Incorporating HIV Prevention into Medical Care Settings (PICS) demonstration project addresses strategies 1 and 3 of the Advancing HIV Prevention Initiative. It will explore the effects of clinic-based, repeated, brief prevention counseling on patient behaviors and sexually transmitted diseases (STDs) in the United States through a program called Positive S.T.E.P.s (Striving to Engage People).
After testing positive for HIV, many people reduce behaviors that may transmit HIV to others; however, such behavioral changes are not always maintained and some people continue to engage in behaviors that place themselves and others at risk. Ongoing, brief prevention counseling is a cost-effective measure that can be incorporated into routine care for HIV-positive individuals. The HIV outpatient clinic is an ideal setting for the delivery of this intervention to large numbers of individuals with HIV in the years following their HIV diagnosis because it provides an opportunity to a) reach a large number of seropositive individuals who visit the clinic on a regular basis, b) implement a safer-sex and needle-sharing intervention across time, c) integrate the intervention with routine clinical care, and d) involve clinic nurses and physicians in the intervention.
The six sites chosen for this project implemented the 2003 Incorporating HIV Prevention into Medical Care Settings Guidelines and assessed their impact on patient-reported risk behaviors, STD rates, tailored risk-reduction counseling, and referrals. Providers at participating sites received training to enhance their HIV prevention and risk-reduction planning and counseling skills. Mountain Plains AIDS Education Training Center (MPAETC) was contracted to provide standardized training at each of the six clinics, as well as a variety of prevention posters and brochures geared toward patients and providers.
The goals of this program are to
- recruit 1,200 patients at six sites (200 per site) with at least 50% racial/ethnic minority representation,
- increase the number of persons with HIV who have information about transmission risks and regularly receive counseling about ways to reduce the risk of transmitting HIV to others,
- increase the number of sexually active persons with HIV who are screened and
tested for STDs,
- enhance the capacity and ability to conduct effective prevention counseling and referral for services (e.g., social, mental health, drug treatment, partner notification), and
- assist in strengthening linkages among health departments, CBOs, and providers of HIV care to facilitate the referral of HIV-positive persons to needed services.
Chapel Hill, North
Carolina, University of North Carolina
(UNC) will conduct the project in their
Infectious Diseases Clinic. They currently
provide services to 1,500 patients referred
to them for HIV care. UNC is incorporating
the services of an on-site prevention
counselor for this project.
Denver, Colorado, Denver Health and
Hospital Authority, Denver Public Health (DPH) is a division of the Denver Health and Hospital Authority. They have 1,250 active patients in their ID/AIDS Clinic. Denver is the only site with an established prevention program targeting HIV positive patients. The PICS project enabled them to increase their prevention efforts and measure outcomes not previously assessed.
Atlanta, Georgia, AIDS Research
Consortium of Atlanta is a non-profit research center that conducts research in 50 private physician offices and six public health clinics. They conducted their project in two Ryan White Clinics located in the Cobb County and Dekalb County Board of Health (BOH) Departments. Dekalb County BOH is the larger clinic serving 850 patients. The Cobb County BOH is a smaller clinic with a patient population of 354, 10 % of whom are of Hispanic ethnicity.
Nashville, Tennessee, Comprehensive
Care Center is an independent 501 (c) (3) organization funded by Ryan White and affiliated with the Infectious Diseases Division of Vanderbilt University Medical Center. Their active patient population of 2,000 has shifted over the last nine years to comprise more minorities and females, which is representative of the HIV epidemic rather than that of the local population. They collaborated with the CBO Nashville CARES to provide more intensive HIV prevention counseling to patients who needed this service.
Brooklyn, New York, State
University of New York (SUNY) Downstate
is the Medical Center composed of the University Hospital of Brooklyn and medical, nursing, and allied health professional schools. Their currently active HIV caseload is 902 patients, 65% of whom are inner-city females. University-wide resources are available to their clinic patients.
Kansas City, Missouri, University
of Missouri conducted the project at the Truman Medical Center Infectious Diseases Clinic. There are currently 470 patients receiving care at the clinic. They expanded their patient services to include prevention counseling as part of the PICS project.
A collaboration between CDC and staff researchers at each of the project sites resulted in the creation of an intervention suitable for uniform administration at all sites. This intervention is designed to reduce HIV transmission by reducing risky behaviors among HIV positive patients. It was delivered as a standard of care to all patients at participating sites. PICS utilizes the opportunity presented by regular provider-patient visits to promote the program.
- Funding announcement:
- Selection of
contractors: September 2003
- Investigator meetings: November 2003; January 2004; June 2005
Cohort: 1109 enrolled April 2004 - October 2004
Cohort interviews: 2,871 interviews completed March 2006
Quarterly patient surveys: 6 waves completed April 2006
Quarterly provider surveys: 6 waves completed April 2006
Qualitative interviews: completed April 2006
Data measuring programmatic effectiveness
will be obtained anonymously from the clinic
population at large. More detailed
measurements will be conducted with patients
enrolled in a cohort measurement group.
All enrolled participants will be asked
to provide baseline data (i.e., demographic
and socioeconomic data, test
knowledge/attitudes/beliefs related to
sexual behavior and drug use, current sexual
and drug practices) via questionnaire or
interview. The survey will be repeated for
all participants at 6 months and again one
year after enrollment.
Providers will use a Behavioral
Assessment Screening Form during patient
exams to facilitate risk-reduction
discussions, delivery of prevention
messages, and establishment of patient
behavioral goals. At all sites except
Denver, this will be a two-step process. The
patient will complete a self-administered
questionnaire that solicits information
regarding risky sex and drug behaviors.
Providers will use these responses to tailor
prevention messages and risk-reduction
plans. In Denver, providers will solicit the
same information during one-on-one
interviews during patient visits.
Medical record abstraction will be done
to obtain lab test data collected on
subjects at baseline and follow-up visits.
Information gathered will include recent CD4
count, viral load, STD diagnosis, and use of
antiretroviral medications and/or
Pneumocystis carinii pneumonia
prophylactics. In addition, referral types
and referral follow-through will be tracked
on participating patients. Data collection
will be handled by MPAETC and will be
systematized across the sites to permit
pooled data analyses and evaluations.
All providers at participating sites will
complete pre- and post-training assessments
to measure their current practice of giving
HIV prevention messages to their
HIV-positive patients and their comfort
level with the same.
Quarterly provider assessments will
coincide with and compliment the quarterly
patient assessments. These will measure
provider fidelity to the intervention.
Results to Date
Providers at the six demonstration project sites received training and implemented the Positive S.T.E.P.s intervention in their clinics. The intervention was delivered as standard of care to all patients.1109 patients enrolled in the PICS cohort were followed for one year after the intervention initiation. Six waves of provider and clinic patient surveys were completed. Qualitative interviews with key clinic staff were conducted at each site. Data analysis for this project is currently in progress.
For more information . . .
Advancing HIV Prevention
Resources on the Advancing HIV Prevention initiative
CDC National Prevention Information
1-800-4 58-523 1
CDC resources, technical assistance, and publications