Running head: PREVENTION STRATEGIES AGAINST DENTAL CARIESPrevention Strategies against Dental Caries
John Smith
Nova Southeastern University
College of Health Care Sciences
Department of Health Science
Master of Health Science Program
MHS 5501: Epidemiology and Biostatistics
Dr. Rose Colon
May 19, 2030
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PREVENTION STRATEGIES AGAINST DENTAL CARIES
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Table of Contents
Chapter
Page
1. Introduction …………………………………………………………………………………………………………………3
2. Dental Caries Prevention Strategies………………………………………………………………………………..4
Primary Dental Caries Prevention ……………………………………………………………………………5
Patient Education ………………………………………………………………………………………..6
Fluoride ……………………………………………………………………………………………………..6
Dental Sealants……………………………………………………………………………………………8
Xylitol ……………………………………………………………………………………………………….8
Antimicrobial Rinses …………………………………………………………………………………..9
Secondary Dental Caries Prevention ………………………………………………………………………..9
Tertiary Dental Caries Prevention ………………………………………………………………………….10
3. Conclusion ………………………………………………………………………………………………………………..11
References ……………………………………………………………………………………………………………………..12
PREVENTION STRATEGIES AGAINST DENTAL CARIES
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Prevention Strategies against Dental Caries
Introduction
Dental caries, which are also commonly referred to as cavities, is the most common
communicable disease of childhood (Mars, Trumbley, & Malik, 2011). The Global Burden of
Disease 2010 Study found that of the 291 diseases and conditions they measured, dental caries
was the most prevalent disease worldwide (Seymour & Barrow, 2014). The Centers for Disease
Control and Prevention (CDC) determined that 91% of Americans over 20 years of age have had
cavities at some point, and that 27% of adults over 20 have untreated caries (American Dental
Association [ADA], 2015). The CDC also estimates that between 12.1% and 41.9% of
Americans over 5 years of age have untreated dental caries, depending on age and income level
(Compton, 2014). Despite improvements in the ability to prevent, detect, and treat dental disease
and our increased understanding of the links between oral and systemic health, untreated dental
caries has risen by 31.8% globally in the last 20 years. As with many diseases, the
disadvantaged, minorities, and vulnerable populations bear the greatest burden for this disease.
While the number of untreated caries is on the rise, the American Dental Association Health
Policy Institute estimated that dental care utilization in 2012 was at the lowest level for working
age adults since 1996 (ADA, 2015). For children who receive Medicaid and who are eligible for
dental care coverage, only 46.9% were able to access dental care in 2013 (Compton, 2014).
Millions around the world suffer from oral pain, missed work or school, chronic dental
infections, the inability to eat, and other negative effects of dental caries (Seymour & Barrow,
2014). Oral pain is the most commonly reported problem with dental caries. Between 2008 and
2010, over two million hospital-based emergency department visits involved dental caries,
equating to $2.7 billion in hospital charges (Seymour & Barrow, 2014).
PREVENTION STRATEGIES AGAINST DENTAL CARIES
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Dental caries is an infectious disease, which is frequently spread from mother to child by
the transmission of Streptococcus mutans (S. Mutans; Marrs et al., 2011). Transmission usually
occurs from 7 months of age until 36 months of age, although as many as 50% of infants may
have S. mutans present by 6 months of age (Marrs et al., 2011). S. mutans living in the oral
cavity utilizes simple sugars for energy and produces acid, which attacks dental enamel and
causes a break down in the enamel through the process of demineralization, ultimately resulting
in caries if the process of demineralization continues (Marrs et al., 2011).
Risk factors for dental caries are multifactorial and include (a) poor oral hygiene habits,
(b) recent fillings or extractions, (c) dental pain/plaque, (d) mother’s or sibling’s caries history,
(e) low educational level or low socioeconomic level, (f) premature birth, (g) poor nutrition, (i)
special health care needs, and (j) xerostomia (Marrs et al., 2011). Because dental caries is
widespread, is communicable, results in decreased oral and systemic health, and is preventable,
preventive intervention is needed.
Dental Caries Prevention Strategies
The dental caries disease process is complex and ongoing and therefore requires
coordination of the three levels of prevention, including (a) primary prevention, (b) secondary
prevention, and (c) tertiary prevention. Primary prevention strategies include (a) increasing
awareness of the disease process; (b) educational programs designed to modify behavior related
to home care and diet; and (c) adjunctive preventive measures. Secondary prevention interrupts
the disease process before it becomes symptomatic and in the case of dental caries, involves
halting the process of demineralization after the caries disease process has begun, but before a
cavitation forms. Tertiary prevention is the treatment of carious lesions by restoring the
PREVENTION STRATEGIES AGAINST DENTAL CARIES
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dentition to health. Expanding the use of all levels of prevention will lower the cost of care and
improve patient health outcomes.
Primary Dental Caries Prevention
Individual risk assessment is a tool used by dental professionals to identify patients at
low, moderate, or high risk of dental caries so that evidence-based prevention strategies can be
adopted (Hurlbutt & Young, 2014). Patient awareness and education are important to the
primary prevention process. Because behavior may contribute up to 40% as a determinant of
health, modifying unhealthy behavior in order to prevent disease is of the utmost importance
(Compton, 2014). Although education is important to all ages of a population, educating
expectant mothers about the causes of dental caries, the disease process, effective home care, and
the positive effects of a healthy diet have proven to be successful as a method of primary
prevention (Marrs et al., 2011; Ismail, Ondersma, Willem Jedele, Little & Lepkowski, 2011).
