual discordant couples with 461 HIV transmission
events found no evidence of transmission from a HIV-infected partner with treatment-induced viral
suppression, although the number of person years of follow-up was low [12]. (See 'Treatment as prevention
(TaSP)' below.)
Source with unknown HIV status — Often the HIV status of the sexual or injecting partner is unknown.
The probability of HIV acquisition from a source person whose HIV status is unknown is approximated by
estimating the likelihood that the source is HIV-infected multiplied by the likelihood of transmission. As an
example, in the United States, the prevalence of HIV infection in men aged 18 to 39 in the NHANES study
(2003 to 2006) was 0.43 percent [34]. Thus, the estimated risk of transmission following a single random
episode of receptive vaginal intercourse in the United States would be approximated by multiplying 0.0043
times 0.001 for an estimate of 0.0000043 (ie, 1 in ~233,000).
However, specific information about the source may increase the likelihood that the he or she is HIV-infected
(eg, a history of injection drug use). Furthermore, such calculations are completely different in parts of the
world, such as many parts of sub-Saharan Africa, where HIV infection is far more prevalent.
Sexual transmission risk factors — The exact risk of transmission of HIV with sexual exposure is
incompletely defined [6,7,35]. However, the data do suggest that risk of HIV acquisition varies by type of
exposure (ie, sexual acts) [36-41].
The risk of acquiring HIV after rape by an unknown assailant depends on many factors specific to the assault.
This issue is discussed in detail elsewhere. (See "Evaluation and management of adult and adolescent
sexual assault victims".)
Sexual behavior — The risk of HIV transmission varies widely depending on the type of sexual exposure.
In general, exposures that lead to mucosal disruption and bleeding are associated with higher risk than other
exposures. Unprotected anal intercourse conveys the greatest probability of HIV transmission [35]. Other
behavioral factors, such as whether condoms were used, the number of sexual partners, or sex under the
influence of recreational drugs, also affect the overall risk of HIV infection. As an example, in a study of 3257
men who have sex with men (MSM) in six US cities, risk factors for HIV acquisition included history of a large
number of sexual partners, unprotected receptive anal sex with a partner with an unknown HIV serostatus,
and use of nitrate inhalants [42].
The risk of HIV transmission for different types of sexual exposure to HIV in discordant couples has been
estimated using different methods (generally through modeling studies) and cohorts (table 1) [43]
● Receptive anal intercourse – One transmission per 72 sex acts

● Insertive anal intercourse – One transmission per 900 sex acts
● Receptive penile-vaginal intercourse – One transmission per 1250 sex acts
● Insertive penile-vaginal intercourse – One transmission per 2500 sex acts
● Receptive or insertive penile-oral sex – Zero to four transmissions per 10,000 sex acts
However, these risk estimates make it difficult to understand the magnitude of the HIV pandemic. Clinicians
need to be aware that such estimates of risk are often based on studies of monogamous couples, among
whom amplifying factors have been treated and repeated exposure may offer as yet unexplained protection
from infection. There are scant empiric data on per contact risk of exposure. Additionally, differences in
infectivity are also strongly influenced by the presence of other cofactors, such as concomitant genital
ulcerative disease [6]. As an example, some models suggest that rates of HIV transmission may be as high
as one transmission event for every three episodes of insertive anal sex between a male source with late-
stage disease and a susceptible female with genital ulcerative disease [44]. Thus, using a single value for
assessing risk of HIV transmission based on route of sexual exposure fails to reflect the variation associated
with other important cofactors.
HIV transmission among MSM is generally higher than among heterosexual partners. Among heterosexual
partners, male-to-female transmission may be slightly more common (ie, efficient) than female-to-male
transmission, as observed for most STIs. The relative risk of male-to-female compared with female-to-male
HIV transmission was well illustrated in one study of 563 HIV serodiscordant couples (including 156 HIV-
infected females and 400 HIV-infected males), in which 19 male partners and 82 female partners acquired
HIV during the course of observation [45]. This study suggested that male-to-female transmission was 1.9
times more efficient (95% CI 1.1-33) than female-to-male transmission.
Notably, female-to-female sexual transmission of HIV has only rarely been reported [46,47].
Lack of circumcision — HIV acquisition rates among uncircumcised males are higher than for
circumcised males. The biologic basis for this observation may be related to a high density of HIV target cells
in male foreskin, including Langerhans cells and macrophages [48]. Randomized controlled trials in Africa
have demonstrated that circumcision reduces the risk of female-to-male HIV transmission by 50 to 60 percent
[49-52], and this benefit is sustained [52]. However, male circumcision of HIV-infected men does not appear
to decrease the risk of HIV transmission to the female partner, and efficacy in men who have sex with men
has not been demonstrated. (See 'Male circumcision' below.)
Sexually transmitted infections — Concurrent sexually transmitted infections (STIs) have been long
known to increase the risk of both acquiring and transmitting HIV infection. The increased risk is widely
acknowledged for STIs that cause genital ulcer disease but is also described with other STIs [53]. It has also
been associated with the change in vaginal flora that characterizes bacterial vaginosis [54,55].
Several studies have demonstrated an increased incidence of HIV infection among patients with genital
ulcerative diseases, such as herpes simplex virus and syphilis [19,56,57]. As an example, in a study of 174
monogamous Ugandan couples with discordant HIV serostatus, the probability of transmission was
approximately four times higher in patients with genital ulceration compared to those without [19]. The effect
of these infections on HIV risk is discussed in detail elsewhere. (See "Epidemiology, clinical manifestations,
and diagnosis of genital herpes simplex virus infection", section on 'HSV-2 and risk of HIV transmission' and
"Epidemiology, clinical presentation, and diagnosis of syphilis in the HIV-infected patient", section on 'HIV
transmission'.)
Increased risk of HIV is not limited to STIs that cause genital ulcer disease. In a prospective study of 242
South African women with high-risk sexual behavior, 28 became infected with HIV over 24 months [58].
Presence of a concurrent STI was associated with an increased risk of infection with HIV (hazard ratio [HR]
3.29, 95% CI 1.5-7.2). The incremental risk for HIV infection with Neisseria gonorrhoeae infection was
greater than that with other infections (Chlamydia trachomatis, Mycoplasma genitalium, Trichomonas
vaginalis). The majority of women with STIs were asymptomatic.
Genetic background — Similarity of HLA-class-I alleles between HIV discordant couples may affect the
risk of transmission by resulting in selected viral strains that are more likely to escape the immune
containment of the uninfected partner. In a study of serodiscordant couples, sharing of HLA-B alleles was
associated with accelerated transmission of HIV after controlling for other variables (HR 2.23, 95% CI 1.52 to
3.26) [11]. (See "Human leukocyte antigens (HLA): A roadmap".)
Hormonal contraceptive use — Some studies have raised concern that certain hormonal contraceptive
methods, specifically depot medroxyprogesterone acetate (DPMA), are associated with an increased risk of
HIV acquisition, although data are mixed. These studies are discussed elsewhere. (See "Depot
medroxyprogesterone acetate for contraception", section on 'Effect on HIV acquisition and transmission' and
"HIV and women", section on 'Risk factors for HIV acquisition'.)
Other factors — There has also been increased interest in defining specific vaginal fluid cytokine profiles
that are associated with and could serve as a marker for increased risk of HIV infection [59,60].
Bloodborne transmission risk factors — The risk of transmission of HIV infection following inadvertent
exposure varies widely depending upon the type of exposure.
The risk of HIV infection has been estimated for different types of bloodborne exposure to a HIV-infected
source (table 1) [8,61,62]:
● Blood transfusion – nine infections per 10 exposures

