Abstract
Objectives:
To determine the prevalence of prevention counseling discussions between HIV care providers and their patients who are newly linked to care and to assess factors that facilitate such discussions.
Methods:
In 2009, a probability sample of HIV care providers in 582 outpatient settings in the United States and Puerto Rico was surveyed regarding provider’s HIV prevention discussions with HIV-infected patients newly linked to HIV medical care.
Results:
A majority of providers reported consistently discussing HIV transmission risk reduction (76%), sexually transmitted disease risk (66%), and adherence to antiretroviral regimens (87%). Only 35% of providers reported consistently discussing partner counseling services.
Conclusion:
The proportion of providers engaged in HIV prevention counseling with patients newly linked to HIV care is generally high, but more work is needed to encourage providers to fully participate as partners in prevention, which is central to preventing onward transmission of HIV.
Introduction
The primary role of HIV care providers is to provide medical care for persons with HIV. However, in 2003, the Centers for Disease Control and Prevention (CDC), the Health Resources Services Administration (HRSA), and others recommended incorporating HIV prevention into the medical care of persons living with HIV. 1 These recommendations identified 3 areas for prevention counseling by medical providers: (1) screening for HIV transmission risk behaviors and sexually transmitted diseases (STDs), (2) providing brief behavioral risk-reduction interventions in office settings and referring selected patients for additional prevention interventions and other related services, and (3) facilitating notification and counseling of sex and needle-sharing partners of infected persons. Given the emphasis on prevention activities for HIV-infected persons reflected in the National HIV/AIDS Strategy for the United States, 2 and the central role of HIV care providers in this effort, it is important to assess providers’ prevention counseling practices and determine how best to promote these practices in order to reduce high-risk behaviors among persons living with HIV.
In recent years, only 2 large surveys have examined prevention counseling practices among HIV care providers. In 2001, the Antiretroviral Treatment Access Study (ARTAS) surveyed providers in 4 US cities with a high prevalence of HIV infection (Atlanta, Baltimore, Los Angeles, and Miami). Antiretroviral Treatment Access Study researchers reported that less than 40% of the 317 HIV physicians who responded to the survey always discussed HIV transmission risk reduction with patients new to HIV care. 3 Physician characteristics that were positively associated with HIV transmission risk-reduction counseling included being Hispanic or Asian, perceiving oneself as having enough time with patients and caring for fewer patients. Although not a national survey, the ARTAS targeted all HIV care providers in 4 cities highly impacted by the HIV epidemic in the United States and provided information about providers’ prevention counseling practices before the release of the 2003 CDC/HRSA recommendations for incorporation of HIV prevention in medical settings.
During 2004 to 2006, shortly after the 2003 CDC/HRSA recommendations were released, Myers and colleagues 4 conducted an HIV provider survey focused on HIV prevention counseling practices in 26 clinics that were part of 15 HRSA demonstration sites. Of the 318 survey respondents, 67% discussed prevention topics with HIV-infected patients at initial care visits. Factors positively associated with prevention discussions included the providers’ sense of responsibility for talking about safer sex and the need to explain the risk of reinfection. Providers who believed that some patients would transmit the virus to others no matter how much counseling was delivered were less likely to discuss prevention with patients.
In order to provide more current data on HIV provider prevention counseling practices, we conducted an analysis of prevention counseling practices using a national probability sample of HIV care providers in the United States and Puerto Rico targeted by the 2009 Medical Monitoring Project (MMP) Provider Survey. We assessed self-reported provider prevention counseling practices on topics included in the 2003 CDC/HRSA recommendations to determine the uptake of these recommendations 6 years after their release and to identify factors that facilitate HIV prevention counseling in medical settings. In addition, we assessed providers’ discussions on adherence to antiretroviral therapy (ART), given the current emphasis of treatment as prevention.
Methods
Sample
Medical Monitoring Project sampling methods have been described elsewhere. 5,6 Briefly, MMP has a 3-stage sampling design. During stage 1 of sampling, 20 geographic areas (19 states and Puerto Rico) were sampled with probability proportional to size based on AIDS prevalence at the end of 2002. During stage 2, a complete list of outpatient medical facilities providing HIV care in each of the 20 geographic areas was assembled, and a representative sample of facilities providing outpatient HIV care was chosen from each area with probability proportional to the numbers of HIV-infected persons receiving care.
For the MMP Provider Survey, after stage 2 was completed for the 2007 MMP data collection cycle, a probability sample of HIV care providers was selected from sampled facilities. In 2009, MMP project staff contacted 582 facilities selected to participate in the 2007 cycle of MMP and obtained a complete list of all HIV care providers working at those facilities. In all, 2600 providers were identified in the 582 facilities, and 1999 were randomly selected to participate in the MMP Provider Survey.