Educating pregnant women, regarding this disease and preventive measures is especially
effective because early intervention can reduce the risk of the transmission of S. mutans from
mother to child, and can aid in the effective application of other preventive interventions such as
good brushing and flossing habits and an improved diet for the entire family. Providing
secondary and tertiary care to these expectant mothers also improves preventive outcomes
(Marrs et al., 2011). Most parents are not aware of the importance of good oral hygiene and the
effect that diet can have on oral health. It is important for parents to understand the increased
acidity and therefore increased caries risk of frequent consumption of juices such as apple juice,
which has a pH of 3.5 (Compton, 2014). Simply modifying one or two risk factors can
significantly reduce caries risk (Compton, 2014).
PREVENTION STRATEGIES AGAINST DENTAL CARIES
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Patient Education. Primary prevention should also include detailed brushing and
flossing instructions for all patients and should be appropriate to the patient’s age and
educational level, but education alone may not be sufficient to change behavior. The Health
Belief Model (HBM), which is commonly used to explain and predict health-related behaviors,
suggests that individuals are more likely to adopt and adhere to recommended oral hygiene
behavior if they believe themselves to be susceptible to oral diseases and understand that oral
diseases can have serious consequences for their health (Anagostopoulos, Buchanan,
Frousiounioti, Niakas, & Potamianos, 2011). Motivational interviewing has been used as tool to
decrease caries risk. This method of communication employees an empathetic and collaborative
style to help build on the patient’s own reasons for change (Ismail et al., 2011). Motivational
interviewing has been particularly effective in helping parents decrease a child’s risk of
developing caries (Ismail et al., 2011).
In addition to home care education, nutritional education, and behavior modification,
adjunctive care is an important part of primary prevention. Various adjunctive therapies have
been proven to reduce the risk of dental caries including (a) fluoride, (b) dental sealants, (c)
xylitol, and (d) antimicrobial rinses.
Fluoride. The addition of fluoride to public water systems has been hailed as one of the
greatest public health interventions of the last century, and fluoridation of community water
systems remains the most cost-efficient and cost-effective method of community caries
prevention (Seymour & Barrow, 2014; Marrs et al., 2011). The United States has seen the
positive effects of public water fluoridation, as there has been a significant reduction in dental
caries in the last century. However, over 100 million people are still without fluoridated water in
the United States, and only 58% receive the optimal dosage of fluoride in their public water
PREVENTION STRATEGIES AGAINST DENTAL CARIES
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system. Optimal fluoride levels in drinking water are 0.7 to 1.2 parts per million, depending on
climate (Marrs et al., 2011). While countless studies have proven the importance of fluoride in
decreasing the risk of caries, and the American Dental Association has increased recommended
fluoride exposure in children under two, there has been growing public confusion and discontent,
regarding the use of fluoride in public water systems. Seymour and Barrow (2014) refer to this
misunderstanding and lack of literacy related to fluoride and its benefits as a “digital pandemic”
in which the media, fueled by information provided by inaccurate studies, has perpetuated the
spread of misinformation. Some communities have opted to eliminate this effective means of
primary prevention.
Fluoride helps to prevent development of dental caries in three ways (Nelson, 2012).
First, it reduces the acid solubility of enamel. It also aids in the absorption of calcium and
phosphate, needed for the remineralization of enamel. Finally, it decreases the rate of transport
of minerals out of the tooth during demineralization (Nelson, 2012). The topical application of
fluoride in toothpaste, mouth rinses, and professional applications in fluoride varnish and gel is
an important primary prevention tool. Since the 1980s, most commercial toothpaste has included
fluoride and this addition to toothpaste has become the most common method for controlling
dental caries (Marrs et al., 2011). Because children tend to ingest these products, care should be
taken with their use. Small children could ingest enough toothpaste to cause dental fluorosis,
damaging developing teeth, or toxicity (Marrs et al., 2011). Parents should be taught to use
caution when using fluoride products with small children. However, a recent Cochrane Review
by Wong et al., (2011) found that there is only weak evidence that starting to use a small amount
of fluoride toothpaste in children under 12 months of age will increase risk of fluorosis, and that
using fluoride toothpaste with concentrations of fluoride of 1000 ppm or higher is more effective
PREVENTION STRATEGIES AGAINST DENTAL CARIES
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for caries prevention. Santos, Nadanovski, and Oliveira (2013) found that standard fluoride
toothpastes are effective in reducing dental caries in the primary teeth of preschool children, an
age group that typically experiences a higher rate of caries prevalence. Over the counter fluoride
rinses (0.05%) have also been proven to reduce the development of new caries by 50% and the
caries level by one-third (Chen et al., 2010). School-based fluoride programs using a 0.2 sodium
fluoride mouth rinse have also been found to be an effective caries preventive measure and are
especially helpful in fluoride-deficient areas in reducing the prevalence of caries (Chen et al.,
2010).
Dental sealants. Dental sealants have proven equally effective as fluoride varnish in
caries prevention (Oliveira & Cunha, 2013). Fluoride varnish, which has a slow release time,
and greater concentration of fluoride has been widely used by dental professionals for caries risk
reduction (Oliveira & Cunha, 2013). Because children (and some adults) experience greater
development of caries in pit and fissure areas on the tooth (primarily on occlusal or chewing
surfaces), pit and fissure sealants help protect against caries development by creating a barrier to
block out bacterial plaque and the colonization of S. mutans (Oliveira & Cunha, 2013).