● Needle or syringe sharing – one infection per 150 exposures
● Percutaneous needle-stick – one infection per 435 exposures
● Mucous membrane exposure to blood (eg, splash to eye) – one infection per 1000 exposures
● Other exposure (eg, human bite) – one infection per 25,000 exposures
Studies on needlestick injuries in the health care setting have identified certain characteristics of injury that
are associated with increased risk of HIV infection [63]. These include a deep injury, injury with a device that
was visibly contaminated with the source individual's blood, injury with a needle that had been placed in a
vein or artery, and terminal illness in the source individual. The volume of blood contributes to the probability
of transmission since the reported risk of HIV acquisition after transfusion with a contaminated unit of blood
ranges from 88 to 100 percent [8]. With the current screening procedures for donated blood, this risk is
vanishingly small (see "Blood donor screening: Laboratory testing", section on 'HIV-1 and HIV-2'). In the
United States, between 2000 and 2013, there has only been a single confirmed case of occupationally-
acquired HIV infection among health care personnel, in a laboratory technician who had a needle puncture
while working with live HIV culture [64].
The risk of HIV may be higher among individuals who inject drugs than is reflected by the risk of needle
sharing. Many individuals who use injection drugs also participate in sexual behavior, such as unprotected
sex and sex with multiple partners, that incrementally increases the risk for HIV infection [65].
Perinatal transmission risk factors — This is discussed in detail elsewhere. (See "Antiretroviral and
intrapartum management of pregnant HIV-infected women and their infants in resource-rich settings" and
"Prevention of mother-to-child HIV transmission in resource-limited settings".)
EFFICACY OF PREVENTION STRATEGIES
Post-exposure prophylaxis — For individuals who have a discrete high-risk exposure to HIV, post-exposure
prophylaxis with an antiretroviral-based regimen is an effective strategy to reduce the risk of infection. This is
discussed in detail elsewhere. (See "Management of healthcare personnel exposed to HIV" and
"Management of nonoccupational exposures to HIV and hepatitis B and C in adults".)
Pre-exposure prophylaxis — For individuals who are at ongoing high risk for HIV infection, pre-exposure
prophylaxis with an antiretroviral-based regimen is an effective strategy to reduce the risk of infection. This is
discussed in detail elsewhere. (See "Pre-exposure prophylaxis against HIV infection".)
Treatment as prevention (TaSP) — Treatment as prevention refers to the concept that successfully treating
HIV with antiretroviral therapy (ART) minimizes the risk of transmission by decreasing the HIV plasma viral
load, and it assumes the potential of a population level benefit.
The efficacy of treatment as prevention was best demonstrated in a large trial (HPTN 052) that included 1763
HIV serodiscordant heterosexual couples from 13 sites in 9 countries in Africa, Asia, South America, and
North America [13,66]. The serodiscordant couples were randomly assigned to an "early ART" arm (initiation
of HIV treatment at enrollment) or "delayed ART" arm (initiation of HIV treatment when the CD4 count
dropped to less than 250 cells/microL or after an AIDS-related illness). ART consisted mainly of zidovudine,
lamivudine, and efavirenz. After 1.7 years of follow-up, interim analysis demonstrated that early ART
substantially reduced the risk of HIV transmission to the partner compared with delayed ART (1 versus 27
linked transmissions, as determined by viral sequencing; HR 0.04, 95% CI 0.01-0.26). Following these
results, ART was offered to the HIV-infected participants in the delayed ART group who had not yet initiated
it; by the end of the study, 96 percent of the delayed group had started on ART. After a median of 5.5 years
and 8904 couple-years of follow-up, the prevention benefits were sustained:
● A total of 46 linked transmissions were identified. Three occurred in couples originally assigned to the
early ART group compared with 43 in the delayed ART group (93 percent risk reduction with early ART).
A total of eight linked transmissions occurred after the HIV-infected partner had initiated ART, but they
either occurred within three months of ART initiation or in the setting of ART failure. Thus, no linked
transmission events occurred when the HIV-infected partner had achieved stable viral suppression on
ART.
● There were an additional 16 HIV infections in each group. Of these, 14 in the early ART group and 12 in
the delayed ART group were determined by viral sequencing to be genetically unlinked (ie, the source
was not the individual's documented partner). An additional six infections (two in the early ART and four
in the delayed ART group) could not be sequenced for technical reasons.
● Overall, the incidence of HIV infection in the study was low (0.9 percent per year overall and 2.2 events
per 100 person years in the delayed ART group at the interim analysis), which potentially reflects other
risk reduction strategies in this study. All participants received condoms and risk reduction counseling.
Complete adherence to condom use was independently associated with a reduced risk of both linked
and unlinked HIV infections.
The efficacy of ART in reducing the risk of HIV transmission to an uninfected sexual partner has also been
supported by several observational studies among heterosexual discordant couples [14,15,67-74]. As an
example, in a large retrospective study of almost 39,000 such couples in China, the incidence of HIV infection
among uninfected partners was lower if the infected partner was on ART versus untreated (1.3 versus 2.6
infections per 100 person years, respectively, adjusted HR 0.74, 95% CI 0.65–0.84) [69]. Similarly, in a large
population-based prospective cohort study of HIV-uninfected individuals in rural KwaZulu-Natal, South Africa,
where transmission is predominantly through heterosexual sex, HIV infection risk was lower in communities
with high ART coverage compared with areas of low ART coverage [75]. Such ecological studies, which
examine relationships between exposures and outcomes at the group level, have a number of
methodological challenges, including selection bias, confounding, and assumptions about the time lag of
effects, which limit the ability to link the exposure to the outcome for the individual [70,76]. Nevertheless,
these results indicate the importance of ART as a prevention strategy.
Although most studies of treatment as prevention have included condom use counseling as part of the
preventive strategy, studies evaluating serodiscordant couples who specifically do not use condoms also
suggest that successful ART prevents transmission [15]. These data are discussed elsewhere. (See
'Counseling on condom use' below.)
The efficacy of treatment as prevention is also reflected in the reduction in the rate of mother-to-child
transmission of HIV with successful ART of the mother during pregnancy and delivery. (See "Antiretroviral
and intrapartum management of pregnant HIV-infected women and their infants in resource-rich settings",
section on 'Efficacy of ART in preventing transmission' and "Prevention of mother-to-child HIV transmission in
resource-limited settings", section on 'Efficacy of maternal ART in preventing transmission'.)
Data on the efficacy of ART to prevent transmission in populations at risk for other modes of transmission (ie,
men who have sex with men [MSM] or injection drug users) are more limited. Several observational studies
have suggested that ART prevents sexual transmission among MSM [15,77]. As an example, a study of 234
