HIV prevention in primary care: impact of a clinical intervention

Discomfort, lack of confidence in skills, and environmental constraints may cause primary care providers to miss opportunities to discuss human immunodeficiency virus (HIV) risk with patients. We used a systems approach to address both intrapersonal and environmental barriers to HIV risk assessment and prevention counseling in a managed care clinical setting. The design was one-group pretest/posttest. The study took place in two primary care clinics of a large Pacific Northwest managed care organization. Participants (n = 49) included physicians, physician assistants, nurse practitioners, registered nurses, and social workers. The intervention included training, clarification of provider/staff roles, assess to tools and materials, and reminders/reinforcers. Outcome measures were provider attitudes, beliefs, outcome expectations, knowledge, confidence in skills, and perceived supports and barriers, measured by written pretest/posttest surveys administered 12 months apart. Seven months after the most intensive part of the intervention, providers' attitudes and beliefs were more favorable to HIV risk assessment and prevention counseling. They were less likely to express frustration with high-risk patients (decrease from 100% to 79% agreement, p = 0.001) and more confident that their advice would be effective with gay men and single adult heterosexuals (p = 0.002 and 0.005, respectively). They reported more confidence in their training in sexual history taking (p = 0.0003) and their skills assessing readiness for change (p = 0.007), and more support in practice environments. This study demonstrated that it is possible to affect important personal and environmental factors that influence primary care providers' HIV prevention behavior using an interactive, real-world systems approach. Further research is needed on providers' impact on patient behavior.     

Integrating HIV care and HIV prevention: legal, policy and programmatic recommendations

Since the start of the HIV epidemic we have witnessed significant advances in our understanding of the impact of HIV disease worldwide. Furthermore, breakthroughs in treatment and the rapid expansion of HIV care and treatment programmes in heavily impacted countries over the past 5 years are potentially critical assets in a comprehensive approach to controlling the continued spread of HIV globally. A strategic approach to controlling the epidemic requires continued and comparable expansion and integration of care, treatment and prevention programmes. As every new infection involves transmission, whether vertically or horizontally, from a person living with HIV/AIDS (PLWHA), the integration of HIV prevention into HIV care settings has the potential to prevent thousands of new infections, as well as to improve the lives of PLWHA. In this paper, we highlight how to better utilize opportunities created by the antiretroviral roll-out to achieve more effective prevention, particularly in sub-Saharan Africa. We offer specific recommendations for action in the domains of healthcare policy and practice in order better to utilize the advances in HIV treatment to advance HIV prevention.     

Sustaining HIV prevention: HIV testing in health care settings

The Centers for Disease Control and Prevention (CDC) recently issued revised HIV testing recommendations, including a recommendation for routine, voluntary screening for all persons aged 13 years to 64 years in health care settings. Screening is not based on risk, and prevention counseling in conjunction with HIV testing in health care settings is not required. The revisions were motivated in part by concerns regarding the substantial undiagnosed fraction of prevalent HIV infections in the United States and evidence awareness of HIV infection leads to substantial reductions in high-risk sexual behavior. It is hoped that implementation of these recommendations, which will require coordination and education initiatives, will increase identification of the large number of HIV-infected individuals unaware of their infection status and facilitate their linkage to care. This article summarizes a presentation on HIV prevention and HIV testing in health care settings made by Kevin A. Fenton, MD, PhD, at the 10th Annual Ryan White HIV/AIDS Program Clinical Update in June 2007 in Phoenix, AZ.     

Towards universal access to HIV prevention, treatment, care, and support: the role of tuberculosis/HIV collaboration

Tuberculosis is the oldest of the world's current pandemics and causes 8.9 million new cases and 1.7 million deaths annually. The disease is among the most common causes of morbidity and mortality in people living with HIV. However, tuberculosis is more than just part of the global HIV problem; well-resourced tuberculosis programmes are an important part of the solution to scaling-up towards universal access to comprehensive HIV prevention, diagnosis, care, and support. This article reviews the impact of the interactions between tuberculosis and HIV in resource-limited settings; outlines the recommended programmatic and clinical responses to the dual epidemics, highlighting the role of tuberculosis/HIV collaboration in increasing access to prevention, diagnostic, and treatment services; and reviews progress in the global response to the epidemic of HIV-related tuberculosis.     

Primary care physicians and their HIV prevention practices

A national random-sample survey of 4011 primary care physicians was conducted to determine the extent to which they are providing HIV prevention and clinical services, and to learn what characteristics and attitudes might impede the provision of such services. Physicians were asked about their history-taking practices for new adult and adolescent patients, including asking about the use of illicit drugs (injection and noninjection), the number of sexual partners, use of condoms and contraceptives, past episodes of sexually transmitted diseases (STDs), sexual orientation, and sexual contact with partner(s) at high risk for HIV. A preliminary analysis was conducted and reported earlier by the Centers for Disease Control and Prevention (CDC), focusing on the HIV-prevention services being provided by primary care physicians. This report provides additional analyses from this study, focusing on characteristics and attitudes that may prevent physicians from providing these services. Male physicians and the physicians' belief that patients would be offended if asked questions about their sex behaviors were strongly predictive of not asking new patients about their sex and drug behaviors. The physician's specialty was also a strong predictor-OB/GYNs were predictive of asking these questions and GP/FPs were predictive of not asking the questions. Physicians who indicated that a majority of their patients were white were less likely to report asking patients about their sex and drug behaviors. The authors conclude that a substantial number of primary care physicians are missing important opportunities to prevent HIV transmission by not adequately assessing patients' risks and not providing necessary risk-reduction counseling during their physician-patient encounters. Physician's attitudes and beliefs about their patients, as well as their level of experience with HIV, may help to explain these observations.     