Xylitol. Xylitol is a sugar alcohol, which is used in many sugar-free products and is
associated with a reduction in dental caries risk. Xylitol has been used since the 1960s in
chewing gum, mints, mouth rinse, and syrups. It has been proven to reduce tooth decay in as low
a dose as 15 grams or less if used for five to twenty minutes, three to five times a day (Marrs et
al., 2011). Xylitol is non-cariogenic and cariostatic, reducing the amount of S. mutans present in
the oral cavity. In pregnant women, studies have demonstrated that the use of xylitol gum during
pregnancy decrease the level of S. mutans present, thereby reducing the risk of transmission of
the caries causing bacteria to their children (Marrs et al., 2011).
PREVENTION STRATEGIES AGAINST DENTAL CARIES
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Antimicrobial rinses. In addition to other primary preventive measures, antimicrobial
rinses may also be added to the prevention armamentarium for patients at higher risk for dental
caries. Chlorhexidine oral rinse of 0.12% concentration is available by prescription and has been
proven to reduce oral bacteria for up to 12 hours after use. Over the counter antimicrobial rinses
may also be recommended. It is important to understand that these are a part of primary
preventive care, but are not as effective as other primary preventive tools. Antimicrobial rinses
should be used in conjunction with other modalities, such as a 0.05% sodium fluoride rinse, for
more effective reduction of caries risk (Hurlbutt & Young, 2014).
Finally, an important part of primary prevention is regular dental visits, which are
recommended by the ADA for everyone one year and older (Nelson, 2012). Regular dental
appointments provide the opportunity for professional evaluation of oral health care, risk
assessment for dental caries, professional fluoride application, the placement of dental sealants,
and patient education opportunities.
Secondary Dental Caries Prevention
Secondary prevention occurs after the patient has developed a carious lesion, but before it
has progressed into a cavitation (Compton, 2014). The goal of this prevention is to identify the
disease and halt the progression of the disease before it becomes symptomatic (Compton, 2014).
Regular visits to a dental professional are important in secondary prevention as well so that
dental caries can be detected early. At this stage of the caries process, remineralization of the
carious lesion is possible and progression of the disease can be arrested. In this stage, the carious
lesion is referred to as early caries or demineralized surfaces. The carious lesion has not yet
penetrated the thickness of the enamel layer and has not reached the dentin. Progression of the
disease process will require a tertiary prevention intervention, but in many cases,
PREVENTION STRATEGIES AGAINST DENTAL CARIES
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remineralization of the tooth can prevent progression of the lesion. According to Compton
(2014), secondary prevention is much preferred over surgical intervention (tertiary prevention)
because studies have proven that if surgical intervention is required and a dental restoration is
placed, there is a very high likelihood that further tertiary prevention will be required in the
future (Compton, 2014). Hurlbutt and Young (2014) report that two-thirds of all restorative
(tertiary) treatment is performed on previously restored teeth. Recurrent decay is cited as the
predominant cause.
Because the goal of secondary dental caries prevention is the remineralization of dental
enamel, all of the approaches to primary prevention may also be utilized in secondary
prevention. Fluoride varnish as well as 1.1% sodium fluoride gel or toothpaste is frequently used
to aid in remineralization. Patient education and nutritional counseling are also used to facilitate
behavior modification so that pH levels may become more balanced and remineralization can
occur.
Tertiary Dental Caries Prevention
When a carious lesion has penetrated the thickness of the dental enamel and reached the
dentin, surgical intervention is the standard of care (Hurlbutt and Young, 2014). Depending on
the severity of the disease progression, interim therapeutic restorations may be needed.
Unfortunately, dental caries left untreated can progress to a point at which restoration of the
existing tooth is not possible. Early detection is important to reduce the level of response needed
in tertiary prevention. If detected early, a small carious lesion may require only a small dental
restoration. However, due to the likelihood of recurrent decay, the surgical-restorative model
promotes increased restoration size and more invasive procedures over time (Hurlbutt and
Young, 2014). If left untreated, the carious lesion may reach the nerve of the tooth, requiring
PREVENTION STRATEGIES AGAINST DENTAL CARIES
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root canal therapy to remove the infection and a restorative crown to protect the tooth. Many
people do not realize that these restorations may also develop recurrent decay. If the decay has
reached a stage beyond repair by restoration, then a dental implant may be placed, or in some
cases, a fixed or removable prosthesis may be used to restore function for the patient.
Conclusion
Prevention is mandatory for control of dental caries. In order to reduce the prevalence of
this pandemic, primary prevention should be the goal of all dental and medical professionals
(ADA, 2015). In order to meet the needs of those who bear the greatest burden of this disease
inter-professional collaboration is necessary. According to Dr. Feinberg, current president of the
ADA, “while it is critical to treat disease that has already occurred, the public health community
needs to increase its focus on proven means of preventing it” (ADA, 2015, p. 2).
PREVENTION STRATEGIES AGAINST DENTAL CARIES
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References
American Dental Association. (2015). ADA statement: New CDC statistics show need for
increased access to dental care, with greater emphasis on preventing disease. Retrieved
from http://www.ada.org/en/press-room/news/releases/2015-archive/may/new-cdc-dataon-adult-cavities/?source=facebook&content=cdc_report%2F
Anagnostopoulos, F., Buchanan, H., Frousiounioti, S., Niakas, D., & Potamianos, G. (2011).
