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  • Incorporating Prevention into Care: Now that We Know It Works, What Should We Do?

    Dr. Thrun

    MARK THRUN, MD
    Director, HIV/STD Prevention and Control
    Director, Denver Prevention Training Center
    Denver Public Health

    Associate Professor, Department of Medicine
    University of Colorado Denver School of Medicine
    Denver, Colorado

    Clinicians have grown to understand the relationship between HIV prevention and HIV care - that they are not mutually distinct realms, but rather synergistic realms of the same spectrum, and that emphasis on both is needed to end the HIV epidemic. Most providers embrace the concept that risk discussions can impact patient behavior and lower the risk of HIV transmission, as a growing body of literature suggests (1-3), and likely agree that these discussions should take place routinely. Even the recent HIV Prevention Trials Network 052 study (4), in which HIV-negative partners of persons started early on antiretroviral agents were less likely to acquire HIV than partners of persons not yet on antiretroviral agents, simply underscored what most providers knew was biologically plausible: Antiretrovirals save lives of both our patients and their partners and that prevention and care are complimentary (5).

    When it comes to implementing prevention in care, however, many providers rely solely on biological prevention methods of improved adherence to antiretrovirals. Risk counseling, the behavioral prevention correlate, is too frequently not undertaken despite its synergistic potential. These conversations should be our goal in clinical practice. Providers should be deliberate about incorporating risk discussions into their clinical routines, thus maximizing prevention and care synergy and thereby keeping both their patients and their patients’ partners healthy.

    The key to a good risk discussion is simply initiating it. Patients, concerned about being judged, often do not share what is occurring in their lives that could potentially allow HIV to be transmitted. They look to us as their providers to begin a conversation about risk, to ask about their partners, to open the door to discussions about reducing risk. Thus, all HIV-care providers must routinely share their interest in their patients’ lives by building into each visit a question, or series of questions, to open the door to discussions about relationships and risk: Who are you dating now? How is your sex life? Tell me about the sex you’ve had since the last we spoke? These open-ended queries let patients know you honor their right to have healthy sex lives while creating an opportunity to follow up with many more detailed, perhaps close-ended, questions: Did you discuss your HIV status? Were you the top or the bottom? Did you use condoms?  These questions should be linked to a routine in the clinical visit: checking vital signs, a review of systems, or following adherence discussions, for example.

    Armed with answers to their questions, providers are optimally poised to correct any misconceptions that a patient might have, deliver patient-specific prevention messages, and develop a risk-reduction plan. Having asked the questions, clinicians will know when to offer screening for sexually transmitted infections or when to refer for more intensive mental health and substance use counseling or to partner services.

    Organizational changes in practices help reinforce prevention messaging offered by providers. Practices should assure that staff represents the diversity of the patient population, is trained to be culturally responsive, and understands the importance of prevention in care. In addition, the use of inclusive forms and risk screeners can improve communication and create dialogue. Prominently displaying posters, brochures and condoms reinforces that the clinic acknowledges their patients’ (safer) sex lives and that discussions are welcome. Formalizing protocols for prevention discussions, implementing electronic or other chart reminders, or including such discussions in quality assurance indicators will help to increase their frequency.

    As two sides of the same coin, prevention and care should be inseparable in clinical settings. Patients - and their partners - will benefit as more providers routinely ask their patients living with HIV questions that lead to prevention discussions.

    References

    1. Richardson JL, Milam J, McCutchan A, et al. Effect of brief safer-sex counseling by medical providers to HIV-1 seropositive patients: a multi-clinic assessment. AIDS. 2004;18:1179-1186.

    2. Fisher JD, Fisher WA, Cornman DH, et al. Clinician-delivered intervention delivered during routine clinical care reduces unprotected sexual behavior among HIV-infected patients. J Acquir Immune Defic Syndr. 2006;41:44-52. 

    3. Gardner LI, Marks G, O'Daniels CM, et al. Implementation and evaluation of a clinic-based behavioral intervention: positive steps for patients with HIV. AIDS Patient Care STDS. 2008;22:627-635.

    4. Cohen MS, Chen YQ, McCauley M, et al. Prevention of HIV infection with early antiretroviral therapy. N Engl J Med. 2011;365:493-505.

    5. Grant RM, Lama JR, Anderson PL, et al. Preexposure chemoprophylaxis for HIV prevention in men who have sex with men. N Engl J Med. 2010;363:2587-2599.

     

     

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