MSM serodiscordant couples in Australia, Thailand, and Brazil did not detect any linked transmission over 88
couple years during which the infected partner was on suppressive ART [77].
Test and treat — Some modeling studies have suggested that biomedical interventions could have a
significant impact on decreasing HIV transmission in HIV endemic countries [78-80]. In one model, it was
assumed that all patients in Africa 15 years of age or older were tested for HIV infection and all newly
diagnosed patients were immediately started on ART [78]. With this "test-and-treat" strategy, the model
estimated that the incidence of HIV would decline to 1 case per 1000 persons within 10 years. Emerging data
on decreased HIV transmission with effective HIV treatment suggest that any cost-analysis of ART must
consider the benefits of HIV therapy not only on overall morbidity and mortality but also on HIV transmission
risk [81,82]. One analysis that took both these effects into account suggested that ART initiation at
presentation (versus waiting until CD4 cell count decreased to below 250 cells/mm3) would be very cost-
effective in resource-limited settings over the scope of a patient's lifetime [83].
Modeling exercises must also try to account for acute HIV infection, but the extent of the role of acute
infection in driving the HIV epidemic is an area of controversy [84-86]. Patients with acute HIV infection are
hard to identify, have high viral load, and may be at the center of HIV transmission clusters (especially among
MSM). If acute HIV infection plays a substantial role in incident infections, then test and treat strategies alone
cannot realize maximal success.
Other concerns about population level prevention are travel and mixing of populations. As an example, one
study used viral phylogenetics and spatial clustering statistics to demonstrate that a fair proportion of new
infections in Rakai, Uganda were introduced from outside the community, including from HIV-infected
individuals in a fishing village [87]. Treatment of HIV-infected individuals in a given community could not be
expected to reduce incident infections that resulted from outside visitors.
To determine the population level benefit of early treatment, community-based trials in Botswana, South
Africa, Zambia, and Uganda have been launched [88]. In one of these, HIV status was ascertained for over
23,000 people in defined study communities in South Africa [89]. The communities, among which 7630 (33
percent) HIV-infected individuals were identified, were randomly assigned to clinics where ART was given
immediately (intervention) or according to national guidelines (control). Although there was no difference in
the incidence of HIV infection between the intervention and control communities, this was likely because of
insufficient ART coverage overall (baseline 32 percent, increasing to 54 percent by the end of the trial),
similar ART coverage in the arms of the study due in part to evolving national guidelines resulting in earlier
treatment, and the limited number of men treated.
Nevertheless, emerging evidence from other community-based trials has supported the feasibility of a test
and treat strategy. In an observational analysis of a trial from Uganda and Kenya, initiation of annual HIV
screening and immediate linkage to care for ART initiation among a cohort of over 75,000 residents were
associated with increases in the proportion of HIV-infected individuals who were diagnosed (65 percent at
baseline to 96 percent two years later), in the proportion of diagnosed patients who initiated ART (80 to 93
percent), and in the proportion of the total HIV-infected population who achieved viral suppression (45 to 80
percent) [90]. The impact of the test and treat intervention on HIV incidence within those communities is yet
to be determined.
Condom use — Consistent condom use effectively decreases the risk of sexual HIV transmission and
acquisition [91-94]. In 2009, a collaborative statement from the American College of Physicians and the HIV
Medicine Association called for wider availability of condoms and education about their proper use to
minimize the risk of HIV transmission [94]. In order for condom use to be effective in decreasing HIV
prevalence, they need to be used consistently and with ongoing exposures, particularly in areas of high
prevalence.
The majority of evidence for condom effectiveness is from observational studies. In a meta-analysis of 12
studies of HIV heterosexual serodiscordant couples, condom usage was classified in three categories:
always, sometimes, or none [91]. HIV infection rates were much higher in those who never used condoms
versus those who always did (6.7 versus 0.9 infections per 100 person years). A subsequent analysis of
these studies suggested that condoms are 90 to 95 percent effective when used consistently [95]. A similar
Cochrane review estimated that the consistent use of male latex condoms, defined as using a condom for all
acts of penetrative vaginal intercourse, reduces HIV incidence by 80 percent, based on several longitudinal
female-to-male and male-to-female serodiscordant couples [93]. Additionally, in a trial of ART to reduce HIV
transmission within serodiscordant couples, a self-report of "100 percent use" of condoms compared with
"less than 100 percent use" was associated with decreased HIV transmission (HR 0.35; 0.14-0.88) [66].
These clinical studies are consistent with the in vitro finding that latex and polyurethane condoms are
impenetrable to HIV viral particles [96].
Since women are often unable to convince their partners to use a condom, there is a need to assess other
barrier methods that women can initiate. Female condoms are also impervious to viruses, including HIV;
however, there are few clinical data regarding efficacy in prevention of HIV transmission [97].
Male circumcision
HIV infection in heterosexual men — Male circumcision reduces the risk of heterosexual men becoming
infected with HIV. Voluntary male medical circumcision is generally safe, but rare cases of tetanus following
circumcision have been reported in locations where uptake of infant tetanus immunization is low [98,99]. (See
"Tetanus".)
The efficacy of male circumcision to protect that male against HIV infection has been established by several
randomized, controlled trials of circumcision conducted in Africa [49-51]. In these trials, men were randomly
assigned to an intervention group, in which immediate circumcision was offered, or a control group, in which
circumcision was delayed until the end of the study. In all cases, circumcisions were performed by clinicians
experienced in the procedure and were rarely associated with moderate or severe adverse effects. These
three trials were all ended early because of evidence of reduced HIV incidence in the intervention groups:
● In a trial in Orange Farm, South Africa, circumcision reduced the risk of HIV infection by 60 percent
among 3274 men aged 18 to 24 years (20 versus 48 new infections in the circumcision and control
groups, respectively, after a mean follow-up of 18 months) [49]. The investigators controlled for
behavioral factors, condom use, and health-seeking behaviors.
● In a trial in Kisumu, Kenya, circumcision reduced the risk of HIV infection by 53 percent among 2784
men aged 18 to 24 years (22 versus 47 new infections in the circumcision and control groups,
respectively, after a median follow-up of 24 months) [50].
● In a trial in Rakai, Uganda, circumcision reduced the risk of HIV infection by 51 percent among 4996
men aged 15 to 49 years (0.66 versus 1.33 new infections per 100 person years in the circumcision and
control groups, respectively, over 24 months) [51]. Following trial closure, the majority of uncircumcised