Self-efficacy and oral hygiene beliefs about toothbrushing in dental patients: A modelguided study. Behavioral Medicine, 37(4), 132-139.
Chen, C., Ling, K., Esa, R., Chia, J., Eddy, A., & Yaw, S. (2010). A school-based fluoride
mouth rinsing programme in Sarawak: A 3-year field study. Community Dentistry &
Oral Epidemiology, 38(4), 310-314.
Compton, R. (2014). Opportunities to increase prevention in dentistry. Canadian Journal of
Dental Hygiene, 48(4), 179-181.
Hurlbutt, M., & Young, D. A. (2014). A best practices approach to caries management.
Journal of Evidence Based Dental Practice, 14S, 77-86.
Ismail, A. I., Ondersma, S., Willem Jadele, J. M., Little, R. J., & Lepkowski, J. M. (2011).
Evaluation of a brief tailored motivational intervention to prevent early childhood caries.
Community Dentistry & Oral Epidemiology, 39(5), 433-448.
Marrs, J., Trumbley, S., & Malik, G. (2011). Early childhood caries: Determining the risk
factors and assessing the prevention strategies for nursing intervention. Pediatric
Nursing, 37(1), 9-15.
Nelson, T. (2012). The key to caries prevention. Dental Assistant, 81(6), 48-64.
PREVENTION STRATEGIES AGAINST DENTAL CARIES
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Oliveira, D. d., & Cunha, R. F. (2013). Comparison of the caries-prevention effect of a glass
ionomer sealant and fluoride varnish on newly erupted first permanent molars of children
with and without dental caries experience. Acta Odontologica Scandinavica, 71(3-4),
972-977.
Santos, A. P. P., Nadanovsky, P., Oliveira, B. H. (2013). A systematic review and meta-analysis
of the effects of fluoride toothpastes on the prevention of dental caries in the primary
dentition of preschool children. Community Dentistry & Oral Epidemiology, 41(1), 1-12.
Seymour, B., & Barrow, J. (2014). A historical and undergraduate context to inform
interprofessional education for global health. Journal of Law, Medicine & Ethics, 42,
9-16.
Wong, M., Clarkson, J., Glenny, A., Lo, E., Marinho, V., Tsang, B., & . . . Worthington, H.
(2011). Cochrane reviews on the benefits/risks of fluoride toothpastes. Journal of
Dental Research, 90(5), 573-579.
PREVENTION STRATEGIES AGAINST DENTAL CARIES
Dental Caries – Evidence and Audience Summary
John Smith
Nova Southeastern University
College of Health Care Sciences
Department of Health Science
Master of Health Science Program
MHS 5501: Epidemiology and Biostatistics
Dr. Rose Colon
May 19, 2030
14
PREVENTION STRATEGIES AGAINST DENTAL CARIES
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Evidence Summary
Dental caries is a widespread disease, affecting much of the global population, and dental
caries is the most common communicable disease of childhood affecting 41% of children in the
United States (Marrs et al., 2011). Globally, dental caries is the most prevalent disease with a
38.1% increase in untreated caries in the last 20 years (Seymour & Barrow, 2014).
Primary prevention strategies include (a) increasing awareness of the disease process; (b)
educational programs designed to modify behavior related to home care and diet; and (c)
adjunctive preventive measures such as fluoride, dental sealants, xylitol products, and
antimicrobial rinses. Use of an risk assessment tool such as caries management by risk
assessment (CAMBRA), which uses 20 factors to determine caries risk, can aid in the adoption
of evidence-based primary prevention strategies (Hurlbutt & Young, 2014). Secondary
prevention strategies focus on early detection of caries and arresting the disease process through
the remineralization of early caries. This is achieved through regular dental visits, patient
education, behavior modification (including dietary changes and improved brushing/flossing,
fluoride use, and xylitol use. Tertiary prevention strategies strive to restore oral function and
prevent disease recurrence. Restorative dentistry seeks to restore function through dental
fillings, root canal therapy, crown and bridgework, prosthesis, or dental implants. Efforts to
improve home care and prevent future caries or recurrent caries are important.
Audience Summary
Are you at risk for dental decay?
You or your family members may be unaware of your risk factors. Men and women are
affected equally, and caries risk is highest in children. Certain populations are at greater risk for
caries including (a) children, (b) African Americans, (c) Hispanics, (d) those with lower
PREVENTION STRATEGIES AGAINST DENTAL CARIES
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socioeconomic status or lower education, (e) the elderly, and (f) certain populations with special
medical conditions (ADA, 2015; Hurlbutt & Young, 2014). Because risk is based upon many
factors, you may be unaware of your risk. Everyone should be aware of his or her risk for caries.
Even if you survived childhood without developing dental caries, the person you date or marry
can expose you to increased levels of S. mutans and increase your risk for caries. If you (a) have
high levels of S. mutans; (b) have poor plaque control; (c) have frequent snacking; (d) have deep
pits and fissures; (e) use drugs recreationally or use prescription medications; (f) have decreased
salivary flow; (g) have exposed root surface; (h) wear an orthodontic appliance; (i) or have
family members who have had dental caries, then you are at higher risk for dental caries.
