"We're going to have to cut loose some of our personal beliefs": barriers and opportunities in providing HIV prevention to African American men who have sex with men and women

In the United States, there is an urgent need to provide HIV prevention services to African American men who have sex with men and women (MSMW) but who do not identify as gay or homosexual. Engaging these men in HIV prevention has historically been challenging. This study used qualitative methodology to explore the beliefs and experiences from community-based service providers (n = 21) and from African American MSMW (n = 21) regarding the provision of HIV prevention education and counseling to these men. Data analysis revealed that (a) African American MSMW who do not identify as gay can challenge service providers' assumptions about sexual behavior and sexual identity; (b) service providers' attitudes toward these men can be affected by ambivalent or negative beliefs that pervade the general community; (c) African American MSMW need safe and nonjudgmental spaces that offer HIV risk reduction, but they also might experience anxiety about disclosing same-sex behaviors to counselors. Findings highlighted the complexities related to culture, masculinity, and sexuality as determinants of HIV risk in African American MSMW, and findings also revealed tensions between these factors that may affect the quality of HIV prevention services. Service providers may need additional training to provide appropriate and non-judgmental HIV prevention counseling and education.     

Translating Concern into Action: HIV Care Providers’ Views on Counseling Patients about HIV Prevention in the Clinical Setting

Recent Centers for Disease Control (CDC) guidelines recommend that HIV care practitioners provide HIV prevention counseling to patients at routine medical visits. However, research shows that HIV care practitioners provide such counseling infrequently, presenting a challenge for clinics implementing these guidelines. Our qualitative study of 19 HIV care providers at an infectious diseases clinic in the southeastern US explored providers’ beliefs about their patients’ HIV transmission behaviors, expected outcomes of conducting HIV prevention counseling, and perceived barriers and facilitators to counseling. Providers’ concern about HIV transmission among their patients was high but did not “translate into action” in the form of counseling. They anticipated poor outcomes from counseling, including harm to patient–provider relationships, and failure of patients to change their behavior. They also listed barriers and facilitators to counseling, most importantly time, state reporting policies, and conversational triggers. Implications for implementation of CDC guidelines and clinic-based “Prevention with Positives” programs are discussed.     

Supporting Positive Living and Sexual Health (SPLASH): A Clinician and Behavioral Counselor Risk-Reduction Intervention in a University-Based HIV Clinic

Effective HIV prevention interventions with HIV-positive persons are paramount to stemming the rate of new infections. This paper describes an HIV-clinic-based demonstration project aimed at decreasing patient HIV-transmission risk behaviors and sexually transmitted infections. Systematic, computer-assisted assessment of patient risk aided primary care providers in delivering prevention messages. Patients at greater risk were referred to an HIV Prevention Specialist for behavioral counseling. Patients completed a computerized behavioral staging assessment to self-identify risk behaviors and readiness to change behaviors and counseling messages were individually tailored based on computer assessment. Challenges to project implementation: primary care provider buy-in, patient privacy concerns during risk assessment, and low participation in behavioral counseling. Forty-six percent of persons completing a risk assessment (2,124) were at risk for HIV transmission. Of 121 patients who scheduled counseling appointments, 42% completed at least one session. Despite challenges, successful implementation of a clinic-based prevention intervention is feasible, particularly with attention to patient and provider concerns.     

Missed opportunities for HIV testing in health care settings among young African American men who have sex with men: implications for the HIV epidemic

