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The Place of Prevention in HIV Clinical Care: A Roundtable Discussion

In January 2001, the CDC announced a new HIV prevention initiative focused on already infected individuals. Thus, HIV-care providers now play a critical role in the CDC's overall prevention strategy. To discuss these changes and the challenges and opportunities for HIV-care providers to incorporate effective prevention counseling into clinical practice, ACC spoke with HIV clinicians involved in prevention counseling and research and HIV prevention experts from the CDC and NIH.

In January 2001, the CDC announced a new HIV prevention initiative focused on already infected individuals. Thus, HIV-care providers now play a critical role in the CDC's overall prevention strategy. To discuss these changes and the challenges and opportunities for HIV-care providers to incorporate effective prevention counseling into clinical practice, ACC Executive Editor Matthew O'Rourke spoke with Drs. Judith Auerbach (Director, Behavioral and Social Science Program, and Prevention Science Coordinator, Office of AIDS Research at the NIH), Carlos del Rio (ACC Associate Editor and Chief of Medicine at Grady Memorial Hospital), Sam Dooley (Associate Director for Science and Program Integration, Division of HIV/AIDS Prevention at the CDC), Gerald Friedland (ACC Contributing Editor and Director of the AIDS Program at Yale-New Haven Hospital), and Renee Ridzon (Assistant to the Director, HIV Prevention and Care, Division of HIV/AIDS Prevention, and Senior Technical Advisor, TB/HIV Global AIDS Program at the CDC).

Mr. O'Rourke: How have our needs in HIV prevention changed since the advent of protease inhibitors, and how have U.S. agencies and clinicians responded to these changes? Specifically, why the recent shift in the focus of prevention efforts toward already infected individuals?

Dr. Ridzon: To begin with, HIV-infected individuals are living longer, healthier lives. Life expectancy from the time of HIV infection has increased from 10 years to more than 17 years, and it is believed that this trend will continue. We are facing a paradigm shift from HIV/AIDS being an inevitably fatal illness to it being a chronic, manageable disease. In addition, we are still facing an estimated annual incidence of 40,000 new HIV infections in the U.S. Thus, the CDC realized that delivering prevention messages to already infected individuals had to become an important adjunct to existing prevention efforts focused on reaching HIV-negative individuals.

Dr. del Rio: The CDC Prevention Strategic Plan Through 2005 provides a succinct summary of the new initiative and the reasons for this shift in focus. One of the key goals of the plan is to increase the proportion of HIV-infected people who are in care and receiving prevention counseling to 80% by 2005. The SAFE (Serostatus Approach to Fighting the Epidemic) initiative is a key strategy for achieving this goal. SAFE has 3 component priorities: increasing the proportion of patients who know their serostatus, increasing the proportion of HIV-infected individuals who are in care, and increasing the proportion of those in care who are receiving prevention counseling.

Dr. Ridzon: A key aspect of the SAFE Initiative is the "know now" campaign, which is designed to get more people who are infected to know their status. Although this is a testing campaign, its ultimate goal is to get people into care. All of this feeds into the goal of reducing by 50% the current incidence of 40,000 new infections per year.

Dr. Friedland: Another clinical and epidemiologic reason to focus on prevention among HIV-positive individuals is the growing risk for transmission of antiretroviral-resistant virus. The likely source of antiretroviral resistance among newly infected individuals is people who are HIV-positive, are in clinical care, have received antiretroviral treatment, and continue to engage in high-risk behavior. So the advent of effective HIV therapy adds an additional imperative to a prevention strategy in clinical care.

Dr. Ridzon: Transmission of resistance is a genuine concern. Of course, the flip side of the coin is that moving HIV-positive patients into care, providing them with antiretroviral treatment, and maintaining their viral loads at undetectable levels may be very important components of, not only the patient's care, but also of preventing HIV transmission in general and drug-resistant HIV transmission in particular.

Dr. Dooley: It is a double-edged sword. Although reducing the viral load probably reduces infectiousness, it is unlikely that even an undetectable viral load eliminates the risk for HIV transmission. Many HIV-infected individuals seem to believe that if their viral loads are below a certain level, they cannot transmit the virus to a sexual partner. Some increases in self-reported risky behaviors and new diagnoses of sexually transmitted diseases (STDs) among HIV-infected individuals appear to be associated with this reliance on antiretrovirals to lower the viral load. Given how little we know about the relation between viral load and infectiousness, we're quite concerned about this phenomenon.

Dr. Ridzon: It's a real challenge to find the right messages to give HIV-infected individuals in this regard. On the one hand, we have effective treatments that will probably make people less infectious, but on the other hand, we don't want that benefit to translate into patient complacency.

