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Written Clinic Procedures Enhance Delivery of HIV “Prevention with Positives” Counseling in Primary Health Care Settings Janet J. Myers, Ph.D., M.P.H.1, Wayne T. Steward, Ph.D., M.P.H. 1, Edwin Charlebois, M.P.H., Ph.D. 1, Kimberly A. Koester, M.A. 1, Andre Maiorana, M.P.H. 1 and Stephen F. Morin, Ph.D. 1 1AIDS Policy Research Center, AIDS Research Institute, University of California, San Francisco, CA, USA

Background The US Institute of Medicine recommends delivery of prevention services to HIV-infected individuals in primary care settings (“Prevention with Positives”). Little is known about the extent to which  HIV prevention services are delivered across publicly funded clinics in the US.

Objectives To assess the frequency of HIV prevention services delivered in clinics funded by the Ryan White CARE Act. To determine if written policies and procedures changed the likelihood that HIV prevention services were delivered.

Methods 614 HIV-infected primary care patients were surveyed as they exited clinics in 16 publicly-funded clinics in nine states. Patients were asked to report on receipt of a variety of health behavior counseling services, including HIV prevention counseling. Primary care providers completed qualitative interviews to determine the existence and extent of use of HIV prevention procedures.

Research Sites

Characteristics of the Patient Sample Half were African American. Three-quarters were men. About half were gay or bisexual. Approximatley three-quarters were high school graduates, over 35 years old, and on ARVs. Two-thirds were sexually active in the last 6 months.

Clinic Types: Approach to prevention

Patients Reporting Receipt of HIV Prevention Counseling in the last 6 months by Clinic Type

Multivariate Predictors of Receipt of Prevention Counseling in the Last 6 Months by Clinic Type

In clinics with no procedures… Sexually active, heterosexual women reported receiving significantly more counseling. Linked to HIV and childbearing? Probably also a function of gay men getting less counseling.

In clinics where providers initiated counseling… Sexually active African Americans reported receiving significantly more counseling. Probably not a function of risk because African Americans did not report more risk. Minority AIDS Initiative influence? Influence of clinic type? Role of race in patient/provider communication?

In clinics with written procedures… HIV-infected patients in clinics with written procedures were significantly more likely to report receiving HIV prevention counseling in the last six months than were patients in clinics with no procedures (OR=3.17, 95% CI:1.24-8.06, p<.02).

In clinics without written procedures… In clinics where individual providers initiated counseling or where no procedures were in place, patient characteristics such as race, gender, and sexual orientation were associated with receipt of prevention counseling. These differences were not observed in clinics with written procedures.

Conclusions Clinicians’ views regarding their role and responsibilities influence the extent to which provider-based interventions are implemented. In clinics without written procedures, clinicians appear to offer HIV prevention services to HIV-infected patients based on client demographics, including race,  gender, sexual orientation and sexual activity.

Conclusions Written procedures increase the likelihood of receipt of ‘Prevention with Positives’ services irrespective of demographic characteristics.

Limitations Patients were not randomly selected. Receipt of counseling was determined through patient self-report. Did not directly address provider perceptions of HIV risk relative to patient characteristics.

Acknowledgements: Ryan White Prevention Project Team