Limited health care access and missed opportunities for HIV and other sexually transmitted infection (STI) education and testing in health care settings may contribute to risk of HIV infection. In 2008, we conducted a case-control study of African American men who have sex with men (MSM) in a southeastern city (Jackson, Mississippi) with an increase in numbers of newly reported HIV cases. Our aims were to evaluate associations between health care and HIV infection and to identify missed opportunities for HIV/STI testing. We queried 40 potential HIV-infected cases and 936 potential HIV-uninfected controls for participation in this study. Study enrollees included HIV-infected cases (n=30) and HIV-uninfected controls (n=95) who consented to participate and responded to a self-administered computerized survey about sexual risk behaviors and health care utilization. We used bivariate analysis and logistic regression to test for associations between potential risk factors and HIV infection. Cases were more likely than controls to lack health insurance (odds ratio [OR]=2.5; 95% confidence interval [CI]=1.1-5.7), lack a primary care provider (OR=6.3; CI=2.3-16.8), and to not have received advice about HIV or STI testing or prevention (OR=5.4; CI=1.3-21.5) or disclose their sexual identity (OR=7.0; CI=1.6-29.2) to a health care provider. In multivariate analysis, lacking a primary health care provider (adjusted odds ratio [AOR]=4.5; CI=1.4-14.7) and not disclosing sexual identity to a health care provider (AOR=8.6; CI=1.8-40.0) were independent risk factors for HIV infection among African American MSM. HIV prevention interventions for African American MSM should address access to primary health care providers for HIV/STI prevention and testing services and the need for increased discussions about sexual health, sexual identity, and sexual behaviors between providers and patients in an effort to reduce HIV incidence and HIV-related health disparities.     

HIV Education Needs Among Sudanese Immigrants and Refugees in the Midwestern United States

Migrant populations may be particularly vulnerable to infectious diseases and often need special considerations in terms of health care. In particular, migrant populations can be at high risk for HIV infection, in part due to lack of education about disease acquisition. This study evaluated knowledge, attitudes, and beliefs about HIV/AIDS as well as risk behavior in the Sudanese immigrant and refugee population of Nebraska (N = 47). The results demonstrated that a significant proportion of individuals from this population are poorly educated about HIV infection, exhibit attitudes and beliefs that may increase their risk for disease acquisition, and create barriers to HIV prevention and care, and engage in high-risk sexual behaviors. Appropriate educational materials are lacking, and there is a pressing need for improved access to culturally appropriate HIV education for this vulnerable population.     

Gonorrhea incidence and HIV testing and counseling among adolescents and young adults seen at a clinic for sexually transmitted diseases.

OBJECTIVE: To determine whether HIV testing and posttest counseling may be associated with an increase in gonorrhea incidence among adolescents and young adults seen at a clinic for sexually transmitted diseases (STD). DESIGN: A historical cohort study with the collection of longitudinal data on the patients' HIV testing and counseling experience. SETTING: Delgado STD clinic of New Orleans, Louisiana, a public ambulatory primary care center that serves mainly the economically disadvantaged Black population. PATIENTS: A record-based inception cohort of 4031 patients aged 15-25 years diagnosed at the clinic between June 1989 and May 1991 with a first lifetime gonorrhea infection. INTERVENTION: Routine confidential HIV tests and posttest counseling sessions experienced at the clinic during follow-up. OUTCOME MEASURE: Incidence rate of reported gonorrhea reinfection. RESULTS: Of the patients, 51.5% were tested once for HIV antibodies and 25.9% twice or more. Formal posttest counseling occurred after 8.5% of the 4665 HIV-negative and 44.0% of the 49 HIV-positive tests. In the most pessimistic of several models controlling for history of gonorrhea, HIV testing and counseling history, and other potential confounding factors, a significantly lower rate of gonorrhea reinfection was observed after a first HIV-negative test than before [adjusted relative risk (RR), 0.66; 95% confidence interval (CI), 0.59-0.74; P < 0.00011. As compared with the pretest period, significantly higher rates of gonorrhea were observed after respectively a second (RR, 1.18; 95% CI, 1.01-1.37; P = 0.03) and a third (RR, 1.52; 95% CI, 1.22-1.88; P = 0.0001) HIV-negative test. No significant association was found between HIV-positive testing and any variation in gonorrhea rate (RR, 0.95; 95% CI, 0.56-1.62; P = 0.85). Posttest counseling for HIV-negative and HIV-positive results were followed respectively by a significantly higher rate of gonorrhea (RR; 1.27; 95% CI, 1.09-1.48; P = 0.002) and a non-significantly lower rate of gonorrhea (RR, 0.53; 95% CI, 0.17-1.60; P = 0.85). CONCLUSION: Our results do not exclude the possibility of a modest increase in gonorrhea incidence after routine HIV testing and counseling in an STD clinic. Nevertheless, this conclusion holds only under the least favorable assumptions and applies solely to a minority of patients.     