men underwent circumcision. After five years, circumcision remained associated with a lower HIV risk
(0.5 versus 1.93 new infections per 100 person years in circumcised and uncircumcised men,
respectively) [52].
Population studies in Africa following wider availability and encouragement of voluntary medical male
circumcision have also suggested an association between circumcision and reduced incidence of HIV
infection and have continued to demonstrate safety of the practice [100-102].
Data from the United States are limited. One study examined visit records of heterosexual African-American
men who underwent HIV testing while attending STI clinics in Baltimore from 1993 to 2000 and analyzed the
association between circumcision and the risk of HIV infection [103]. "Known" HIV risk was defined as patient
notification by either their sexual partner or by an intervention specialist from the partner notification system
of recent HIV exposure. Among 394 visits by patients with known exposure, circumcision was associated with
lower HIV prevalence (10.2 percent versus 22 percent; adjusted prevalence rate ratio, 0.49 [95% CI 0.26-
0.93]). In the United States, however, the majority of sexually-acquired HIV infections are among men who
have sex with men (MSM), among whom circumcision does not have established benefit with regard to HIV
risk. (See 'HIV infection in MSM' below.)
Any policy to promote circumcision to protect against HIV infection needs to take into account cultural and
human rights considerations, the risk of complications from the procedure performed in various settings, the
prevalence of infection, and the potential to undermine existing protective behaviors and prevention
strategies that reduce the risk of HIV infection [50,104]. Results from observational studies of men who
underwent circumcision suggest that this prevention intervention is not necessarily offset by an adverse
behavioral impact [105,106]. One study compared sexual behaviors of 324 recently circumcised and 324
uncircumcised Kenyan men at 1, 3, 6, 9, and 12 months after study enrollment [105]. Circumcised men did
not engage in more risky behaviors.
HIV infection in women — Although male circumcision reduces HIV acquisition in men, studies have not
demonstrated a reduction in HIV acquisition among female sexual partners of HIV-infected men who undergo
circumcision. Results of these studies suggest that HIV transmission from men to their sexual partners
reflects the HIV concentration in genital secretions (ie, semen) rather than exposure to the uncircumcised
glans penis.
In a trial from Uganda, 922 HIV-infected men with CD4 cell counts ≥350 cells were randomly assigned to
immediate versus delayed circumcision for 24 months [107]. Circumcision did not reduce HIV transmission to
the HIV-uninfected female sexual partners; over a 24-month period, the cumulative probability of female
acquisition of HIV was 22 percent in the intervention group and 13 percent in the control group (adjusted HR
1.49; 0.52-3.57). In addition, excess HIV transmission occurred within the first six months in the male
circumcision arm, particularly among those who resumed intercourse prior to wound healing. These findings
suggest sexual abstinence or condom use should be strongly advised until surgical recovery (estimated at six
weeks).
HIV infection in MSM — To date, no randomized controlled studies of male circumcision for HIV
prevention have been conducted among MSM. Observational studies have suggested a possible but
uncertain protective effect. Because some (but not all) MSM engage in both insertive and receptive anal
intercourse, it is difficult to conduct studies to show a benefit of circumcision in this setting.
In a meta-analysis performed of 15 observational studies among 53,567 MSM (52 percent of whom were
circumcised), the odds of being HIV-infected were 14 percent lower among the circumcised men, but the
difference was not statistically significant [108].
Counseling and harm reduction strategies — Risk-reduction counseling and harm reduction strategies
can reduce behavior that results in higher risk of HIV infection. Risk-reduction counseling ranges from high-
intensity behavioral discussion tailored to an individual's risk to brief prevention messages to group-based
strategies [109,110].
Individuals report greater condom use and fewer sexual partners with behavioral risk-reduction interventions,
and some studies report that counseling decreases risk of sexually transmitted infection (STI), including HIV
[111,112]. The precise efficacy of risk-reduction counseling may depend, in part, on how it is conducted. (See
"Prevention of sexually transmitted infections", section on 'Risk reduction counseling'.)
For injection drug users, harm reduction interventions, such as voluntary opioid substitution therapy and
needle exchange programs, can reduce risky injection behavior. Opioid substitution therapy is associated
with decreased illicit opioid use, injecting use, and sharing injection equipment [113]. Needle exchange or
supervised injection programs have also been associated with decreased needle reuse and sharing, safe
syringe disposal, and more hygienic injection practices [114]. Although these strategies have not been
evaluated in high-quality trials, observational and modeling studies suggest that they are associated with
decreases in HIV infection [113,115,116]. Treatment of opioid addiction with buprenorphine/naltrexone is also
associated with increased use of and adherence to ART among HIV-infected individuals [117].
Treatment of sexually transmitted infections — "Classical" sexually transmitted infections (STIs) that
cause ulcers or mucosal inflammation are strongly associated with HIV transmission [53]. However, it has
been difficult to reliably demonstrate the benefits of STI treatment for HIV prevention [118]. Screening and
treatment of STIs in at-risk individuals are important for general sexual health. (See "Screening for sexually
transmitted infections", section on 'Introduction'.)
Population-based studies have generally been unable to show a decrease in HIV incidence with treatment or
prevention of STIs [119,120]. It is generally concluded that STI treatment to prevent HIV infection requires
treatment of just the right STI pathogen, at just the right time, with effective agents, goals that are not readily
achieved. Additionally, the findings in these studies may reflect problems with methodology, patient
adherence, and overlapping interventions in the control group in these studies as opposed to a true lack of
preventive benefit with STI treatment [118]. This is also discussed in more detail elsewhere. (See "Effect of
herpes simplex virus on HIV infection: Implications for HIV prevention".)
Experimental approaches — A vaccine to prevent HIV infection has been an elusive goal of HIV research.
Despite several candidates, an effective HIV vaccine has yet to be developed. One vaccine tested in
Thailand demonstrated some short-lived protection from HIV, which was ascribed to antibody dependent
cytotoxicity [121]. Noteworthy HIV vaccine trials are discussed elsewhere. (See "Immunology of HIV-1
infection", section on 'HIV vaccine development'.)
More recently, discovery and characterization of antibodies that neutralize a large number of strains of HIV
have generated hope that such antibodies can be delivered or generated in some way to provide long-acting
prevention from HIV [122-125].
Other experimental approaches include development of antiretroviral agents (eg, long-acting forms) intended
to improve outcomes with antiretroviral treatment or pre-exposure prophylaxis. (See "Overview of
antiretroviral agents used to treat HIV" and "Pre-exposure prophylaxis against HIV infection".)
CLINICAL APPROACH TO HIV PREVENTION — A comprehensive approach to HIV prevention includes