Dr. del Rio: I'm very concerned about the increased incidence of STDs we're seeing among HIV-infected individuals. Not only does this confirm that high-risk sexual behavior is increasing, but it also raises the theoretical concern that the immune stimulation resulting from acquisition of new sexually transmitted infections could cause HIV-infected individuals with viral suppression to lose that virologic control.

Dr. Auerbach: Our central challenge, I think, is to understand the confluence of all of these biologic, behavioral, and epidemiologic phenomena, because we can't talk about any of these issues in isolation. We can't simply debate whether reducing viral load makes people less infectious or whether their perceptions of being less infectious increase complacency because several other factors are at work. For example, we need to recognize that a lot of HIV-infected individuals are now able to have sex who weren't able to in the past because their basic sexual functioning and drive were so diminished. Thus, the increases in risky sex are a function not only of optimism about treatment, but the physical possibility and joy of having sex again. It's very difficult to understand the interactions of all of these factors sufficiently to craft an effective prevention strategy and message.

Dr. del Rio: That's the crux of the issue for clinicians: how do you assess and address all of these issues in a 15-minute clinical visit when you also need to talk about adherence to and side effects of antiretroviral therapy?

Mr. O'Rourke: Which leads us to the question: what is the proper role of HIV clinicians in prevention, and is there widespread agreement on this?

Dr. Friedland: I think that Drs. del Rio and Auerbach have indeed identified the crux of the issue. We haven't really learned how to incorporate prevention counseling into the HIV clinical care setting. It's not impossible to do, but to date the energy that most clinicians have dedicated to diagnosis and treatment far surpasses what they've been able to dedicate to prevention. Perhaps incorporating prevention into clinical practice seems more daunting than it should. We need to find simple ways in which prevention can be inserted into the clinical armamentarium. One of our top prevention priorities should be to use the skills of clinicians and the relationships that they develop over time with patients -- because HIV care is an ongoing chronic disease process of multiple clinical encounters -- as a setting in which prevention might be effectively realized.

Dr. Auerbach: So for HIV clinicians, is incorporating prevention a function of simply having the time, resources, and training, or do their attitudes need to be changed?

Dr. Friedland: We are currently doing a project to assess the barriers to prevention counseling and have started with focus groups among clinicians. Most clinicians, I think, understand the importance of prevention counseling. There are some who don't feel it would be productive and therefore reject it attitudinally. The biggest barriers, however, are the lack of training and skills and the sense that the time required to work on prevention is not available or, in some settings, is not reimbursable.

Dr. del Rio: In a CDC-funded study that we are currently conducting, we looked at the prevention-counseling practices of HIV-care providers in 4 U.S. cities (2001 National HIV Prevention Conference, Atlanta, August 2001. Abstract 440). What we have found is that the prevention message is being delivered in about 60% of initial encounters, but in only about 15% of subsequent encounters. The prevention message needs to be delivered repeatedly in order to be effective. As Dr. Auerbach noted, the better the patient feels, the more you need to address prevention, because as the patient improves clinically, sex is more likely to become part of his or her life.

Dr. Friedland: I agree. Prevention is like adherence or any other behavior; it can fluctuate over time, and you can't just mention it at the first visit and then forget about it. It has to be worked on over the entire course of clinical encounters.

Dr. del Rio: Clinicians have had an incredible burden to carry with antiretroviral therapy and its complications; they are spending a lot of time talking with patients about adherence, toxicities, cholesterol, and other issues, and it's easy to neglect matters that are more difficult to discuss, like sex.

Dr. Dooley: Indeed, the clinician's comfort level in talking about sexual and drug-use behaviors is important. Many doctors believe that patients don't really want to discuss sexual behavior with their clinicians; however, surveys indicate that most patients do want their doctors to initiate conversations about sex and prevention.

Dr. Friedland: We've certainly learned that in the study we are doing now. Patients expect these discussions and may even be disappointed when they don't occur. Talking about sex and drug use can become a routine part of the clinical encounter. We've added the tactic of giving patients a "prevention prescription," so that in addition to getting their medication prescriptions -- which is the final point of a clinical encounter for most and has a lot of meaning for patients -- we have attempted to incorporate prevention into the therapeutic exchange, and it doesn't take very much time at all.

Mr. O'Rourke: Are there any important issues in HIV clinical practice that correlate closely with engaging in high-risk behaviors and thus should sound alarm bells about prevention?

Dr. Ridzon: Certainly it should sound an alarm when patients come into the office with new STDs.