Factors influencing the acceptance of changes in antiretroviral therapy among HIV-1-infected patients

Physicians routinely consider modifying antiretroviral therapy (ART) regimen for their patients with HIV. Little is known about the factors associated with patients' willingness to accept providers' recommended ART changes. This multicenter prospective observational study examined factors associated with willingness to accept ART changes recommended by their providers among HIV-infected adults from six urban outpatient HIV clinics. Patients were surveyed using the Patient Attitudes about Altering Antiretroviral Therapy Survey questionnaire (PAAARTS). Factors associated with willingness to accept ART changes were assessed using a multivariate generalized estimating equation (GEE) model to account for correlated responses. The Classification and Regression Trees (CART) analysis was also performed to determine subgroups of patients with higher acceptance of change. 216 of 289 patients (75%) definitely accepted recommended changes. Odds for acceptance were 3.2, 2.3, and 2.8 times higher for patients with higher attitudes and beliefs about ART (p < 0.01; 95% confidence interval [CI] = 1.59, 6.52), patients who rated their provider's care as excellent (p < 0.05; 95% CI = 1.07, 4.78), and non-Hispanic patients (p < 0.05; 95% CI 1.03, 7.57), respectively. CART analysis showed similar results and identified that when patients had less positive attitude about ART, acceptance rates were higher for non-Hispanic patients with higher assessments of their patient-provider communication. While most patients accepted providers' recommendation for ART changes, this willingness was influenced by both patients' attitudes and beliefs about ART and their assessment of either the effectiveness of patient-provider communication or their rating of providers' care. ART acceptance rates among Hispanic patients were lower.     

A mobile HIV education and testing program: bringing services to hard-to-reach populations

Few programs exist that offer a range of human immunodeficiency virus (HIV) services to multiple populations (i.e., substance abusers, individuals on probation, sex workers and their clients, court-mandated perpetrators of domestic violence) in multiple settings (i.e., courts, methadone maintenance clinics, residential and outpatient substance abuse treatment programs). The purpose of this article is to describe a model mobile HIV program, highlighting its flexibility in providing services to clients who infrequently present to traditional clinic-based testing sites. This mobile HIV program was developed to provide on-site HIV testing and counseling, education, and linkages to primary care services. The implementation of the program begins with training of agency staff, who then provide preliminary orientation with clients regarding HIV testing. Approximately 3 weeks later, the mobile program staff (HIV nurse specialist and HIV counselors) provide standardized group pretest counseling and education. Clients who decide to be tested meet with mobile program staff for individualized risk assessment and specimen collection. Two weeks later, clients meet with mobile program staff to obtain results and receive posttest counseling; risk reduction strategies are reemphasized at that time. Unique to this program is the provision of referrals for a wide range of primary care services for both seropositive and seronegative clients. Since 1994, the mobile program has been implemented at six sites, and over 1100 clients have been served. Two major outcomes from the program have been observed: 1. With adequate preparation and psychological support, 40% of hard-to-reach populations will elect to be HIV tested. 2. Through social networks of program participants, HIV-positive individuals not previously engaged in care have been referred to a comprehensive HIV primary care program.     

Assessment of emergency department health care professionals' behaviors regarding HIV testing and referral for patients with STDs

The objective of this study was to evaluate human immunodeficiency virus (HIV) counseling, testing, and referral practices of emergency department health care professionals (i.e., medical doctors [MD], physician assistants [PA], nurse practitioners [NP], and registered nurses [RN]) for patients presenting with other sexually transmitted diseases (STD). All health care professionals from 10 emergency departments in a northeastern county were asked to complete an anonymous survey. The surveys were returned by 154 (41%) health care professionals (RN = 99, NP = 5, PA = 7, MD = 39, other = 4). The average years in practice were 11. Only 7% of respondents were certified to provide state mandated HIV pretest counseling (certification not required for MD). Respondents reported caring for an average of 13 patients per week with suspected STD. Fifty-five percent of respondents reported that they always or usually warn STD patients of their HIV risk, yet only 10% always or usually encouraged these patients to consent to HIV testing in their emergency department (RN = 7%, NP = 25%, PA = 0%, MD = 16%). Reasons for not offering HIV testing in their emergency department were follow-up concerns (51%), not certified to provide pretest/posttest counseling (45%), and too time consuming (19%). Twenty-seven percent of respondents indicated HIV testing was not available in their emergency department despite all hospital laboratories reporting HIV testing capability. Ninety-three percent of respondents were aware that confidential testing sites were available, but only 35% always or usually referred patients not tested in the emergency department elsewhere for testing. Emergency department health care professionals frequently fail to provide HIV counseling, testing, and/or referral for patients with suspected STD.     