Identifying your risk for dental caries and the presence of caries
It is important to visit your dental professional for routine visits and preventive care.
Dental radiographs and oral exams help to identify carious lesions early. If detected before the
lesion has progressed through the depth of your enamel, correct care may prevent the disease
from progressing further and your decay may be stopped before restoration is required. Your
dental professional can help you to assess your risk for decay and design a customized
prevention plan that can protect your oral and systemic health. Remember that your mouth is
positioned between your two most vital organs: your heart and your brain. Do not leave
infection untreated in your mouth. Oral infection affects more than just your mouth.
Decreasing your risk for decay
Although your dental professional can assist you in maintaining good oral health,
ultimately, only you can control your risk factors. Primary preventive strategies include, (a)
understanding the decay process; (b) having a healthy diet, low in sugars; (c) having great home
care, including brushing two times a day with a fluoride toothpaste and flossing daily; (d) using
PREVENTION STRATEGIES AGAINST DENTAL CARIES
17
additional fluoride if needed; (e) getting pit and fissure sealants when needed; and (f) reducing
bad bacteria with the use of antimicrobials such as xylitol or mouth rinses (Hurlbutt & Young,
2014). Seeking early treatment for dental decay also prevents pain associated with caries,
reduces your costs for restorations, and prevents tooth loss.
Dental Resources.
If you are unable to afford preventive or restorative care, seek care at a public health
facility, such as your county health department. Many communities also offer free or reduced
cost dental clinics. Additionally, your community may be home to a dental hygiene school or a
dental school. These programs offer excellent dental care at reduced rates. Many companies,
which produce dental care products, offer free resources online. You may visit the following
websites for additional resources:
•
The American Dental Association at www.ada.org offers services such as find
a dentist, resources for improving your oral health, and an additional site
MouthHealthy.org, which offers the information you need to take better care
of your mouth today so it will take care of you for life.
•
www.crest.com offers information on everything related to your oral health
along with coupons for products.
•
Colgate offers product information, coupons, and an oral and dental health
resource center to answer all of your family’s dental questions at
www.colgate.com.
•
Sites are available to help you find free or reduced dental care in your area.
Check out http://www.freedentalcare.com.
PREVENTION STRATEGIES AGAINST DENTAL CARIES
•
Information about dental caries is available through the Centers for Disease
Control and Prevention by searching “Dental Caries” at www.cdc.gov or by
visiting http://www.cdc.gov/healthywater/hygiene/disease/dental_caries.html.
Finally, if you are unable to locate affordable dental care, talk to your pediatrician
or primary care physician about your oral health. She/he may offer you additional
community resources or help you address your oral health needs before they become a
problem, which is out of control.
18
PREVENTION STRATEGIES AGAINST DENTAL CARIES
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References
American Dental Association. (2015). ADA statement: New CDC statistics show need for
increased access to dental care, with greater emphasis on preventing disease. Retrieved
from http://www.ada.org/en/press-room/news/releases/2015-archive/may/new-cdc-dataon-adult-cavities/?source=facebook&content=cdc_report%2F
Hurlbutt, M., & Young, D. A. (2014). A best practices approach to caries management.
Journal of Evidence Based Dental Practice, 14S, 77-86.
Marrs, J., Trumbley, S., & Malik, G. (2011). Early childhood caries: Determining the risk
factors and assessing the prevention strategies for nursing intervention. Pediatric
Nursing, 37(1), 9-15.
Seymour, B., & Barrow, J. (2014). A historical and undergraduate context to inform
interprofessional education for global health. Journal of Law, Medicine & Ethics, 42,
9-16.
PREVENTION STRATEGIES AGAINST DENTAL CARIES
Printed Material
Outside of Brochure
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PREVENTION STRATEGIES AGAINST DENTAL CARIES
Inside of Brochure
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HIV TRANSMISSION PREVENTION STRATEGIES
HIV Transmission Prevention Strategies for
Seronegative and Seropositive Individuals
Nova Southeastern University
HIV TRANSMISSION PREVENTION STRATEGIES
Introduction
Human immunodeficiency virus (HIV) is a retroviral infection that has spread to global
pandemic levels. Its long period of invisibility following infection rendered it easy to ignore,
enabling the virus to spread unchecked for many years. The virus first emerged in low levels in
remote areas, and disseminated into more populated areas where it spread among sexually active
populations. The virus then spread quickly to various regions of the world through population
travel, and set the scene for an explosive global epidemic. The escalation phase of the virus
occurred in the 1980’s, when transmission was amplified among high-risk populations. In
Southeast Asia, 4 million individuals were infected in just 5 years. The final stage of the
evolution of HIV was when transmission seemed to stabilize, in which the number of new HIV
infections and the number of AIDS deaths began to equalize (Quinn, 1996). The human
immunodeficiency virus (HIV) had infected 33.2 million people worldwide as of 2010 (Gardner,
McLees, Steiner, del Rio & Burman, 2011).
HIV has spread to every country on every continent; however, there is a substantial
amount of geographic variability among infected individuals. In Sub-Saharan Africa, which has
been heavily impacted by HIV transmission with 22.5 million of all HIV cases, HIV is mainly
spread between heterosexual individuals in the general population. In the rest of the world, the
epidemic is concentrated in high-risk populations, such as men who have sex with other men,
intravenous drug users, sex workers, and their partners (Fisher & Smith, 2009, Gardner, McLees,
Steiner, del Rio & Burman, 2011).