Dr. del Rio: David Cohen presented a poster from the Denver Department of Health at the 8th Retrovirus Conference that showed that poor medication adherence correlated with increased high-risk sexual behavior (8th Conference on Retroviruses and Opportunistic Infections, Chicago, February 2001. Abstract 213).

Dr. Friedland: Very little is known about this important issue. Medication adherence and sexual or drug use behavior could be discordant or concordant and their relation could change over time in any given patient. We definitely need more research here.

Dr. Dooley: There is, of course, a correlation between injection-drug use behavior and degree of adherence to substance-abuse treatment programs, at least in cross-sectional studies.

Dr. Friedland: Yes, substance-abuse treatment reduces the risk for HIV infection by injection drugs -- that has been well studied in patients receiving methadone. What is less well known and not convincingly shown is that substance-abuse treatment per se reduces high-risk sexual behavior among drug users. Preliminary data indicate that independent predictors for high-risk sexual behavior among HIV-infected individuals are age and quality-of-life measures. The younger one is, the more likely one is to engage in risky behavior, and as Drs. Auerbach and del Rio noted, better physical functioning is associated with greater likelihood of engaging in risky behaviors. Conversely, however, lower levels of mental-health functioning are associated with greater likelihood of engaging in risky behavior. It appears that mostly affective disorders, like depression, seem to increase the likelihood of engaging in risky behaviors. So a very general portrait of an HIV-infected person vulnerable to engaging in high-risk sexual behavior is that of a younger, physically healthy, but emotionally depressed individual. This is not to say that all persons in this category are likely to engage in such behaviors, but only to note that these attributes may increase risk.

Dr. del Rio: Another important issue is the many HIV-positive people who know that they are infected, but who are not in care. As clinicians learn to talk about prevention, moving infected individuals into care will help decrease HIV incidence. At the same time that the CDC was coming out with the SAFE initiative, the DHHS was coming out with new guidelines suggesting that antiretroviral therapy can be safely delayed until the CD4 count dips below 350 cells/mm³, and some people saw a contradiction between the two. We should not, however, conflate HIV care with antiretroviral therapy.

Dr. Ridzon: To expect people to get their prevention messages somewhere other than where they get their care is probably not helpful for the patient. The point of diagnosis and referral and the initial clinic visit may be the only place where patients are going to come into contact with someone who can tell them about prevention, so that's where the message needs to be delivered.

Dr. Friedland: I can't emphasize enough the precious nature of the physician-patient relationship; most patients trust their providers. Data on interventions for other behavioral issues, such as weight reduction and smoking cessation, show that patients do listen to their clinicians, want to hear prevention messages, and that these messages can be effective. So the clinical setting offers unique opportunities to bring people into care, establish relationships, and then use them, in the best sense, as a foundation for prevention.

Mr. O'Rourke: What, if anything, do we know about how prevention counseling should be performed in the HIV clinical care setting?

Dr. Auerbach: This is where it gets tricky. We know that each patient is different, and that their risk profiles are different, and each clinician knows his or her patients better than anyone else. So the challenge is for the clinician to take what she knows about the patient and meld it with some essential ingredients of a good prevention message without feeling that she necessarily has to engage in some very rigid intervention. Some people in the scientific community seem to believe that someone is going to design a single effective intervention that can simply be plopped into a clinical setting, and that just doesn't seem reasonable given the variability of patients and settings.

Dr. Friedland: There are techniques, however, that are used very effectively in the prevention world and are unknown to most clinicians. These techniques don't necessitate dealing with the specifics of conduct. Instead, they open up the door to productive discussions about behavior and use the patients' own strengths and views as tools to help them arrange for safer behavior. Of course, these interventions can't be effectively performed on a one-shot basis, but only over time. We have this sense of urgency about getting the prevention message out and having an immediate effect, but it's a process that might take multiple encounters to be effective.

Dr. Dooley: It is worth noting, however, that although clinicians may be the best individuals to introduce the topic of prevention, they may not always be the best individuals to do the intervention. There are patients who have risk-behavior problems that are too complex for many clinicians to deal with in the context of also providing medical care, and I think that a lot of physicians are not aware that there are community-based HIV prevention resources to which patients can be referred. Clinicians are not alone.

Dr. del Rio: But in referring patients somewhere else for prevention, clinicians are missing an opportunity. I agree with Dr. Friedland that the clinical care setting provides an ideal chance to do prevention. Part of the problem we have in the U.S. is that prevention and care of HIV are financed by 2 different agencies: the CDC and HRSA, respectively. Now, with this strategy of incorporating prevention into care, it is unclear who is responsible for what. Our approach to HIV is too fragmented.