A community-based study of barriers to HIV care initiation

Timely treatment of HIV infection is a public health priority, yet many HIV-positive persons delay treatment initiation. We conducted a community-based study comparing HIV-positive persons who received an HIV diagnosis at least 3 months ago but had not initiated care (n=100) with a reference population of HIV-positive persons currently in care (n=115) to identify potential barriers to treatment initiation. Study participants were mostly male (78.0%), and persons of color (54.9% Latino, 26.3% black), with median age 37.8 years. Median time since HIV diagnosis was 3.7 years. Univariate analysis revealed that those never in care differed substantially from those currently in care with regard to sociodemographics; HIV testing and counseling experiences; perceived barriers to care; and knowledge, attitudes, and beliefs regarding HIV. Factors independently associated with never initiating HIV care were younger age (adjusted odds ratio [AOR]=0.93; 95% confidence interval [CI]: 0.88, 0.99), shorter time since diagnosis (AOR=0.87; 95% CI: 0.77, 0.98), lacking insurance (AOR=0.11; 95% CI: 0.03, 0.35), not knowing someone with HIV/AIDS (AOR=0.09; 95% CI: 0.03, 0.30) not disclosing HIV status (AOR=0.13; 95% CI: 0.02, 0.70), not receiving help making an HIV care appointment after diagnosis (AOR=0.04; 95% CI: 0.01, 0.14), and not wanting to think about being HIV positive (AOR=3.57; 95% CI: 1.22, 10.46). Our findings suggest that isolation and stigma remain significant barriers to initiating HIV care in populations consisting primarily of persons of color, and that direct linkages to HIV care at the time of diagnosis are critical to promoting timely care initiation in these populations.     

STD and HIV counseling practices of British Columbia primary care physicians

This study evaluated British Columbian primary care physicians' use of sexually transmitted disease (STD) and HIV counseling guidelines. The authors sought to assess barriers to integrated HIV and STD testing and counseling, with the objective of developing and revising practice guidelines to meet the needs of primary care physicians in diverse settings. The BC College of Physicians and Surgeons membership of general practice/family medicine practitioners was stratified by practitioner location; 1200 physicians were randomly selected to receive a mailed self-administered questionnaire. Four hundred seven completed questionnaires were returned. Female physicians reported better adherence to practice guidelines on many items than their male counterparts. A minority of primary care physicians routinely integrated HIV and STD testing and counseling. Physicians in nonurban areas were more likely to report that they lacked sufficient information on HIV and STD risk and prevention. Although male primary care physicians in British Columbia were more likely to provide care for people with HIV infection, female physicians were more likely to undertake ongoing screening for sexual risk behavior and sexually transmitted infections (STIs) among their HIV-positive patients. Clinical practice guidelines are theoretically equally available to all physicians, but they are not universally used. Physicians may not receive adequate training in sexual health during their medical education; continuing education opportunities may be limited to physicians outside of urban centres. Accessible and relevant continuing medical education in novel formats are needed to address the gap between ideal and actual practice in HIV and STD prevention, treatment, and care in Canada.     

Changes in knowledge, attitudes, and behavior as a result of a community-based AIDS prevention program

The study evaluates the outcome of a California-based AIDS prevention program, "Stop AIDS." Community discussion groups focusing on information, attitudes, and behavior associated with HIV infection and transmission were conducted in one-time, 3 1/2-hour sessions. Participants completed different versions of the AIDS Prevention Test before and after the discussion group. Significant positive shifts in information, attitudes, and behavior were observed as a function of the discussion group participation. Whereas pretest knowledge correlated with pretest behavior and posttest knowledge, only pretest behavior correlated with the crucial variable of posttest intended behavior. When changes from pretest to posttest were analyzed, both information and attitude change correlated to changes in behavior. The intervention and evaluation procedures are proposed as a replicable national model for community-based AIDS prevention programs.     