risk reduction among HIV-infected individuals to reduce transmission and among at-risk individuals to reduce
acquisition. Biomedical interventions (such as the antiretroviral-based strategies of treatment as prevention
and pre- and post-exposure prophylaxis, as well as voluntary medical circumcision for uninfected
heterosexual males) are proven and highly effective in reducing HIV infection. Nevertheless, behavioral
interventions (such as condom use and risk-reduction counseling) remain crucial elements of prevention, and
most studies of biomedical interventions included continued emphasis on behavioral modification. While no
single behavioral intervention is perfectly effective, in aggregate, it is believed that such interventions have
reduced the spread of HIV in some populations. The magnitude of the epidemic without such interventions
cannot be predicted.
Accordingly, the following section discusses how certain aspects of biomedical and behavioral interventions
are combined for a patient-specific approach. This discussion is generally consistent with recommendations
on HIV prevention from multiple expert organizations [126-128]. Discussion of the studies supporting the
individual prevention strategies is found elsewhere. (See 'Efficacy of prevention strategies' above.)
HIV-infected individuals — Preventing transmission of HIV from infected individuals relies on engaging and
maintaining HIV-infected patients in care, initiating antiretroviral therapy (ART) early, maintaining successful
therapy, and reducing behavioral risk factors.
Antiretroviral treatment — Suppression of plasma viremia with ART effectively minimizes the risk of
sexual [15,66,67,129] and perinatal HIV transmission and likely does the same for other modes of
transmission. Thus, ART is a key strategy to curb the spread of HIV. (See 'Treatment as prevention (TaSP)'
above.)
In the United States, ART initiation is recommended for all HIV-infected patients, regardless of CD4 cell
count, to decrease AIDS and non-AIDS associated morbidities and mortalities [126,130]. Prevention of HIV
transmission is an additional rationale for the more widespread use of ART. For resource-limited settings, the
World Health Organization (WHO) has also recommended ART initiation for all HIV-infected patients,
regardless of CD4 cell count or clinical stage, given the mounting evidence of the clinical benefit of ART, even
at high CD4 cell counts [131,132], and the reduction in the risk of transmission to uninfected partners with
successful ART [127]. (See "When to initiate antiretroviral therapy in HIV-infected patients" and "The impact
of antiretroviral therapy on morbidity and mortality of HIV infection in resource-limited settings", section on
'Recommendations from the World Health Organization'.)
Successful administration of ART relies upon public health measures to optimize timely linkage of newly
diagnosed HIV-infected individuals with medical care and retaining them in care. Treatment success also
relies on patient adherence to medication, which can be facilitated by reductions in pill burden, looser dosing
frequency, and ongoing counseling to assess and encourage ART adherence.
Counseling on condom use — All HIV-infected patients who are not on stable ART should use condoms
to reduce the risk of sexual transmission. For HIV-infected individuals with durable viral suppression on ART,
the risk of transmission to an uninfected sexual partner is negligible [13,67,133]. Nevertheless, we counsel
such patients that consistent condom use remains prudent for the following reasons:
● Although "negligible," the risk of sexual transmission from a virally suppressed individual cannot be
completely ruled out. Most trials of HIV "treatment as prevention" in heterosexual discordant couples
included condoms in the prevention package so the benefits of ART could not be disaggregated from the
potential benefit(s) of condoms. (See 'Treatment as prevention (TaSP)' above.)
Subsequent studies have evaluated the risk of sexual transmission in the absence of condom use. In a
prospective observational study of serodiscordant (548 heterosexual and 340 MSM) couples who chose
not to use condoms and among whom the HIV-infected partner was virally suppressed on ART (<200
copies/mL), there were no documented intra-couple transmission events after more than 1200 couple-
years of follow-up [15]. One heterosexual and ten MSM partners acquired HIV infection during the study
https://www.uptodate.com/contents/hiv-infection-risk-factors-and-prevention-strategies/print?source=search_result&search=hiv%20transmissio… 10/23
period, but viral sequence analysis suggested that these infections were not transmitted from the long-
term HIV-infected partner. However, the potential for intra-couple HIV transmission risk could not be
completely ruled out by this study (95% CI 0-0.30 for any sex and 0-0.71 for anal sex). Furthermore,
there was some uncertainty as to whether the sequencing analysis in this study could completely rule out
linked infection [134].
● Condoms effectively protect against other sexually transmitted infections (STIs), which are common
among HIV-infected individuals, regardless of ART [135].
● Condoms offer protection from HIV transmission in case the HIV-infected partner has loss of virologic
suppression.
Risk reduction — Routine assessment of ongoing risk behavior should be performed, and counseling on
reducing those risks should be individualized.
For injection drug users, addiction treatment (eg, with opioid substitution or with buprenorphine-naltrexone)
and participation in needle exchange programs, if available, are additional useful strategies to decrease risk
behavior and, likely, HIV transmission. (See 'Counseling and harm reduction strategies' above.)
Finally, we screen and treat STIs in HIV-infected individuals given the increased risk of STIs in this
population, the association of STIs with HIV transmission, and the benefit of treating STIs beyond potential
HIV prevention [135]. (See 'Treatment of sexually transmitted infections' above and "Screening for sexually
transmitted infections", section on 'HIV-infected patients'.)
Individuals at risk for HIV
Identifying new infections — Identifying HIV-infected individuals is crucial to directing interventions to