There were an estimated 1.1 million adults and adolescents living with HIV in the United
States as of 2006. In some cities there was a prevalence HIV infection of 1- 2% among the
general population while the prevalence was 13% among men who have sex with other men
HIV TRANSMISSION PREVENTION STRATEGIES
(Gardner, McLees, Steiner, del Rio & Burman, 2011). Of the 1.1 million adults and adolescents
living with HIV in the United States, it is estimated that 232,700 (21%) were unaware of their
infected status (Gardner, McLees, Steiner, del Rio & Burman, 2011).
HIV effectively counteracts all components of the immune system. It does very well at
taking advantage of cellular pathways despite its molecular size. In the early stages of infection,
the HIV virus accesses the cells without causing lethal damage, but stimulating the cell’s signal
cascades that allow viral replication (Simon, Ho & Karim, 2006).
Through several complicated steps, the viral genome is released into the cell’s cytoplasm
and then injected into the host’s chromosomal DNA. The cell is now irreversibly transformed
into a production center for new mature and infectious virions. New virions produced by this
cell will incorporate characteristics of the new host cell. Once infected T-lympohocytes migrate
into the blood stream, the infection is amplified in the gastrointestinal tract, spleen, and bone
marrow, resulting in massive infection. The naïve and memory CD4+ T-lymphocyte cells are
gradually destroyed, which is the hallmark of HIV infection. In the late stage of the disease,
infected individuals’ CD4+ T-lymphocyte numbers get so low that they develop acquired
immunodeficiency syndrome (AIDS). Disease progression can be predicted based on the
infected individuals immune activation (Simon, Ho & Karim, 2006).
With great advances in HIV testing technology, HIV infection can be diagnosed in as
little as 20 minutes. The diagnosis is based on detection of specific HIV antibodies or antigens.
These tests can be done on plasma, serum, whole blood, or saliva, and the rapidity of these tests
is important for surveillance, screening, and diagnosis. One shortfall of the rapid serological
HIV antibody tests is during the primary infection phase when antibodies are absent in the host,
and also in infants younger than 18 months who may present with maternal HIV antibodies. The
HIV TRANSMISSION PREVENTION STRATEGIES
only way to test for HIV in these individuals is by directly detecting the virus and quantifying the
viral load (Simon, Ho & Karim, 2006). Testing of CD4+ cell count and viral load can indicate
the stage of the disease and the effectiveness of treatment in infected individuals (Simon, Ho &
Karim, 2006).
Prevention Strategy for HIV Infection
Primary, secondary, and tertiary preventative strategies are necessary to reduce the spread
of HIV and to improve the lives of people living with HIV/AIDS. For many years following the
global outbreak of HIV preventative strategies were focused primarily on seronegative
individuals. Preventative strategies were not expanded to include people living with HIV until
the second decade of the outbreak (Fisher & Smith, 2009). With there being over 5 million
people considered at high risk for HIV infection in the United States alone, it’s important to
target both seropositive and seronegative individuals in order to curb the spread of HIV.
Primary Prevention
Primary preventative strategies are those strategies that are directed at individuals who
have not yet come in contact with the disease. HIV testing and counseling of high-risk
individuals has been the typical model to reduce HIV transmission in seronegative individuals.
Mayer and his associates (2012) showed availability of HIV testing and counseling an individual
is more likely to use an effective strategy to increase education of sexual behavior and awareness
of one’s serostatus.
There is significant evidence to show that male circumcision may provide a two to eight
fold decrease in the likelihood of contracting HIV and has been nicknamed the “surgical
vaccine” (Rotherman-Borus, Swendemen & Chovnick, 2009). With this in mind, it’s important
to recognizing a recent decline in male circumcision in the United States. This is the result of
HIV TRANSMISSION PREVENTION STRATEGIES
healthcare changes and ethnic cultural differences. These changes will result in health disparities
in the future (Rotherman-Borus, Swendemen & Chovnick, 2009).
Barrier methods are an important part of primary prevention methods. These include
male condoms, female condoms, diaphragms, and microbicides. Condom use has been the
cornerstone of HIV prevention strategies since the epidemic began. Condoms have been shown
to be extremely effective in HIV prevention, as high as 95% when used consistently (RothermanBorus, Swendemen & Chovnick, 2009). Female condoms are more expensive, less available,
and less familiar than male condoms, but evidence has been shown to support their efficacy in
preventing sexually transmitted diseases. Diaphragms have been shown to have potential in
preventing HIV transmission, but there is not yet any evidence to support this. Microbicides are
antimicrobial agents that could be used intravagianlly or intrarectally. However, there is not
sufficient evidence to support their efficacy in preventing HIV transmission either (RothermanBorus, Swendemen & Chovnick, 2009).
There is promising research from improved antiretroviral drugs and preexposure
prophylaxis. This work may have an answer for prevention of HIV transmission in individuals
with occupational or ongoing exposure. This could also be effective for individuals who are
seronegative but who have seropositive partners (Baeten, Donnell, Ndase, Mugo, Campbell,
Wangisi… & Celum, 2012).