Individual-level predictors for HIV testing among antenatal attendees in Lusaka, Zambia

Despite the availability of antiretroviral prophylaxis, roughly one-fifth of public-sector antenatal patients decline HIV testing in Lusaka, Zambia. We administered a survey to determine individual-level predictors of HIV testing. Of 1064 antenatal attendees approached after pretest counseling, 1060 (>99%) participated. Of these, 686 (65%) agreed to HIV testing. On bivariate analysis controlling for clinic of attendance, women younger than 20 years old (adjusted RR [ARR] = 1.14), unmarried (ARR = 1.14), pregnant for the first time (ARR = 1.14), with lower educational attainment (ARR = 1.15), and with lower income (ARR = 1.14) were all more likely to undergo testing. When HIV risk was considered, women with low self-perceived risk were most likely to undergo HIV testing. As risk perception increased, likelihood for testing decreased (P for trend < 0.001). Although not statistically predictive, we identified prevalent community beliefs that may act as barriers to testing. Because individual-level characteristics were only weakly predictive of HIV testing, future work should concentrate on community-level factors.     

Providers’ perspectives on preconception counseling and safer conception for HIV-infected women

Introduction: Unplanned pregnancy among HIV-infected women can have negative health consequences for women, partners, and neonates. Despite recommendations, preconception counseling (PCC) appears to be infrequently addressed in HIV care. This study explored knowledge, attitudes, and practices among health-care providers regarding PCC, safer conception and pregnancy among HIV-infected women. Methods: Physicians, physician assistants, and nurse practitioners (n = 14) providing obstetric/gynecological and HIV care in urban south Florida public and private hospitals completed structured qualitative interviews. Dominant themes arising included provider perceptions of patient knowledge and practices, provider knowledge and attitudes regarding safer conception, and provider practices regarding reproductive health. Results: Providers perceived patients to have limited reproductive knowledge. Patients’ internalized HIV stigma was a barrier to patient initiation of conception-focused discussions. Provider knowledge and utilization of PCC protocols were limited. PCC barriers included competing medical priorities, failure to address fertility desires, limited knowledge, time limitations, and unclear standard of care. Providers routinely used condom-based HIV prevention as a proxy for addressing reproductive intentions. Discussion: Provider, patient, and structural factors prevented implementation of PCC and provision of information on safer conception; neither were routinely discussed during consultations. Both providers and patients may benefit from interventions to enhance communication on conception.     

HIV testing practices as reported by HIV-infected patients in four European countries

HIV testing constitutes an important strategy to control the HIV epidemic, which therefore merits an observation of HIV testing practices to help improve testing effectiveness. In 2008, a cross-sectional survey among recently diagnosed (≤ 3 years) HIV-infected patients was conducted in Belgium, Estonia, Finland and Portugal. Participants were questioned about reasons for HIV testing, testing place and testing conditions. Univariate and multivariate analyses were performed. Out of 1460 eligible participants, 629 (43%) were included. Forty-one per cent were diagnosed late and 55% had never undergone a previous HIV test with perceived low risk being the primary reason for not having been tested earlier. Heterogeneity in HIV testing practices was observed across countries. Overall, tests were most frequently conducted in primary care (38%) and specialised clinics (21%), primarily on the initiative of the health care provider (65%). Sixty-one per cent were tested with informed consent, 31% received pretest counselling, 78% received post-test counselling, 71% were involved in partner notification and 92% were in care three months after diagnosis. The results showed that HIV testing is done in a variety of settings suggesting that multiple pathways to HIV testing are provided. HIV testing practice is being normalised, with less focus on pretest counselling, yet with emphasis on post-test follow-up. Major barriers to testing are centred on the denial of risk. Efforts are needed to concurrently promote public awareness about HIV risk and benefits of HIV testing and train clinicians to be more proactive in offering HIV testing.     