Dr. Dooley: I wouldn't disagree with that. I think that prevention should be part of every encounter between clinician and patient. There are situations, however, in which what is needed is more than the clinician has the time or the expertise to provide. So yes, they should introduce the topic, they should be providing those messages, but they may need help from someone else who has more time and more expertise. For example, I have depressed patients whom I can care for adequately, but I have other depressed patients who clearly need additional attention from a psychologist or psychiatrist.

Dr. del Rio: Absolutely. But I think that the initial challenge that we face is that many providers are not even introducing the topic of prevention with their HIV-infected patients.

Dr. Auerbach: So who is supposed to tell physicians that this is their responsibility and provide them with the necessary skills?

Dr. Ridzon: Guidelines cosponsored by the CDC, HRSA, NIH, and IDSA and entitled "Recommendations for Incorporating HIV Prevention into the Medical Care of HIV-Infected Persons" will be released soon. These recommendations are still in draft form, and some of the details may change, but basically they identify 4 key activities for clinicians: (1) screening for risky behaviors and STDs, (2) providing general and tailored risk-reduction messages to patients, (3) when indicated, referring patients for additional risk-reduction services and other services that may affect HIV risk reduction (e.g., substance abuse treatment), and (4) ensuring that patients are provided partner counseling and referral services.

Dr. Auerbach: Is there a strategy to say "this means you" to clinicians when they become public? I know that clinicians use guidelines regularly, but they are also deluged with this kind of information. Is it just a question of telling clinicians that the information is out there, or do we need to actively convince clinicians that they are the ones best able to deliver the prevention message?

Dr. Ridzon: We are currently developing a strategy to promote the guidelines. We want to make sure that we get the word out that they exist and that they don't just stand alone but are actively supported by the CDC and HRSA. As for convincing clinicians that they can and should be involved in HIV prevention counseling, we've been talking with IDSA and the HIV Medicine Association (a subgroup of IDSA) about how to do just that. We've also shared the draft recommendations with the ACP, American Academy of Family Practitioners, the National Medical Association, and a number of other professional organizations for comment. We're hoping that once the guidelines are released these organizations will endorse them in their journals.

Dr. Friedland: In terms of convincing doctors that they can and should be performing risk-reduction counseling, it is important to note that clinical care sites are increasingly under scrutiny and have to document all sorts of quality assurance requirements, and these are sometimes linked to billing. It would be of additional benefit if we could incorporate the need to do prevention work into these measures. Right now, prevention counseling is not rewarded financially in the clinical care setting; in fact, you may be penalized for it because it takes time away from the tasks you are supposed to be performing. There are both real and imagined structural disincentives to doing prevention counseling.

Dr. Auerbach: The Veterans Affairs has made a huge effort in this direction. They have a guidebook for clinicians (The VA HIV Prevention Handbook), and it's a nifty little volume.

Dr. Dooley: The VA volume is quite good, as is the New York State AIDS Institute Guidebook, which is currently being revised.

Dr. del Rio: Dr. Friedland brings up an excellent point. We do quality assurance monitoring to assess what percentage of patients with CD4 counts less than 200 cells/mm³ are receiving PCP prophylaxis, and there ought to be a way that we can monitor what percentage of patients are receiving prevention messages during their visits.

Dr. Dooley: How would you do that?

Dr. del Rio: It may be having a checkoff box on the encounter form that asks, "Was prevention discussed?" I also really like this idea of the "prevention prescription" that Dr. Friedland is testing. One could ensure that the patient received the prescription. Maybe while waiting for their drugs to be refilled at the pharmacy, patients could also fill their "prevention prescription" and receive a booklet or free condoms or sit through an instructional video. This provides a way not only to do prevention counseling, but also to monitor it; you could see how many patients actually received the "prevention prescription" and how many took it to the pharmacy and filled it.

Dr. Dooley: As Dr. Friedland has suggested, the solution clearly involves not just individual clinicians but care systems, because the latter actually establish the quality-of-care measures along with the attendant reminder and documentation systems. The VA has set an excellent example in this regard; there's a huge system of care that has normalized prevention counseling.

Dr. Friedland: And fee-for-service care systems should make prevention counseling a reimbursable activity.

Mr. O'Rourke: Given that identifying HIV-infected individuals and moving them into care is a central priority of the CDC's new prevention strategy, are there proven designs of testing, counseling, and referral programs?

Dr. Ridzon: Well, one of the goals of the "Know Now" campaign is to identify the best methods for these programs; it's in a demonstration phase right now. Some studies have been done among HIV-negative individuals in a limited number of settings. The most common approach is to target the populations that are at highest risk. What we do know is how difficult it is to make broad recommendations about these programs; you have to tailor the message according to both setting and population.