Secondary Prevention
Secondary prevention strategies are those strategies that are directed at individuals who
have contracted HIV but have not shown any clinical manifestations of the disease. Similar to
primary prevention, increased testing and education is still a important component in secondary
prevention. Increased testing will identify those seropositive individuals who are unaware of
HIV TRANSMISSION PREVENTION STRATEGIES
their seropositive status, and further education of safe sexual behavior will decrease further
transmission. Once they have been identified as seropositive, it is important to initiate and
maintain HIV care. Primary care visits and continued monitoring have been shown to reduce
behavioral and biological risk, while lack of care has been associated with poorer health
outcomes (Fisher, Smith & Lenz, 2010).
Initiation of antiretroviral treatment is critical. Antiretroviral treatment has been shown
to decrease viral load in the plasma and genital tract, which reduces the biological risk of HIV
transmission. It’s important that individuals undergoing antiretroviral treatment adhere to
routine HIV care and behavioral interventions. If individuals to not adhere to their treatment, it
is possible to develop treatment resistance (Fisher, Smith & Lenz, 2010).
Tertiary Prevention
Tertiary prevention strategies are those strategies that are directed at individuals who
have manifested symptoms of the disease. Again, education of safe sexual behavior is important
in reducing the transmission to seronegative individuals. Antiretroviral treatment may slow the
progression of AIDS and decreases morbidity and mortality of seropositive individuals
(Rotheram-Borus et al 2010). Transmission of HIV from mother to child can also be prevented
with antiretroviral treatment. An HIV infected mother who is undergoing antiretroviral
treatment has a 1 to 2% chance of transmitting the disease to her child, as compared to a 40%
chance in HIV infected mothers who do not undergo antiretroviral treatment (Rotherman-Borus,
Swendemen & Chovnick, 2009).
Similar to secondary prevention, it is imperative that seropositive individuals have
continuous HIV care and adhere to antiretroviral therapy. About 50% of known seropositive
individuals do not have regular HIV care. Interrupted antiretroviral treatment may lead to a
HIV TRANSMISSION PREVENTION STRATEGIES
resistance to treatment and an increased risk of HIV transmission (Gardner, McLees, Steiner, del
Rio & Burman, 2011).
Conclusion
Human immunodeficiency virus has been a difficult epidemic to control because of its
long period of “invisibility” following infection. Increased testing and education is vitally
important to all levels of prevention. With increased education of risky behavior and safe sexual
practices, both seronegative and seropositive individuals will be able to reduce their risk of HIV
transmission. Once contact has been made, HIV care must be initiated immediately, and
adherence to HIV treatment must be maintained.
HIV TRANSMISSION PREVENTION STRATEGIES
References
Baeten, J., Donnell, D., Ndase, P., Mugo, N., Campbell, J., Wangisi, J. … Celum, C. (2012).
Antiretroviral prophylaxis for hiv prevention in heterosexual men and women. The New
England Journal of Medicine, 367, 399-410.
Fisher, J., & Smith, L. (2009). secondary prevention of hiv infection: The current state of
prevention for positives. Curr Opin HIV AIDS, 4, 279-287.
Fisher, J., Smith, L., & Lenz, E. (2010). Secondary prevention of hiv in the united states:
Past, current, and future perspectives. J Acquir Immune Defic Synd, 55, 106-115.
Gardner, E., McLees, M., Steiner, J., del Rio, C., & Burman, W. (2011). The spectrum of
engagement in hiv care and its relevance to test-and-treat strategies for prevention of hiv
infection.HIV/AIDS, 52, 793-800.
Mayer, K., Ducharme, R., Zaller, N., Chan, P., Case, P., Abbott, D., Rodriguez, I., & Cavanaugh,
T. (2012). Unprotected sex, underestimated risk, undiagnosed hiv and sexually
transmitted diseases among men who have sex with men accessing testing services in a
new england bathhouse. J Acquir Immune Defic Syndr, 59, 194-198.
Quinn, T. (1996). Global burden of the hiv pandemic. The Lancet, 348, 99-106.
Rotheram-Borus, M., Swendemen, D., & Chovnick, G. (2009). The past, present, and future of
hiv prevention: Integrating behavioral, biomedical, and structural intervention strategies
for the next generation of hiv prevention. Annu Rev Clin Psychol, 5, 143-167.
HIV TRANSMISSION PREVENTION STRATEGIES
HIV Prevention Presentation
for At-Risk, Seronegative Individuals
Nova Southeastern University
HIV TRANSMISSION PREVENTION STRATEGIES
Evidence Summary
As previously stated, HIV is a global pandemic and worldwide it has infected millions
(Gardner, McLees, Steiner, del Rio & Burman, 2011). MSMs (men who have sex with men) and
IV drug users continue to be considered high-risk populations (Fisher & Smith, 2009, Gardner,
McLees, Steiner, del Rio & Burman, 2011). Overall, this virus impairs the immune system and
advances in medicine have improved detection. HIV impacts all members of society (Gardner et
al.).
Primary prevention has focused on condom use (Rotherman-Borus, Swendemen &
Chovnick, 2009). Diagnosing requires the results of CD4+ cell count and viral load (Simon, Ho
& Karim, 2006). Secondary prevention once diagnosed and staging requires commencing
antiretroviral treatment, regular care. It can be expected with vigilant secondary prevention there
will be improved health status and health outcomes (Rotherman-Borus, Swendemen &
Chovnick, 2009).
Target Audience
The target audience for this presentation would be high-risk individuals who are
either seronegative or do not know their serostatus.
Audience Summary
What is HIV/AIDS?
