Clinic interventions help reduce risk in MSM
Study finds 12-month decline in risk
A recent study has found that men who have sex with men (MSM) will reduce their risk-taking behavior when they're given brief prevention education at their regular HIV clinic visits.1
"This is an intervention where we tried and successfully got providers to deliver very concise two-to-five minute messages to patients, built around whatever the physician saw in the risk screen," says Lytt I. Gardner, PhD, an epidemiologist in the division of HIV/AIDS prevention at the National Center for HIV, Viral Hepatitis, STD and TB Prevention of the Centers for Disease Control and Prevention (CDC) in Atlanta, GA.
These were quick behavioral assessment screenings conducted at the time of routine patient visits, and they are very simple, Gardner says.
"The basic longitudinal results were very promising, showing a big reduction in unprotected anal and vaginal intercourse with any partners going down from 42% at baseline to 25% at the sixth-month follow-up," he says.
Results showed that MSM who were highest at risk for transmitting HIV and who had multiple partners had a very strong decline in numbers of partners exposed to risk over a 12-month period, Gardner says.
Before the intervention they had exposed a mean 3.6 partners to risk. After the intervention, this declined to 1.3 partners per individual exposed to risk of HIV infection, he adds.
"The size of that decline was very encouraging," he says. "Another main group was people with CD4 cell counts above 500 cells, and even though that group started at a lower baseline number of at risk partners exposed, they dropped [exposing partners to HIV risk] more than 25% in 12 months."
These findings were particularly encouraging because it showed that the patients who were taking antiretroviral medications and likely feeling better and healthier still were responding to provider messages about reducing their risky behaviors and better protecting their sexual partners, Gardner says.
"This is very compelling evidence that we're not just seeing any subgroups that are resistant to the messages, and subgroups with the greatest potential to spread HIV infection seemed to be responding very well," he adds.
The study enrolled some women and there were modest declines in their risk behaviors, Gardner adds.
"But the numbers were kind of small to show in a multivariable analysis," he says.
The intervention involved training providers to give these brief prevention messages to patients.
"The trick and problem with interventions like this is we have to convince clinicians that they can squeeze out two to four minutes of time," Gardner says. "They're incredibly busy people and most of them are overworked."
Researchers made it clear that the intervention had a fair probability of success if it was done consistently and if clinicians connected with patients, he notes.
"It's easy to say, but it's hard for me to show a clinician how to connect with a patient," Gardner says. "We had professional trainers from the AIDS Education Training Center (AETC) deliver training in partnership with a physician from the Denver Public Health department, and I think that was a good team to deliver the intervention."
The trainers convinced clinicians that the intervention could be done quickly and simply by adding messages that were tied to the behavioral assessment screener, which is available through the Mountain Plains AIDS Education and Training Center, affiliated with the University of Colorado Health Sciences Center in the department of medicine, division of infectious diseases. There nine screening questions include the following:
- Why are you here today?
- Thinking over the last three months, did you have sex with anyone? (oral, anal, or vaginal sex)
- How many different sex partners did you have in the past three months: # males, # females?
- Have you had any main sex partners in the past three months? (someone you are committed to)
- Have you had any occasional sex partners in the past three months? If yes, how many?
- Were you told you had a sexually transmitted infection other than HIV in the past three months?
- Did you smoke any crack or use crystal in the past three months?
- Have you injected any recreational drugs in the past three months?
- Is there anything about sex or drugs that you want to talk to your provider about today?
Evidence is strong enough that the intervention works that when investigators studied it for the recent poster, presented at the 17th Conference on Retroviruses and Opportunistic Infections (CROI), held Feb. 16-19, 2010, in San Francisco, CA, they were unable to make the study a randomized, controlled trial, Gardner notes.
"It wasn't ethical to do a clinical trial with a true control group because there was enough evidence that having clinicians do this would work," he explains. "We think the results were very strong given the study design we had."
Ideally, all HIV clinicians would incorporate the quick intervention into their routine when meeting with HIV patients. But this is the sort of intervention that would be improved by clinicians having a clinical medical director champion and some initial training, Gardner says.
"All a clinician has to do is contact the AETC that serves their region and find out what the schedule is for this training," he explains. "Even if they can't make it to the physical training, the Mountain Plains AETC still has a poster and screener available on their website at http://mpaetc.org/pwp_web/provider_resources.html.
For this program to continue over the long run there would need to be a commitment from clinic leaders and a continual push by the clinic medical director, he adds.
"We found that only two of the six sites in our study continued it the way we originally designed it," Gardner says. "Two of the other sites gave the responsibility to someone else at the clinic, which is kind of typical."
Reference
- Gardner L, Marks G, Daniels CO, et al. Declines in partners exposed to risk of HIV infection: the CDC Prevention in Care Settings study. Presented at the 17th Conference on Retroviruses and Opportunistic Infections. San Francisco; February 2010.
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