Dr. Auerbach: A lot of research is under way to look at effective methods for testing, counseling, and referral, but as Dr. Ridzon noted, there is such diversity in populations and settings that I think we are coming up with a lot of different answers to the question you have posed.

Dr. Friedland: I'm concerned that if we dwell too much on differences, it may appear nearly impossible to make recommendations. Aren't there any broad fundamentals that we can promote?

Dr. Ridzon: Yes, and I think that we've touched on some of them: Patients expect and want their clinicians to talk with them about risk behavior and prevention interventions. People are willing to get tested if they are approached and asked. Patients want testing to be at least confidential, if not anonymous. Knowledge of HIV status alone can be a factor in reducing high-risk behavior.

Mr. O'Rourke: To what extent does prevention counseling in clinical practice also vary according to population? Are there fundamental principles for prevention counseling?

Dr. Auerbach: We know that the messages should be nonpunitive, supportive, and confidential.

Dr. Dooley: There's pretty good evidence that counseling that focuses on individual risks and needs is much more effective than a more didactic approach to counseling.

Dr. Auerbach: Indeed. We can agree on the general categories of sensitivities that go into successful programs, but the specifics of these categories might be different in each instance. Clinicians have a host of risk-assessment batteries that explore all of these patient variables, and the clinician must use the results of these assessments in the context of the physician-client relationship.

Dr. Friedland: I do think that clinicians need help in scripting these conversations, even if they know their patients quite well. I've learned that clinicians, including myself, are enormously helped by having strategies, interviewing techniques, and even phrases that allow them to delve into these issues efficiently and sensitively.

Dr. Auerbach: How focused do those scripts need to be? Do you need a specific script for a poor African-American male who injects drugs and has sex with other men but doesn't acknowledge his sexual behavior? How about for a homeless woman? As Dr. Friedland pointed out earlier, as we become increasingly attuned to differences, it becomes increasingly difficult to make clear and consistent recommendations.

Dr. Ridzon: Given that there are important issues of diversity, the soon-to-be-released CDC/IDSA guidelines contain very rough scripts for different patient populations.

Dr. Friedland: I've used the term scripted, but I don't want it to sound mechanical. Where the scripting comes in is not in working through every subtlety of patient characteristics but, as Drs. Dooley and Ridzon suggested, in helping the patient discuss behavior and make decisions about it. The technique of motivational interviewing encourages the patient to describe what he or she does and allows the patient to develop his or her own solutions. You might ask the patient "What behaviors are you involved in now? Would you feel comfortable discussing them? Can you think of anything that you might like to change about these behaviors, and what interest might you have in changing them? How might you be able to reduce the riskiness of your behavior?" These are general questions that allow you to draw patients out and make them the major discussers and describers. They are the ones most knowledgeable about the details of their behavior. Often, you don't have to make recommendations, because most patients know what they should do; you are just helping them think it through and come up with their own solutions.

Dr. Dooley: Motivational interviewing is very useful and it allows you to work effectively across a diverse patient population. Unfortunately, most of us aren't trained in it. This technique should be taught to clinicians; it would be useful for other elements of clinical practice. It probably should be part of medical school curricula.

Dr. Friedland: Yes, I now use it in several aspects of my practice. It should also be included in CME courses.

Dr. Dooley: CME courses on HIV management tend to be very clinically focused, and it wouldn't be that difficult to add sections dealing with prevention counseling. I suspect that the reason motivational interviewing and prevention counseling aren't included in these courses is that the people running the courses have the same attitude that some clinicians do: we've got so much therapeutic information to include that we don't have time to address these issues. I don't think it would take much time, however, to provide some very basic, but very useful, training in these techniques.

Mr. O'Rourke: Any final thoughts?

Dr. Friedland: I think it's important to note that clinicians can really help with HIV prevention in additional ways apart from risk-reduction counseling. For example, routine screening, diagnosis, and treatment of sexually transmitted infections among both HIV-positive and HIV-negative individuals will help reduce HIV transmission. And in most clinical care settings such screening is not routinely performed; it's ad hoc and symptom-based. Strengthening adherence to medication to reduce antiretroviral resistance and possible resistance transmission is another example. Both are areas in which clinicians need to improve. The clinical care setting offers prevention opportunities -- both in terms of behavioral and more traditional, technical medical issues -- and all of these activities should become more formalized and incorporated into our clinical practices.

— Judith D. Auerbach, PhD, Carlos del Rio, MD, Sam Dooley, MD, Gerald H. Friedland, MD, Renee Ridzon, MD

Published in AIDS Clinical Care June 1, 2002

FURTHER READING

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