Medication adherence practices of HIV/AIDS case managers: a statewide survey in North Carolina

The primary objective of this study was to examine the adherence-related practices and attitudes of HIV/AIDS case managers in North Carolina. All North Carolina HIV/AIDS case managers (n = 111) employed by agencies that were state certified to provide HIV case management were sent an adherence counseling survey. Negative binomial regression was used to examine the relationship of case managers' characteristics and attitudes with their medication adherence counseling practices. Of the 94 HIV/AIDS case managers who responded to the survey, the majority (65%) reported discussing medications with almost every client. The adherence-related behaviors that case managers most frequently provided were related to monitoring medication usage rather than providing medication instruction. Most case managers believed that medication adherence counseling is part of their role (77%); however, a substantial minority, (36%) did not believe that their adherence counseling skills were adequate. Multivariate analysis revealed that case managers who provided more adherence counseling services reported greater confidence in their adherence counseling skills, believed that adherence counseling is a HIV/AIDS case management role, and had a higher proportion of substance-abusing clients in their caseload. The adherence counseling activities of HIV/AIDS case managers can potentially supplement the counseling provided by other health professionals and promote greater adherence to medications. However, variability in perceived skills and adherence-related activities suggests that the role of case managers in medication adherence counseling needs to be better defined and appropriate training provided to meet the expectations of this role.     

Sex,Risk and Responsibility: Provider Attitudes and Beliefs Predict HIV Transmission Risk Prevention Counseling in Clinical Care Settings

We examined factors associated with the frequency of HIV “prevention with positives” (PwP) counseling delivered by providers participating in demonstration projects at 26 clinics. Three hundred and fifteen primary care and support service providers completed a survey assessing the frequency of PwP delivered at initial medical care visits and at regular care visits. Providers reported delivering PwP counseling to more patients at initial visits (67%) than to those returning for regular care (53%; t = 11.8, p < 0.001). During initial and regular care visits, providers reporting a sense of responsibility for conducting PwP and those regularly discussing the risk of reinfection with patients reported significantly more frequent PwP counseling. Providers expressing a belief that no matter how much counseling was delivered, some HIV-infected patients would still infect others (prevention fatalism) reported significantly less frequent counseling at all visits. To improve the quality and quantity of HIV PwP counseling, providers training should address attitudinal barriers and facilitators to counseling and the importance of addressing risk routinely.     

Behavioral change in preventive medicine

We designed and evaluated a program to teach internal medicine residents behavioral counseling skills for multiple risk factor modification. Integrating physician-patient communication, negotiation skills, and the transtheoretical model of behavior change, we used small group discussion and standardized patients. The 18 participating residents increased their ability to modify patient behavior during videotaped interviews, mean pretest/posttest score: 33.1/40.1 (Student’s pairedt test, p<.0001). Physician self-efficacy in screening for risk factors and effecting behavioral change in patients was increased (p<.0001), as were positive attitudes toward psychosocial factors (p<.003). Our teaching effectively increased the residents’ self-efficacy and performance of behavioral counseling.     

Effect of an HIV counseling and testing program on AIDS-related knowledge and practices in tuberculosis clinics in Abidjan, C?te d'Ivoire.

SETTING: Two out-patient tuberculosis treatment centers, Abidjan, C?te d'Ivoire. OBJECTIVE: To assess the effect of a human immunodeficiency virus (HIV) counseling and testing program on acquired immune-deficiency syndrome (AIDS) related knowledge and behaviors among persons with newly diagnosed tuberculosis. DESIGN: Since 1994, patients with newly diagnosed tuberculosis have received individual or group HIV pretest counseling, informed consent, free HIV testing for those who consent, and post test counseling. From January 1995 through August 1996 in Abidjan's two largest tuberculosis clinics, knowledge and beliefs about HIV/AIDS were assessed before and immediately after the group pretest sessions, and again 4 months later. RESULTS: Prior to pretest counseling, 68.9% and 68.0% of the 559 enrolled subjects could correctly identify five modes of HIV transmission and five modes of HIV prevention. These proportions increased significantly immediately after pretest counseling (90.0%, 86.6%, respectively), and remained higher 4 months later (83.7%, 87.7%) (all P < 0.01). Among men, consistent condom use during the preceding 4 months with a partner who was not a commercial sex worker increased from 9.9% at enrollment to 23.6% at the 4-month visit (P = 0.001), but not for women (6.3% vs. 9.5%, P = 0.40). CONCLUSIONS: An HIV pretest counseling program conducted in an out-patient tuberculosis clinic was well accepted, and significantly increased the level of HIV/AIDS knowledge and, among men, self-reported condom use.