Perspectives of HIV agencies on improving HIV prevention,treatment, and care services in the USA

HIV healthcare services in the USA are made available through a complex funding and delivery system. We present perspectives of HIV agencies on improvements that could lead to an ideal system of HIV prevention, treatment and care. We conducted semi-structured interviews with representatives from 21 HIV agencies offering diverse services in Baltimore, MD. Thematic analysis revealed six key themes: (1) Focusing on HIV prevention, (2) Establishing common entry-points for services, (3) Improving information availability, (4) Streamlining funding streams, (5) Removing competitiveness and (6) Building trust. We recommend that in addition to addressing operational issues regarding service delivery and patient care, initiatives to improve HIV service systems should address underlying social issues such as building trust.     

Misconceptions about HIV prevention and transmission in Botswana

Misconceptions about how HIV can be transmitted or prevented often prevent individuals from making informed choices and taking appropriate action. The purpose of the research was to explore the socio-demographic and behavioural factors in Botswana that are associated with misconceptions about HIV prevention and transmission. The data used were from the Botswana AIDS Impact Survey II conducted in 2004, which constitutes a nationally representative sample. Results from bivariate and multivariate analyses show that young people, males, the less educated, those who did not use a condom during their last instance of sexual intercourse, and those who believe that nothing can be done to reduce HIV infection are most likely to harbour misconceptions about how HIV can be prevented and transmitted. Since misconceptions may prevent people from making informed choices, intervention programmes aimed at HIV prevention should aim to dispel misconceptions about HIV and AIDS as an important part of their strategy. Targeted HIV prevention and education programmes are needed in an effort to dispel such misconceptions and likewise to address the needs of different population sub-groups.     

New challenges in HIV care: prevention among HIV-infected patients

The HIV-infected population has been understudied and underserved with respect to risk reduction and prevention interventions. Increases in high-risk sex practices and sexually transmitted diseases (STDs) have prompted considerable concern and have led to initiatives to implement routine STD screening and risk reduction counseling among the HIV-infected population. Available evidence indicates that risk reduction counseling can be effective. Improved attention to risk reduction counseling in the HIV medical care setting in needed, and efforts to improve access and maintain linkage to care must be increased. This article summarizes a presentation given by Carlos del Rio, MD, at the March 2003 International AIDS Society-USA course in Atlanta.     

Maximizing the impact of HIV prevention efforts: Interventions for couples

Despite efforts to increase access to HIV testing and counseling services, population coverage remains low. As a result, many people in sub-Saharan Africa do not know their own HIV status or the status of their sex partner(s). Recent evidence, however, indicates that as many as half of HIV-positive individuals in ongoing sexual relationships have an HIV-negative partner and that a significant proportion of new HIV infections in generalized epidemics occur within serodiscordant couples. Integrating couples HIV testing and counseling (CHTC) into routine clinic- and community-based services can significantly increase the number of couples where the status of both partners is known. Offering couples a set of evidence-based interventions once their HIV status has been determined can significantly reduce HIV incidence within couples and if implemented with sufficient scale and coverage, potentially reduce population-level HIV incidence as well. This article describes these interventions and their potential benefits.     

Culture and African contexts of HIV/AIDS prevention,care and support

Culture plays a vital role in determining the level of health of the individual, the family and the community. This is particularly relevant in the context of Africa, where the values of extended family and community significantly influence the behaviour of the individual. The behaviour of the individual in relation to family and community is one major cultural factor that has implications for sexual behaviour and HIV/AIDS prevention and control efforts. As the impact of HIV/AIDS in Africa remains unabated, a culture-centered approach to prevention, care and support is increasingly recognised as a critical strategy. In this article PEN-3, a model developed to centralise culture in health promotion interventions, is presented as a framework to be used in HIV/AIDS prevention, care and support in Africa. The three domains of the PEN-3 model incorporate specific constructs: relationships and expectations, cultural empowerment, and cultural identity.The cultural empowerment and relationships and expectations domains are ‘assessment/appraisal’ domains used for cultural assessment. Community identity is the ‘application/transformation’ domain that helps the public health practitioner assist the community to identify the point of entry of the intervention. In this paper the authors describe PEN-3 and then present examples of how the assessment/appraisal domains can be utilised to frame HIV/AIDS-related concerns in the context of Africa.     

HIV testing and antiretroviral treatment strategies for prevention of HIV infection: impact on antiretroviral drug resistance

'Test and treat' is a strategy in which widespread screening for human immunodeficiency virus (HIV) is followed by immediate antiretroviral therapy for those testing positive, thereby potentially reducing infectiousness in larger cohorts of infected patients. However, there is a concern that test and treat could lead to increased the levels of transmissible drug-resistant HIV, especially if viral load and/or drug resistance is not routinely monitored. Reviews of the existing literature show that up to now, even in the absence of laboratory tests, drug resistance has not created major problems in sub-Saharan Africa. Here, we discuss the current evidence for the effectiveness of a preventive test and treat approach and the challenges and implications for daily clinical practice and public health.