prevent transmission. Thus, HIV testing is a major element of comprehensive preventive strategies. In
particular, acutely infected individuals, who often have exceptionally high levels of viremia, have been
identified as major sources of transmission (see 'Viremia in the source individual' above). Testing strategies
should employ diagnostic tests that are highly sensitive for acute infection and should include routine
screening for all individuals with repeat testing of individuals with high ongoing risk for HIV. (See "Screening
and diagnostic testing for HIV infection".)
Once HIV infection has been diagnosed or excluded, preventive efforts for that patient can be individualized.
(See 'HIV-infected individuals' above and 'Risk reduction' below.)
Risk reduction — In uninfected individuals, preventing acquisition of HIV focuses on reducing behaviors
that increase the risk of infection and utilizing antiretroviral-based prophylactic strategies. In areas where the
prevalence of HIV is high and sexual transmission is primarily among heterosexuals, voluntary medical
circumcision is another important strategy.
All uninfected patients should be assessed for their risk of HIV infection, and counseling on reducing those
risks should be individualized.
● For all patients at risk for HIV infection, we continue to advise consistent condom use. (See 'Condom
use' above.)
We also recommend screening and treatment of STIs in individuals at risk for HIV given the shared risk
factors for HIV and other STIs, the association of other STIs with HIV infection, and the benefit of treating
STIs beyond potential HIV prevention [135]. (See 'Treatment of sexually transmitted infections' above
and "Screening for sexually transmitted infections", section on 'Screening recommendations'.)
● For injection drug users, addiction treatment (eg, with opioid substitution or buprenorphine-naltrexone)
and participation in needle exchange programs, if available, are additional useful strategies to decrease
risk behavior and, likely, HIV acquisition. (See 'Condom use' above and 'Counseling and harm reduction
strategies' above.)
● For those who have high ongoing risk for HIV infection, daily pre-exposure prophylaxis with tenofovir-
emtricitabine effectively reduces the risk of infection.
● For those who have had a mucosal or parenteral exposure to HIV within the prior 72 hours, post-
exposure prophylaxis with an antiretroviral regimen is associated with a reduced risk of infection. (See
"Management of nonoccupational exposures to HIV and hepatitis B and C in adults", section on
'Exposure to HIV' and "Management of healthcare personnel exposed to HIV", section on 'Post-exposure
prophylaxis'.)
Circumcision has demonstrated efficacy in reducing the risk of HIV infection among heterosexual men. WHO
and the Joint United Nations Programme on HIV/AIDS (UNAIDS) recommend scaling up voluntary male
circumcision as a HIV prevention intervention in several African countries with high rates of HIV and low
baseline rates of male circumcision. In the United States and Europe, where sexual transmission among men
who have sex with men (MSM) is dominant, circumcision has not demonstrated substantial benefit. (See
'Male circumcision' above.)
Serodiscordant couples — The term “serodiscordant couples” refers to ongoing sexual partnerships
between an HIV-infected and an uninfected individual. Prevention strategies for HIV-infected and at-risk
individuals are thus relevant to each of the members of the serodiscordant couple, respectively. (See 'HIV-
infected individuals' above and 'Individuals at risk for HIV' above.)
HIV transmission can be reduced with ART for the HIV-infected partner [13,66] and with pre-exposure
prophylaxis for the uninfected partner [136]. For all HIV-infected patients in a serodiscordant partnership, we
recommend initiation of ART in order to prevent transmission to the uninfected partner (see 'Treatment as
prevention (TaSP)' above). No studies have directly compared the two strategies for HIV prevention, but ART
for the HIV-infected partner has the additional benefit of reducing the AIDS and non-AIDS morbidity and
mortality for that individual [66]. Pre-exposure prophylaxis for the HIV-uninfected partner may be indicated
until the infected partner has achieved stable viral suppression on ART (typically by six months after initiating
therapy [137,138]), if ART fails to suppress HIV in the infected partner for any reason, and for risk-taking
behavior outside the partnership. (See "Pre-exposure prophylaxis against HIV infection".)
Counseling on condom use and other risk reduction strategies is discussed elsewhere. (See 'Counseling on
condom use' above and 'Risk reduction' above.)
Options for serodiscordant couples desiring pregnancy are also discussed elsewhere. (See "Use of assisted
reproduction in HIV- and hepatitis-infected couples", section on 'Natural conception in serodiscordant
couples'.)
Pregnant and breastfeeding women — Prevention of mother-to-child transmission of HIV involves ART for
the pregnant woman and post-exposure prophylaxis for the infant. Precise management differs in resource-
rich and limited settings and is discussed elsewhere. (See "Antiretroviral and intrapartum management of
pregnant HIV-infected women and their infants in resource-rich settings" and "Prevention of mother-to-child
HIV transmission in resource-limited settings" and "Prevention of HIV transmission during breastfeeding in
resource-limited settings".)
SOCIETY GUIDELINE LINKS — Links to society and government-sponsored guidelines from selected
countries and regions around the world are provided separately. (See "Society guideline links: HIV
prevention".)
SUMMARY AND RECOMMENDATIONS
● HIV infection is acquired through sexual intercourse, exposure to infected blood, or perinatal
transmission. For all modes of transmission, a higher viral load in the HIV-infected source individual is
associated with a greater risk of transmission. (See 'Modes of acquisition' above and 'Viremia in the
source individual' above.)
● The risk of sexual transmission of HIV varies widely depending on the type of exposure. In general,
exposures that lead to mucosal disruption and bleeding are associated with higher risk than other
exposures. Unprotected anal sex conveys the greatest probability of HIV transmission and oral sex the
lowest. Lack of circumcision is associated with HIV acquisition in men, and concurrent sexually
transmitted infections are associated with both transmission and acquisition. Other behavioral factors,
such as whether condoms were used, the number of sexual partners, and sex under the influence of
recreational drugs, also affect overall sexual HIV transmission risk. (See 'Sexual transmission risk
factors' above.)
● The risk of parenteral transmission of HIV depends on the volume of contaminated blood that an
individual is exposed to and the depth of the injury or exposure (eg, mucous membrane exposure,
needle-stick, or injection into vessel). (See 'Bloodborne transmission risk factors' above.)
● A comprehensive approach to HIV prevention includes risk reduction among HIV-infected individuals to
reduce transmission and among at-risk individuals to reduce acquisition (see 'Clinical approach to HIV
prevention' above):
• For HIV-infected individuals, successful antiretroviral therapy (ART) is a key strategy to prevent
transmission. The risk of transmission from a HIV-infected individual who has achieved stable viral
suppression is vanishingly small ("negligible"). (See 'HIV-infected individuals' above and 'Treatment
as prevention (TaSP)' above.)
• For at-risk individuals, routine screening and having a low threshold to test for HIV in order to
identify new HIV infections is crucial to directing interventions to prevent transmission. Condom use
and risk-reduction counseling as well as harm reduction interventions can reduce behavior that
results in higher risk of infection. Once infection is excluded, antiretroviral-based strategies that can
reduce the risk of HIV acquisition include daily pre-exposure prophylaxis for individuals with high
ongoing risk, and post-exposure prophylaxis for those who have had a mucosal or parenteral
exposure to HIV within the prior 72 hours. (See 'Individuals at risk for HIV' above and "Screening
and diagnostic testing for HIV infection" and "Pre-exposure prophylaxis against HIV infection" and
"Management of nonoccupational exposures to HIV and hepatitis B and C in adults".)
• For serodiscordant couples, we recommend antiretroviral treatment of the HIV-infected partner as

