New streamlined risk assessment for HIV clinicians
It's based on CDC report on prevention for positives
The public health community noted improvements in sexual risk behaviors among HIV positive people in the 1990's, but the positive gains have been lost in the 21st century as unsafe sexual behaviors have increased among some HIV positive populations.
"We've had an alarming increase in sexually transmitted diseases (STDs) and unsafe sex behaviors among certain subsets of HIV infection," says Jeanne Marrazzo, MD, MPH, associate professor at the University of Washington in Seattle, WA.
"Unfortunately, HIV care providers and infectious disease physicians often are not in the forefront of taking sexual history from patients and talking about risk assessment and looking at ways to reduce risk in this population," Marrazzo says.
The Centers for Disease Control and Prevention (CDC) of Atlanta, GA, addressed this problem in July, 2003, in a consensus document of recommendations, titled, "Incorporating HIV Prevention into the Medical Care of Persons Living with HIV."1
The recommendations were made by the CDC, the Health Resources and Services Administration (HRSA), the National Institutes of Health (NIH), and the HIV Medicine Association (HIVMA) of the Infectious Diseases Society of America (IDSA).
Three main areas were addressed by the recommendations, including the following:
- STD-related risk assessment and drug use risk assessment in HIV infected people;
- delivering universal and tailored behavioral interventions;
- focusing on how best to approach and manage partners of HIV-infected people.
"What has happened since then is the CDC, amazingly, has allocated some funds from the HIV division to fund the group I'm involved in, which is the STD/HIV Prevention Training Centers," Marrazzo says. "We do clinical and behavioral and partner management for people with STDs."
The CDC funds were used to create a curriculum that delivers modules focusing on the recommendations from the earlier CDC report, Marrazzo says.
"A group of 12 of us met frequently over the last year and a half to create a pretty nice curriculum," Marrazzo says. "It includes speaker materials, speaker notes, participant guides, reference materials guide, an electronic finder package that helps HIV care providers learn about this issue, and tools to address the problems of HIV-infected people."
The program focuses on four priority strategies of the CDC's Advancing HIV Prevention campaign. The program's PowerPoint presentation cites these priorities as follows:
- Make voluntary testing a routine part of medical care;
- Implement new models for diagnosing HIV infections outside medical settings;
- Prevent new infections by working with persons diagnosed with HIV;
- Further decrease perinatal HIV transmission.
HIV and infectious disease clinicians need to be reminded as to the fundamentals of what's happening with HIV risk behaviors, and they need to know there are resources to help them with the behavioral pieces that might be outside their comfort zones, Marrazzo notes.
In the partner management module, for example, physicians are taught about legal issues involving HIV reporting and how to handle the delicate situation of a patient asking the doctor to help him or her tell a partner about the infection, Marrazzo says.
"It's important information that's not viewed as critical by the typical HIV continuing education courses, which are focused on antiretroviral therapy," she says. "But there's a lot more information that's needed."
The HIV prevention training curriculum has been taught in pilot sessions in six cities and was recently approved by the CDC, Marrazzo says.
"We're partnering with the Association of AIDS and HIV Medicine (AAHIVM) to deliver some of the modules," Marrazzo says.
So far the curriculum has been well-received, and a couple of hundred people have received training, Marrazzo says.
"We've delivered in our region to over 75 people," she adds. "We're training the leaders in the HIV field to get out there and go to their sites and take on this role."
AIDS Education and Training Centers are paid to assist with finding clinics and other sites where training can be delivered, Marrazzo says.
"It's an unprecedented effort by agencies that aren't often on the same page in a practical sense," Marrazzo says. "Most of the people doing the training are providers, so we're training doctors, as well as mid-level providers, including physician assistants and nurse practitioners."
Attendees are offered continuing medical education credits, and the training is marketed in the HIV world. Eventually the course may be offered on-line, she adds.
Feedback shows that HIV clinicians are motivated to learn more about prevention, Marrazzo says.
"I think most physicians are frustrated right now with this upturn in the epidemic, and they're frustrated particularly with crystal meth—it makes everybody crazy," Marrazzo says. "They're very fatalistic about meth patients, which is too bad."
While the module doesn't address meth addiction directly, there is information about resources and behavioral counseling that is applicable to people using drugs, she notes.
"There's definitely a morale issue in HIV care, and we received a lot of feedback about that," Marrazzo says.
"And there are still people in the HIV world who don't realize that we're dealing with a syphilis epidemic among HIV-infected people."
Marrazzo says she's heard of secondary and primary syphilis cases being misdiagnosed, often in HIV care settings.
"So if this education does nothing but remind people that the STD epidemic is not over with HIV-infected people, and it's being driven in part by things like crystal meth, that will help people diagnose and treat this problem," Marrazzo says.
Reference:
- CDC. Incorporating HIV Prevention Into the Medical Care of Persons Living with HIV. MMWR Recomm Rep. 2003;52:1-24. Erratum in: MMWR Recomm Rep. 2004;53:744.
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