Human immunodeficiency virus is a very impressive virus that has become a global
epidemic. HIV effectively counteracts all components of your immune system and hijacks
your own cells mechanisms for replication, causing the cells to replicate the virus. The
virus is very debilitating, eventually shutting down your immune system. This condition is
called acquired immunodeficiency syndrome, or AIDS. Modern treatments with
HIV TRANSMISSION PREVENTION STRATEGIES
antiretroviral therapy can prolong the development of AIDS, but there is not yet a cure for
HIV and AIDS is the final stage of the disease. When HIV infection transitions to AIDS, it
leaves the host open to opportunistic infections, such as pneumonia, and this is usually
what leads to the host’s death.
How prevalent is HIV?
HIV exists in every country on every continent. As of 2010, 33.2 million people had
been infected with HIV worldwide. However, there are wide variations in the prevalence of
HIV. Sub-Saharan Africa has a disproportionately large number of global HIV cases. In that
population, HIV is mainly spread through heterosexual individuals. In the rest of the world,
especially in industrialized countries, the epidemic is spread mainly among “high-risk”
populations. These populations include men who have sex with other men, intravenous
drug users, sex workers, and their partners.
Can you have HIV?
HIV has been particularly difficult to control because its initial phase of infection is
“invisible”. You could be infected for years before you start to manifest any symptoms of
HIV infection. This is why it’s extremely important to get tested regularly, especially if
you’re in a high-risk group.
What steps can I take to avoid HIV transmission?
The best thing to do is to practice safe sex. Barrier methods have been shown to be
very effective in preventing the transmission of HIV. Barrier methods include male
condoms, female condoms, diaphragms, and microbicides. Diaphragms and microbicides have
not been studied well enough to have definitive results, but the primary findings are promising.
HIV TRANSMISSION PREVENTION STRATEGIES
It’s also important to get tested regularly, even if you are practicing safe sex. Methods for safe
sex are not 100% effective, and there is always a risk of HIV transmission.
How do they test for HIV?
Technological advances in HIV testing have made it incredibly quick and easy. You
can get results in as little as 20 minutes, and they can get the sample from simply swabbing
your saliva from your mouth. There are even testing kits that you can order, which allow
you to maintain your privacy. The shortcoming of this type of test is that it cannot detect
HIV antibodies in the initial “invisible” phase of the infection, so you can falsely test
negative during this period. If you feel you may have been in contact with HIV, you can also
go to your primary care physician and have a blood test done where they can directly
identify the virus and your viral load.
What do I do if I test positive for HIV?
If you test positive for HIV, you must seek HIV care immediately. It’s imperative that
you start antiretroviral therapy as quickly as possible. Antiretroviral therapy can prolong
the development of AIDS and can keep your viral load low. Maintaining a low viral load will
increase your overall health as well as decrease the chance of transmitting the disease to
others.
Where can I get help?
Remember, it’s very important to get tested, especially if you’re in a high-risk group.
You can get tested at your local health department, order a test, or get tested by your
primary physician. If you test positive, you should immediately contact your primary care
physician to begin HIV treatment.
HIV TRANSMISSION PREVENTION STRATEGIES
References
Baeten, J., Donnell, D., Ndase, P., Mugo, N., Campbell, J., Wangisi, J. … Celum, C. (2012).
Antiretroviral prophylaxis for hiv prevention in heterosexual men and women. The New
England Journal of Medicine, 367, 399-410.
Fisher, J., & Smith, L. (2009). secondary prevention of hiv infection: The current state of
prevention for positives. Curr Opin HIV AIDS, 4, 279-287.
Fisher, J., Smith, L., & Lenz, E. (2010). Secondary prevention of hiv in the united states:
Past, current, and future perspectives. J Acquir Immune Defic Synd, 55, 106-115.
Gardner, E., McLees, M., Steiner, J., del Rio, C., & Burman, W. (2011). The spectrum of
engagement in hiv care and its relevance to test-and-treat strategies for prevention of hiv
infection.HIV/AIDS, 52, 793-800.
Quinn, T. (1996). Global burden of the hiv pandemic. The Lancet, 348, 99-106.
Rotheram-Borus, M., Swendemen, D., & Chovnick, G. (2009). The past, present, and future of
hiv prevention: Integrating behavioral, biomedical, and structural intervention strategies
for the next generation of hiv prevention. Annu Rev Clin Psychol, 5, 143-167.
What is HIV/AIDS?
Human immunodeficiency virus is transmitted through contact with infected blood and effectively
counteracts all components of your immune system to hijack your own cells mechanisms for
replication, causing the cells to replicate the virus. The virus is very debilitating, eventually shutting
down your immune system. This condition is called acquired immunodeficiency syndrome, or AIDS.
Modern treatments with antiretroviral therapy can prolong the development of AIDS, but there is not
yet a cure for HIV and A IDS is the final stage of the disease. When HIV infection transitions to AIDS, it
leaves the host open to opportunistic infections, such as pneumonia, and this is usually what leads to
the host’s death.
Are you at risk?
How can I be safe?
HIV is spread through contact with
infected blood. Anyone can catch
HIV through unsafe sex practices,
however, the people at highest risk
for HIV infection are:
• IV drug users
• Men who have sex with other
men
• Partners of men who have sex
with other men
The best thing you could do is
practice safe sex. Barrier methods
have been shown to be very effective
in preventing HIV transmission, but
they are not 100% effective. Barrier
methods include:
• Male condoms
• Female condoms
• Diaphragms
• Microbicides
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