Data Collection Methods
Providers who met the following conditions were eligible for inclusion: (1) had provided care to HIV-infected patients aged ≥18 years at a participating MMP facility at the time of the survey; and (2) were physicians, nurse practitioners (NPs), or physician’s assistants (PAs). Providers were recruited by using a modified version of the Dillman method, 7 which included mailing individualized recruitment packets to all selected providers. The recruitment packets included a recruitment letter from CDC explaining the purpose of the survey, instructions for completing the self-administered survey via paper or Web-based forms, and a US$15 gift card. Nonrespondents were sent 3 additional mailings at set intervals over the following 7 weeks. All data collection were conducted during June 2009 to September 2009.
The survey took approximately 15 minutes to complete and consisted of questions concerning provider characteristics, clinic practice characteristics, patient characteristics, HIV treatment referral practices, HIV care and treatment practices, HIV risk-reduction counseling practices, and perceptions of patients’ barriers to HIV care.
The institutional review board of CDC determined that the MMP Provider Survey was public health surveillance, not a research activity; however, state and local jurisdictions requested review for the protection of human participants and obtained approvals as necessary in their respective areas.
Analyses
To assess consistency of HIV prevention counseling discussions with patients newly linked to HIV care, the following questions were asked: “Please indicate whether you discuss each of the following topics with your patients living with HIV/AIDS who are new to HIV care—HIV transmission risk reduction; availability of partner counseling services; STD risk; and adherence to antiretroviral regimens (for patients prescribed HIV medications).” New patients were defined as persons who had never obtained HIV care, not new to the practice. The response options were (1)
HIV care providers were categorized as physicians, NPs, and PAs. Provider characteristics included gender, race/ethnicity, age, years practicing HIV care, whether providers considered themselves specialists in HIV care, and self-perceived knowledge of HIV treatment issues. Provider practice characteristics included an estimate of the percentage of the provider’s patients living with HIV/AIDS who were women, who had ever injected drugs, and who were men who have sex with other men (MSM). The HIV patient load was defined as the number of providers of HIV-infected patients reported caring for per month and was categorized as follows: small (1-25 patients), medium (26-100 patients), and large (more than 100 patients). Additional information collected from providers included their perception of having sufficient time to provide all HIV care, actual amount of time spent with patients (0-30 and 31-60 minutes), referral practices for initial consultation, and communicating with patients in another language besides English to provide care.
All variables associated at
Results
Of 1999 HIV care providers who were mailed surveys, 1743 (87%) were eligible, and of those who were eligible, 734 (42%) completed the survey. Of the respondents, most were physicians (70%), 68% were aged 41 to 60 years (mean age, 49 years), 50% were men, and 71% were non-Hispanic white (Table 1). A substantial proportion (43%) had cared for HIV-infected patients for more than 15 years. When asked about HIV treatment knowledge, 83% reported being extremely or very knowledgeable.
Provider, Practice, and Medical Care Characteristics of HIV Care Providers, MMP Provider Survey 2009.a
a Numbers may not add to total, and percentage may not total 100% because of missing data. Values exclude don’t-know responses.
In terms of characteristics of the medical practice, a substantial proportion of providers (46%) provided HIV care to 26 to 100 patients per month, and a majority of providers (55%) reported that 50% or more of their patients were MSM. Furthermore, in terms of providers’ HIV care practices, most providers (67%) were able to spend an average of 31 to 60 minutes with their patients new to HIV care, while 39% reported providing medical care in more than one language (Table 1).
Regarding providers’ prevention counseling practices, the percentages of respondents who consistently discussed the following HIV prevention topics with their patients new to HIV care were HIV transmission risk reduction, 76%; STD risk, 66%; partner counseling services, 35%; and adherence to ART with new patients for whom ART had been prescribed, 87% (Table 2).
Selected Characteristics Associated with Prevention Counseling Practices of HIV Care Providers with Patients New to HIV Medical Care, MMP Provider Survey, 2009.
a Denotes row percentage.
b
c Numbers may not add to total because of missing data.
In the multivariable regression model assessing consistent discussions of HIV transmission risk reduction, female providers (aOR = 1.7, 95% CI, 1.2-2.5), providers who considered themselves extremely/very knowledgeable regarding HIV treatment (aOR = 1.7, CI, 1.0-2.9), and providers who spent 31 to 60 minutes on average with new patients (aOR = 1.7, CI, 1.1-2.5) had higher odds of reporting discussing this topic consistently (Table 3). Likewise, black/African American providers (aOR = 3.7, CI, 1.3-10.7) had higher odds of discussing this topic consistently than white providers.
Results from Multivariable Logistic Regression Models Assessing Factors Associated with Consistently Providing Prevention Counseling to Patients New to HIV Care Among 700 HIV Care Providers, MMP Provider Survey, 2009.
