Incorporating HIV Prevention into the Medical Care of Persons Living with HIV

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Incorporating HIV Prevention into the Medical
Care of Persons Living with HIV

• Ask Screen Intervene

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Consultant Work Group Members

• John Bartlett, MD Johns Hopkins University
  School of Medicine
• Wayne Bockmon, MD Montrose Clinic
• John T. Brooks, MD Centers for Disease Control
  and Prevention
• Kevin Carmichael, MD El Rio Special Immunology
  Associates
• Alwyn Cohall, MD Mailman School of Public
  Health
• Eric Daar, MD Harbor-UCLA Medical Center

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Consultant Work Group Members

• David Hardy, MD Cedars-Sinai Medical Center
• Peter Meacher, MD South Bronx Health Center for
  Children and Families, Montefiore Medical Center
• Evelyn Quinlivan, MD University of North
  Carolina, Chapel Hill
• Peter Shalit, MD Swedish Medical Center
• Mark Thrun, MD Denver STD/HIV Prevention and
  Training Center

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• John T. Brooks, MD
• Leader, Clinical Epidemiology Team
• Division of HIV/AIDS Prevention
• NCHSTP, CDC
• Atlanta VA Medical Center
• Atlanta, GA

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• Alwyn T. Cohall, MD
• Associate Professor, Clinical Public Health and
  Pediatrics, Columbia University
• Director, Harlem Health Promotion Center
• New York, NY

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• Keith Rhoades
• Mental Health Specialist
• HIV-Positive for 4 Years
• Torrance, CA

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Incorporating HIV Prevention into the Medical
Care of Persons Living with HIV

• Ask Screen Intervene

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Prevention in Care Recommendations

• Developed by CDC, HRSA, NIH, HIVMA, with
  evidence-based approach
• Apply to medical care of all HIV-infected
  adolescents and adults
• Intended for those providing medical care to
  HIV-positive persons

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Background Advancing HIV Prevention (AHP)

• Rationale for AHP
• AHP primary goal reduce HIV transmission
• AHPs 4 priority strategies
• Recommendations address strategy 3

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Rationale for Recommendations

• AHP with treatment, more Americans are living
  with HIV and AIDS.
• Every transmission comes from an HIV-positive
  person.
• Newly diagnosed patients tend to modify behavior
  to prevent transmissionbut often relapse.
• Providers unique opportunity to influence
  prevention practices of HIV-positive patients
  during medical visits.

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The Potential Impact of Healthcare Providers

• Many HIV care providers do not ask their patients
  about ongoing HIV transmission risk.
• This is a missed opportunity.
• Trust
• Provider credibility

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Whats Stopping Us?

• Responsibility
• Time
• Privacy
• Comfort Level
• Skills

• Scope
• Resources
• Impact
• Reimbursement
• Beliefs/perceptions

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Prevention in Care The Basic Steps

• Ask
• Brief assessment of HIV transmission risk
  behaviors
• Screen
• Identify and treat other STDs
• Intervene
• Deliver brief prevention messages
• Address misconceptions
• Make a plan select a first step and/or refer

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How to Ask
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Ask Brief Assessment of HIV Transmission Risk
Behaviors

• Definition of brief assessment for behavioral
  risk factors
• Pointers
• Be tactful and respectful
• Be clear, avoid medical jargon
• Be non-judgmental
• Use both open- and closed-ended questions
• Use permission-giving statements

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Tools Available to Start Risk Assessment
Conversations
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How to Screen
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Screen Identify and Treat Other STDs

• Diagnostic testing vs. screening
• Who do you screen?
• Everyone one time per year
• Everyone who discloses risk behavior

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Screen Focus on Hepatitis C1

• One-quarter of HIV-positive patients are also
  infected with Hepatitis C (HCV)
• 50-90 of people infected with HIV through
  intravenous drug use (IDU) have HCV
• 75-85 of HCV infections become chronic
• HIV-HCV co-infection has been associated with
• Higher titers of HCV
• More rapid progression to HCV-related liver
  disease
• An increased risk for HCV-related cirrhosis of
  the liver
• Guidelines recommend all HIV-infected persons are
  screened for HCV infection

• CDC FAQs About Co-infection with Hepatitis C
  Virus http//www.cdc.gov/hiv/resources/qa/HIV-HCV_
  Coinfection.htm

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How to Intervene
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Intervene Communicate Prevention Messages

• Frequency
• Every patient, every visit
• Three main components
• Address misconceptions
• Deliver prevention messages
• Make a plan select a first step and/or refer

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Intervene Deliver Brief, Tailored Prevention
Messages

• Definition of prevention message
• Prevention messages tailored to patients-examples
• STDs facilitate transmission of HIV
• There is a risk of superinfection
• Injection drug use increases risk
• You can still transmit HIV despite ART, PEP
• Low viral load does not mean you cannot transmit
  HIV

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Intervene Deliver Brief, Tailored Prevention
Messages

• Brief, tailored prevention messages
• What are they?
• How do they work with
• patient education?
• Why are they effective?
• Marx, et al research
• Can lead to first steps

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Address Common Misconceptions Risk of Acquiring
HIV Based on Specific Sexual Behaviors
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Intervene Identify Misconceptions Sample
Questions

• What do you know about how people get STDs?
• What do you know about how people get HIV?
• What are your concerns about giving HIV to
  someone else?
• What are your concerns about getting an STD or
  hepatitis?

