Abstract and Introduction
Clinician-delivered prevention interventions offer an opportunity to integrate risk-reduction counseling as a routine part of medical care. The HIV Intervention for Providers study, a randomized controlled trial, developed and tested a medical provider HIV prevention training intervention in 4 northern California HIV care clinics. Providers were assigned to either the intervention or control condition (usual care). The intervention arm received a 4-hour training on assessing sexual risk behavior with HIV-positive patients and delivering risk-reduction-oriented prevention messages to patients who reported risk behaviors with HIV-uninfected or unknown-status partners. To compare the efficacy of the intervention versus control on transmission risk behavior, 386 patients of the randomized providers were enrolled. Over six-months of follow-up, patients whose providers were assigned the intervention reported a relative increase in provider-patient discussions of safer sex (OR = 1.49; 95% CI = 1.06 to 2.09), assessment of sexual activity (OR = 1.60; 95% CI = 1.05 to 2.45), and a significant decrease in the number of sexual partners (OR = 0.49, 95% CI = 0.26 to 0.92). These findings show that a brief intervention to train HIV providers to identify risk and provide a prevention message results in increased prevention conversations and significantly reduced the mean number of sexual partners reported by HIV-positive patients.
Improved HIV treatments and decreased mortality from AIDS-related illnesses have been paralleled by increases in HIV infection rates. Even as many HIV-positive persons take steps to reduce their risk for transmitting the virus, high-risk sexual behaviors continue to be reported. In San Francisco, for example, among men who have sex with men, the numbers of those living with AIDS increased over 15% from 2000 to 2007, whereas during the same period, the percent of HIV-infected men who have sex with men reporting unprotected anal sex in the last 6 months increased from 46% to 67%. Further, one study estimated that approximately 33% of HIV-positive individuals, across all groups and in different geographical settings, have unprotected anal and vaginal intercourse. More specifically, in a study of sexual risk behavior among HIV-positive intravenous drug users (IDUs), Purcell et al found 27% had engaged in unprotected anal or vaginal intercourse in the 3 months before study enrollment. Multiple studies, therefore, have demonstrated parallel increases in sexual risk behavior among high-risk individuals nationwide. Further, research has shown that these behaviors continue even when individuals are knowledgeable about transmissions risks.
Increasing availability of HIV antiretroviral therapy and the consequent decreases in morbidity and mortality among HIV-infected individuals has transformed the experience of being HIV infected. Important improvements in the health and well being of people living with HIV/AIDS (PLWHA), however, bring new challenges. Research with HIV-infected individuals indicates that their prevention needs are different from the prevention needs of those who are not HIV infected. As one recent study showed, HIV-infected persons reported high rates of knowledge about how HIV is prevented in general (eg, abstain from sex, be faithful to partners, use condoms when having sex) but were uncertain about how to approach specific risk-reduction behavior changes within their own lives and personal relationships. This included uncertainty regarding specific prevention behaviors and factors that may affect risk of transmission with different sexual partners. The prevention needs of PLWHA differ and can include negotiating sexual relationships, disclosure to partners, preventing transmission to partners or unborn children, and dealing with the stigma of HIV infection-posing a challenge to develop effective interventions.
In response to the specific needs of PLWHA, therefore, several behavioral prevention interventions have been developed and tested to understand the potential impacts by interventions on risk behavior. These range from individual interventions and group interventions to peer empowerment interventions. These interventions are effective and have shown that they can affect the risk behavior of serostatus-aware HIV-infected individuals. Research has also revealed that the clinical setting may be an opportune site for HIV Positive Prevention (PP). Indeed, it has become clear that many PLWHA not only maintain an interest in HIV prevention-related topics but are willing to dialogue with their medical providers about prevention.
Within the HIV care setting, the one-on-one interactions that occur between providers and patients provide excellent opportunities to integrate risk-reduction counseling because of the following: (1) most patients see their providers on a regular basis; (2) patients may be comfortable discussing intimate issues with their providers; and (3) risk-reduction counseling is an extension of clinical health care. Numerous studies also demonstrate that clinicians can be trained to be effective risk-reduction counselors. For example, clinician-based counseling interventions addressing sexually transmitted infection risk, tobacco and alcohol use, nutrition, and exercise have been successfully implemented and readily adapted by providers. Linking clinician-delivered prevention messages to the HIV clinical care setting, therefore, may reduce HIV transmission risk behavior. For this reason, the integration of PP services into the standard of care in HIV clinical settings is one of the national objectives of the CDC HIV Prevention Strategic Plan.
Despite the unique opportunity presented by the clinical setting to engage in HIV prevention, there are challenges in implementing such interventions. Few medical providers are adequately trained to deliver health education and prevention content within the medical care encounter. In one study, strategies in addressing PP varied considerably among healthcare providers. Among those who discussed transmission risk with patients, some performed HIV risk assessment and prevention counseling only in the initial encounter, while the counseling efforts of others were triggered by specific medical conditions such as emergent sexually transmitted infections. Further, a number of providers assessed risk behavior in response to patient questions, and still others reported regularly assessing risk and providing prevention counseling to their HIV patients.
Considering this variation in the delivery of prevention messages, it may be that providers' attitudes toward PP affect whether HIV-positive patients are provided with risk assessments and risk-behavior counseling. Myers et al report that some providers felt uncomfortable discussing sex and drug use. In another study, some HIV providers expressed concern over expanding their role beyond that of providing treatment to include a responsibility for carrying out risk assessment and prevention counseling. Time also is a factor for many providers who believe they must prioritize the clinical needs of the patient over delivering public health messages. Although studies have demonstrated that a clinician-delivered HIV prevention intervention can be effective in reducing risk behavior, these studies have utilized various theoretical approaches to addressing risk and prevention in the HIV clinical setting, for example, framing messages and clinician motivational interviewing techniques utilizing the Information Motivation and Behavioral framework. The HIV Intervention for Provider (HIP) intervention, by contrast, provided for a flexible prevention model that was focused on clinician-initiated prevention conversations, assessing patient risk in a detailed manner that would provide an understanding of behavior and context of risk, improving the ability of providers to deliver a prevention message that is tailored to the individual, adapted to their way of practice, and is sensitive to incremental reductions in risk.
In the current study, we trained HIV health care providers to conduct one-on-one prevention interventions with their HIV-positive patients during routine clinical visits. Through emphasizing a tailored approach to risk reduction oriented in a risk-reduction framework, we understand that eliminating risk behavior is not always achievable and that working toward incremental change and/or risk elimination through developing understandings of behavior and context is vital. Our intervention, therefore, trained providers to assess patients and intervene to reduce risk. We hypothesized that the intervention would build providers' skills to ask detailed questions about patient behavior, develop a risk assessment, and then deliver a prevention message, leading to increased communication between patients and their providers and a resulting decrease in risk behavior among patients. To test this hypothesis, we assessed the effect of the intervention on patient sexual behavior, examining the intervention effect on unprotected vaginal or anal intercourse with HIV-negative or unknown-status partners.