Abbreviations: aOR, adjusted odds ratio; CI, confidence interval; NS, not significant in χ 2 analyses and not included in the model.
In the multivariable regression model assessing discussions regarding STD risk, 41- to 60-year-old providers (aOR = 0.6, CI, 0.4-0.9) and providers who had 26% to 50% of MSM in their practice (aOR = 0.5, CI, 0.3-0.7) had lower odds of consistently discussing STD risk than 20- to 40-year-old providers and providers with 75% to 100% MSM did in their practice, respectively. Black/African American providers (aOR = 4.1, CI, 1.9-9.8) and provider practices with a large patient load (aOR = 2.0, CI, 1.2-3.4) had higher odds of discussing this topic consistently than white providers and provider practices with a low patient load did, respectively. Likewise, providers who spent 31 to 60 minutes with patients new to HIV care (aOR = 1.8, CI, 1.2-2.7) had higher odds of discussing this topic consistently (Table 3).
In the multivariable regression model assessing discussions about the availability of partner counseling services, NPs (aOR = 1.8, CI, 1.2-2.8) and providers who spent 31 to 60 minutes with patients new to HIV care (aOR = 1.9, CI, 1.2-2.8) had higher odds of discussing this topic consistently (Table 3).
Finally, in the multivariable regression model assessing discussions regarding ART adherence with newly linked patients initiating ART, providers who reported being extremely or very knowledgeable regarding HIV treatment issues (aOR = 2.1, CI, 1.1-4.5) had higher odds of discussing this topic consistently than those reporting being less knowledgeable (Table 3).
Discussion
The 2003 CDC/HRSA recommendations call for HIV care providers to play a central role in delivering HIV prevention counseling messages to HIV-infected persons new to care as part of HIV clinical care. Compared to earlier surveys, 3,4 we found a higher reported prevalence of such discussions, which may indicate wider adoption by providers of recommendations for incorporation of HIV prevention counseling into medical care. Our findings indicate that a substantial proportion of HIV care providers reported discussing HIV transmission risk reduction, STD risk, and adherence to ART with their patients new to HIV care, but a lower (<40%) proportion reported discussing the availability of partner counseling services.
Seventy-six percent of all MMP providers consistently discussed HIV transmission risk reduction with patients new to HIV care compared with 37% of providers surveyed by Gardner et al 3 in 2001 and 67% of providers surveyed by Myers et al 4 in 2004. Although the Gardner et al analysis focused on physicians and we included other types of health care providers, our data show that even among physicians the increase is substantial (from 37% to 75%). This may reflect the success of efforts by federal and state/local public health officials since the release of the CDC/HRSA recommendations to engage HIV care providers as partners in prevention. On the other hand, the fact that 26% of HIV care providers do not report consistently discussing HIV transmission risk reduction with patients new to HIV care suggests that more work needs to be done to reach certain HIV care providers. For example, our findings confirm the need to increase HIV counseling practices among male providers who have long been identified as less likely to discuss risk reduction topics such as sex and substance use behaviors with their new patients. 8 The data also indicate that providers who reported being more knowledgeable about HIV treatment were more likely to report having HIV transmission risk reduction discussions. This finding stresses the importance of continuing medical education curricula for HIV care providers that focus on HIV care and prevention topics.
Only two-thirds of providers reported consistently engaging their patients new to HIV care in discussions regarding STD risk. Discussions of STD risk are recommended in the 2003 CDC/HRSA recommendations for incorporating HIV prevention into the medical care of HIV-infected persons, CDC STD treatment guidelines, 9 and the IDSA/HIVMA HIV primary care guidelines, 10 but too few providers are engaging in this activity consistently with their patients new to HIV care. This is particularly concerning because this activity is a preamble for determining high-risk sexual behaviors, possible exposure to other STDs, and the need for further testing of sexual partners. In the 2007 cycle of MMP, only 39% of HIV-infected patients reported being tested for a bacterial STD in the past 12 months; 11 these data plus our survey findings highlight that a significant proportion of HIV providers may benefit from additional training on screening HIV-infected patients for STDs. Our results suggest the need to focus on providers who are white, older, have a small patient load, and have fewer MSM patients in their practice. Providers caring for MSM patients should be a high priority for these efforts, given the high degree of coinfection between HIV and both syphilis and gonorrhea among MSM in the United States. 12,13
Antiretroviral therapy has been demonstrated to decrease HIV transmission in the HIV Prevention Trials Network 052 study, which showed a 96% decrease in the sexual transmission of HIV among heterosexual sero-discordant couples for whom ART was prescribed early to the HIV-infected partner. 14 This landmark study highlights the importance of ART for HIV prevention, but to achieve HIV viral suppression, adherence to ART is critical. 15 Significantly, although the Department of Health and Human Services (DHHS) Guidelines for the Use of Antiretroviral Agents in HIV-1-Infected Adults and Adolescents that were in effect at the time of the survey recommended that ART adherence should be discussed at each clinical encounter, 16 only 87% of all MMP providers reported consistently discussing adherence to ART regimen with their patients new to HIV care who were being prescribed ART. The proportion of MMP physicians discussing ART adherence (88%) was similar to the 84% reported by Gardner and colleagues 3 who surveyed physicians 8 years earlier. Our findings indicate that, as for transmission risk-reduction discussions, providers who reported being more knowledgeable about HIV treatment issues had higher odds of always discussing ART adherence with their patients new to HIV care. Increasing provider knowledge regarding HIV treatment issues appears to be of utmost importance given current recommendations, which expand the use of ART to all HIV-infected patients. 17