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Intervene Make a Plan

• Behavior change is a process, not an event.
• To make a plan for change, offer options and
  discuss these with your patient to find a first
  step
• Referrals may be a first step
• Help create a back-up plan

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Intervene On-going Prevention at Every Visit

• Ask patient about progress
• If patient is not taking the first step toward
  the goal
• Positive reinforcement
• Anticipate new problems or changes (Ask what if
  . . .? questions)
• Identify next steps

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Intervene On-going Prevention at Every Visit

• Ask patient about progress
• If patient is not taking the first step
• Ask more questions about circumstances,
  attitudes, readiness
• Revise first step
• Consider referrals

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Intervene Referral Resources

• Referrals to
• Behavioral interventions
• Individual, group, community
• Referrals to other services
• Patient education materials available in your
  office
• HIV Comprehensive Risk-Reduction Counseling and
  Services (CRCS)
• Providers of Services

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HIV Comprehensive Risk-Reduction Counseling and
Services (CRCS)

• Voluntary and confidential service
• Assists persons living with HIV to tell their
  partner(s) about possible exposure
• Provides access to testing and other prevention
  services

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Screen Physician-Patient Communication Key to
Overall Outcomes

• Ensure the office staff andculture are not
  discriminatory
• Display visuals and literaturesensitive to
  sexual diversity
• Provide non-intimidatingmedical literature
• Use inclusive language inintake forms
• Be aware of verbal and bodylanguage
• Be open and non-judgmental
• Show willingness to listen
• Be sensitive to confidentialityconcerns
• Remember It only takes a few more minutes to
  motivate your patients

Source Kaplan SH, et al. Med Care. 27(3
Suppl)S110-S127.
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Conclusions

• Ask, Screen, Intervene
• Brief assessment and message(s)
• Every patient, every visit
• Unique opportunity

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Prevention IS Care Resources

• The Prevention IS Care Provider Resource Kit
  contains materials and resources to guide you
  with prevention messages
• Physician Intervention Tools
• Patient Education Materials
• Available in English and Spanish
• For more information www.cdc.gov/PreventionISCare

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Additional Resources

• Local Health Department HIV/AIDS Programs
  http//www.cdc.gov/nchstp/dstd/Public_Health_dept.
  htm
• National Alliance of State and Territorial AIDS
  Directors (NASTAD) www.nastad.org
• Advancing HIV Prevention Interim Technical
  Guidance for HIV Partner Counseling and Referral
  Services (Centers for Disease Control and
  Prevention) www.cdc.gov/hiv/partners/Interim/partn
  ercounsel.htm
• State STD Program Managers

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Additional Resources

• National Coalition of STD Directors
  www.ncsddc.org
• HIV Criminal Law and Policy Project -
  www.hivcriminallaw.org
• National Network of STD/HIV Prevention Training
  Centers Partner Management and Program Support
  Services Training www.nnptc.org

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Patient Perspective

• Keith Rhoades
• HIV-Positive for 4 Years
• Torrance, CA

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My HIV Diagnosis Experience

• Initial symptoms
• Request for an HIV Test
• Physician delivery of diagnosis
• Search for new physician x2

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Evolution of Relationship

• 1st Visit Awkward to discuss sex, fear of
  judgment
• 2nd Visit Comfort increases, more open dialogue
• 3rd Visit Trust being built, begin honest
  conversation, ready to listen to prevention
  messages

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Today During Every Visit

• Medication
• Prevention messages
• Overall health
• Keeping me healthy
• in ALL aspects of my life
• Constant reminders

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Effective Messages

• HIV is not a death sentence
• Decrease anxiety of initial shock
• Increase hope of a longer life
• Develop a sense of manageability
• Focus turns to long-term health and prevention
  transmission behaviors keeping self and others
  healthy

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Effective Messages

• Every visit ensures we
• Maintain comfort level
• Maintain a non-judgmental environment
• Maintain open and honest dialog increasing
  likelihood of disclosing risky behavior
• Because of his approach, I listen and act

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Effective Messages

• Providing Informational Resources
• Creates comfort for patient to research in
  private
• Gives hope about new research and medication
• Decreases anxiety between visits
• Keeps me focused on keeping me healthy

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Final Thoughts

• Building relationships takes time
• Consistency is key in changing behavior
• Realize your words do matter