the primary prevention strategy instead of antiretroviral prophylaxis for the uninfected partner
(Grade 1A). Pre-exposure prophylaxis for the HIV-uninfected partner is additionally indicated until
the infected partner has achieved stable viral suppression on ART (typically by six months after
initiating therapy), if ART fails to suppress HIV in the infected partner for any reason or for risk-
taking behavior outside the partnership. Management of serodiscordant couples desiring pregnancy
is discussed elsewhere. (See 'Serodiscordant couples' above and "Use of assisted reproduction in
HIV- and hepatitis-infected couples", section on 'Natural conception in serodiscordant couples'.)
• Behavioral interventions (such as condom use and risk-reduction counseling) remain crucial
elements of prevention. For HIV-infected individuals who have achieved viral suppression and their
sexual partners, continued condom use remains useful to reduce risk of other STIs and in case viral
suppression fails. We counsel those who choose not to use condoms that the risk of HIV
transmission is negligible when viral suppression has been stably achieved, but it cannot be
completely ruled out. (See 'Condom use' above and 'Counseling and harm reduction strategies'
above and 'Serodiscordant couples' above.)
• We screen for and treat sexually transmitted infections in all individuals with or at risk for HIV
infection given the shared risk factors for HIV and other STIs, the association of other STIs with HIV
infection, and the benefit of treating STIs beyond potential HIV prevention. (See 'Treatment of
sexually transmitted infections' above.)
• Circumcision has demonstrated efficacy in reducing the risk of HIV acquisition among heterosexual
men, but the benefit among men who have sex with men (MSM) is uncertain. In areas where the
prevalence of HIV is high and sexual transmission is mainly among heterosexuals, such as in
several African countries, voluntary medical circumcision can be an effective element of HIV
prevention intervention. (See 'Male circumcision' above.)
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Topic 16612 Version 27.0
GRAPHICS
Estimated per-act risk for acquisition of HIV, by exposure route
Risk per 10,000 exposures to an