Our findings related to discussions of the availability of partner counseling services are concerning, given that only 35% of providers reported consistently discussing this topic with new patients. Discussing partner counseling services with patients new to HIV care was one of the key topics of the 2003 CDC/HRSA recommendations and a main topic in the Prevention Counseling for HIV-Infected Patients section of the DHHS Guidelines for the Use of Antiretroviral Agents that were in effect at the time of the survey. 16 Referral to partner counseling services is crucial for preventing new infections in sex partners who are not infected and for ensuring that infected partners promptly receive HIV care. Because partner counseling services identify a population with high HIV prevalence, 18 federal agencies and state/local health departments should make sure that all HIV care providers, especially physicians, are aware of and follow CDC’s updated guidelines for partner services. 19
We consistently found that being able to spend more time with newly linked patients was associated with discussing prevention topics. Spending more time with patients was significantly associated with 3 of our outcomes (HIV transmission risk reduction, partner counseling services, and discussions of STD risk) in the multivariable analyses and significantly associated with the fourth (adherence to ART) in the bivariate analyses. This finding is consistent with the work of other research in this area. 3,20,21 The strong association between being able to spend more time with patients and engaging consistently in these prevention counseling practices indicates a need to reassess current practices, including reimbursement policies, that limit providers’ time with patients new to HIV medical care.
Our findings that self-reported knowledge about HIV treatment was associated with 3 of our 4 outcome variables in the bivariate analyses suggest that increasing provider knowledge regarding HIV treatment issues may also promote increased prevention counseling. AIDS Education and Training Centers (AETCs), which operate nationwide providing education and training programs for health care providers treating persons living with HIV/AIDS, can be instrumental for this purpose. The AETCs have played an important role in increasing provider knowledge regarding HIV clinical care, 22 which has been shown to lead to better patient outcomes. 23 They have also developed training curricula and other materials that provide clinicians with the knowledge and skills to incorporate HIV prevention activities into clinical care. For example, in collaboration with CDC, the AETCs, and the AETC National Resource Center, the National Network of STD/HIV Prevention Training Centers developed Ask, Screen, Intervene: Incorporating HIV Prevention into the Medical Care of Persons Living with HIV, a multimodule curriculum that provides training on risk screening, prevention messages, tailored behavioral interventions, and partner services (http://depts.washington.edu/nnptc/online_training/asi/). The AETCs can play a key role in promoting prevention counseling in clinical settings by striving to reach greater numbers of HIV practitioners, especially physicians and PAs, with courses that focus on treatment as prevention.
In recent years, CDC and HRSA have been collaborating with several governmental and nongovernmental organizations to update the 2003 CDC/HRSA recommendations (http://www.cdc.gov/hiv/pwp/). 24 The new recommendations are intended to “consolidate a more comprehensive set of behavioral and biomedical interventions that reduce transmission behaviors or the infectiousness of persons with HIV,” the prevention counseling topics featured in this analysis will continue to be part of the new recommendations. The information presented in this analysis may help inform implementation of these guidelines and support an increase in prevention counseling practices among HIV care providers.
Limitations
Our data were based on self-report and thus subject to recall and social desirability bias. In addition, response rates were relatively low, so the data were not weighted; therefore, our results may not be representative of all HIV care providers in the United States. However, this was the first HIV provider survey to use rigorous, population-based methods to draw a probability sample of HIV care providers in the United States.
Conclusion
The percentage of providers who engage in certain HIV prevention counseling practices with patients new to HIV care has increased but improvements are needed. Providers can be key partners in prevention by identifying and addressing risk behaviors for HIV/STD transmission and ensuring adherence to ART among their HIV-infected patients. Understanding factors that are associated with discussions of HIV prevention issues can assist in developing training curricula that will enhance providers’ skills in HIV prevention counseling.
Footnotes
Declaration of Conflicting Interests
The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding
The author(s) received no financial support for the research, authorship, and/or publication of this article.