CDC and investigators find success with intervention in HIV clinics
"Positive Steps" works, study shows
The more scientists and public health officials learn about HIV prevention, the more they realize that targeting specific cultural and demographic groups of people who are not infected is a costly and labor-intensive venture.
With federal HIV prevention funding essentially flat-lined for seven years now, the CDC has shifted its focus to Prevention for Positives initiatives. And what better place to find positives and provide these prevention messages than the HIV clinic?
This was the genesis of the CDC's Positive Steps intervention that was implemented in seven HIV clinics in six states from New York City, NY, to Denver, CO.
"Patients are routinely coming to the clinic, so there's an opportunity that you will otherwise miss," says Lytt Gardner, PhD, an epidemiologist with the division of HIV/AIDS prevention at the CDC.
"The other reason for this type of intervention, and this wasn't touched on in our study, but some studies have shown that patients are very receptive when they hear a message from their main medical provider," Gardner says. "So those are two very important reasons for doing it in the clinic."
Investigators found that the intervention successfully reduced risk behavior among patients over a one year period, Gardner says.
"All of the risk behavior groups — men who have sex with men (MSM), heterosexual men and women — showed the same degree of declines in unprotected anal or vaginal intercourse," Gardner says. "We saw the same degree of decline in risk behavior subgroups."
The results were gratifying, he notes.
"We were very pleased to see how consistent the results were, and there was consistency on every dimension," Gardner says. "It was consistent across clinics and across risk groups, and it's a continuing process as it should be."
Here's how the intervention worked:
• Use screening form: Patients arriving at a clinic complete a screening form that asks them to list their recent sexual activity and drug use, Gardner says.
"The information they put on the form was used by the provider to initiate the discussion of risk behavior," he says. "That was how the conversation was started."
Most of the clinics in the study used paper screening forms, and one clinic used an electronic version. It typically was given out to patients while they were in a waiting room, and nurses were available to assist them in completing the form, Gardner says.
• Develop risk reduction plan: After the clinician and patient finish the three-to-four minute conversation about risk behaviors, the provider develops a risk reduction plan for the patient, Gardner says.
"This is given to the patient so that the patient has something to carry away," he says.
• Offer counseling to those who need it: "Some patients have many problems and those patients could receive additional counseling at the clinic," Gardner says.
The counseling session might provide more detailed descriptions of specific risk reduction practices, such as sexual negotiation with sex partners, he explains.
"This is something that takes a little more time and can't be crammed into three or four minutes," he adds. "People with master's degrees provided the counseling."
• Providers gave tested prevention messages: "The messages that the medical providers used were based on messages used for the Partnership for Health intervention, carried out on the West Coast," Gardner says. "So what the providers said to patients had some basis in previous successful interventions."
The Partnership for Health intervention is designed for outpatient clinic and healthcare providers. It has them provide brief, behavioral prevention messages through message framing, repetition, and reinforcement at each clinic visit.1
This clinic-based intervention can be implemented successfully with fairly modest amounts of training, Gardner says.
"That kind of training can be provided by the AIDS Education and Training Centers (AETC)," he says.
"We've received requests from other clinics for the materials, and although we — in our little research group — don't provide those materials, the materials that were used are available on an AETC Web site [www.aidsetc.org]," Gardner adds. "So that's one thing that we direct clinics to look at."
More information about the CDC's modified behavioral screener, which is titled, "Ask, Screen & Intervene," can be found on this AETC Web site: www.pamaaetc.org/events.asp.
"The part with the greatest correlation with Positive Steps is the screener," Gardner says. "That was the one thing unique about our study; we created a screener, and that's important when you're trying to figure out how to get conversation started with patients."
The CDC study did not contain a control group and was designed as a demonstration project, Gardner notes.
"So there is some caution that should be exercised when interpreting Positive Steps," he says. "However the previous clinical trials have provided the efficacy data that's needed to allow people to conclude that this type of activity is useful."
The value of Positive Steps is that it's a simple intervention that can be successfully implemented in multiple HIV clinics with a small investment of time and money, he says.
"We would certainly encourage clinics to adopt this because it is consistent with the recommendations that the CDC published in 2003 about incorporating HIV prevention into the medical care of people living with HIV," Gardner says. "What we're doing is a way clinics can implement most of those recommendations."
Reference:
- Richardson JL, 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.
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