Exposure route
infected source (risk)
Blood-borne Blood transfusion 9000 (9/10)

exposure
Needle-sharing injection drug use 67 (1/150)
Percutaneous needle stick 23 (1/435)
Mucous membrane exposure to blood (eg, 10 (1/1,000)

splash to eye)
Sexual Receptive anal intercourse 138 (1/72)

exposure
Insertive anal intercourse 11 (1/900)
Receptive penile-vaginal intercourse 8 (1/1250)
Insertive penile-vaginal intercourse 4 (1/2500)
Receptive or insertive penile-oral intercourse 0-4
Other Biting, spitting, throwing body fluids (including Negligible

semen and saliva), sharing sex toys
There are scant empiric data on per contact risk of exposure. This table lists the estimated risk by exposure type
in the absence of antiretroviral treatment of the HIV-infected source and in the absence of amplifying factors.
Most of these estimates are derived through modeling studies of different cohorts. Clinicians need to be aware
that estimates of sexual risk are often based on studies of monogamous couples among whom amplifying factors
have been treated and repeated exposure may offer as yet unexplained protection from infection. Using a single
value for assessing risk of HIV transmission based on route of sexual exposure fails to reflect the variation
associated with important cofactors. A variety of amplifying factors and conditions have been identified, and these
factors can be expected to increase transmission probability.
Data from:
1. Donegan E, Stuart M, Niland JC, et al. Infection with human immunodeficiency virus type 1 (HIV-1) among
recipients of antibody-positive blood donations. Ann Intern Med 1990; 113:733-9.
2. Baggaley RF, Boily MC, White RG, Alary M. Risk of HIV-1 transmission for parenteral exposure and blood
transfusion: A systematic review and meta-analysis. AIDS 2006; 20:805.
3. Kaplan EH, Heimer R. HIV incidence among New Haven needle exchange participants: updated estimates from
syringe tracking and testing data. J Acquir Immune Defic Syndr 1995; 10:175-6.
4. Patel P, Borkowf CB, Brooks JT, et al. Estimating per-act HIV transmission risk: A systematic review. AIDS 2014;
28:1509-19.
5. Cohen MS. Amplified transmission of HIV-1: Missing link in the HIV pandemic. Trans Am Clin Climatol Assoc 2006;
117: 213–225.
6. Centers for Disease Control and Prevention, US Department of Health and Human Services. Updated Guidelines for
Antiretroviral Postexposure Prophylaxis After Sexual, Injection Drug Use, or Other Nonoccupational Exposure to
HIV—United States, 2016.
Graphic 60145 Version 5.0
Contributor Disclosures
Myron S Cohen, MD Consultant/Advisory Boards: Merck [Implantable prep agents]. John G Bartlett,
MD Nothing to disclose Allyson Bloom, MD Nothing to disclose
Contributor disclosures are reviewed for conflicts of interest by the editorial group. When found, these are
addressed by vetting through a multi-level review process, and through requirements for references to be
provided to support the content. Appropriately referenced content is required of all authors and must conform
to UpToDate standards of evidence.
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HIV infection: Risk factors and prevention strategies

Author: Myron S Cohen, MD

In contrast, in resource-limited areas, penile-vaginal intercourse is responsible for 70 to 80 percent of HIV

sexual assault victims".)

● Receptive anal intercourse – One transmission per 72 sex acts

● Blood transfusion – nine infections per 10 exposures

EFFICACY OF PREVENTION STRATEGIES

CLINICAL APPROACH TO HIV PREVENTION — A comprehensive approach to HIV prevention includes

Individuals at risk for HIV

Identifying new infections — Identifying HIV-infected individuals is crucial to directing interventions to

SUMMARY AND RECOMMENDATIONS

• For serodiscordant couples, we recommend antiretroviral treatment of the HIV-infected partner as

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Topic 16612 Version 27.0

Estimated per-act risk for acquisition of HIV, by exposure route

Risk per 10,000 exposures to an

Blood-borne Blood transfusion 9000 (9/10)

Percutaneous needle stick 23 (1/435)

Mucous membrane exposure to blood (eg, 10 (1/1,000)

Sexual Receptive anal intercourse 138 (1/72)

Receptive penile-vaginal intercourse 8 (1/1250)

Insertive penile-vaginal intercourse 4 (1/2500)

Receptive or insertive penile-oral intercourse 0-4

Other Biting, spitting, throwing body fluids (including Negligible

Graphic 60145 Version 5.0

Conflict of interest policy

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