Most of the more than 900,000 Americans living with HIV know that they are infected and have regular contact with a health care system.1,2 It is estimated that most HIV-infected persons have at least 1 annual primary medical care visit.3,4 Current HIV treatment guidelines recommend at least quarterly assessment of plasma HIV RNA viral load and CD4 count and more frequent assessments when patients initiate or switch their antiretroviral therapy,5 so many HIV-positive patients may see a primary provider at least quarterly. Monitoring for possible drug toxicities may necessitate additional clinic visits. Yet, since the advent of highly active antiretroviral therapy (HAART) in 1996, sexually transmitted diseases (STDs) have increased among many HIV-infected and at-risk individuals.6–8 Some public health researchers suggest that HIV incidence has increased among men who have sex with men (MSM),9 even though HIV treatment may plausibly be expected to be associated with decreased infectiousness,10 because of increases in STDs that potentiate HIV transmission. Recent surveillance data from urban areas in the United States, Canada, Europe, and Australia indicate a resurgence in syphilis and gonorrhea among MSM, who are disproportionately HIV infected.6–8
WHY MIGHT HIV-INFECTED PERSONS HAVE RISKY SEX?
Several studies have shown that a substantial minority of HIV-infected patients may engage in risky sexual practices.11–15 The reasons for unprotected sex, particularly among MSM, are complex. Although some have postulated that MSM may practice risky sexual practices because of optimism about current HIV treatments or because of “prevention fatigue,” others have challenged these hypotheses as being too simplistic.16–18 Factors consistently associated with risk behavior include a lack of willingness to change one’s sexual behaviors,12 emotional distress,19 substance use,12 past sexual abuse,20 and sexual compulsivity.11,21 In an analysis of 4295 men who had engaged in anal sex in the prior year, Chesney et al22 found more than 60 patterns of risk correlates in combination among the cohort; important variables included peer norms, depression, sexual negotiation skills, attitudes of reduced sensation when using condoms, and alcohol and substance use. There is no single simple answer as to why HIV risk-taking behavior among HIV-infected persons seems to be increasing, so providers may need to implement individualized approaches to assess risk behaviors and appropriate interventions to promote safer sexual practices.
PROVIDER BARRIERS TO DISCUSSING HIV RISK BEHAVIOR
HIV Providers Have Increasingly Tight Schedules and Responsibilities
Many private managed care and Ryan White–funded programs anticipate that routine patient care visits for people living with HIV will last for 15 to 30 minutes. Given that they need to discuss recent laboratory results, medication side effects, adherence, and other medical conditions, ranging from hepatitis C coinfection to treatment of lipodystrophy, providers may find it difficult to prioritize discussions of safer sex with their patients.
Providers May Not Feel Comfortable Discussing HIV Risks With Their Patients
Providers may worry that patients will perceive them to be judgmental if they assess sexual or drug-using behaviors. Heterosexual providers may think that MSM will be uncomfortable disclosing behaviors to them, and providers whose sexual orientation is similar to that of their patients may feel that this topic may blur professional boundaries. Providers may also feel uncomfortable in discussing sex in general because of a lack of attention to this training in professional school, personal religious beliefs, or societal homophobia. Finally, concerns about stigmatizing patients may make it difficult for some providers to be comfortable in discussing injection drug use and strategies that may reduce the risks of HIV transmission among people who share needles.
Providers May Believe That Patient Care Is Their Primary Concern Rather Than Public Health Issues
Any discussion of transmission issues may be perceived as ultimately benefiting individuals who are not being cared for by primary providers. Thus, initiation of conversations about safer sex may entail discussions with individuals who the provider does not know and who do not receive medical care in their health care setting.
Discussions Elucidating Risk-Taking Behaviors May Reveal Activities That Are Reportable to Public Health Authorities
Several states have “duty to notify” laws in which medical providers are obliged to notify public health authorities if they have reason to suspect that a patient has knowingly exposed a partner to HIV. Criminal litigation has sometimes ensued in these situations. Concerns about obligation to report may create dissonance in providers who believe that the confidentiality of the provider-patient relationship is inviolate, so they may elect to avoid the topic to prevent complications.
Providers May Feel Uncomfortable Delivering an Overly Complex HIV Prevention Message
Although it is well established that most HIV transmission events are caused by unprotected vaginal or anal intercourse, there are many nuances of the sexual encounter for which data are less definitive.23 For example, providers may be asked to quantify the riskiness for specific sexual acts. Providers may then feel duty-bound to discuss the many caveats in the studies that comprise this literature—for example, that estimates of per contact risk are obtained via sexual histories and assessment of whether acute HIV infections occurred but that many participants in these studies may not have been able to describe which event or behavior resulted in transmission. Other issues that may be challenging to communicate easily in a brief effective message include the role of biologic cofactors (eg, viral load, STDs) in transmission risk, the lack of an agreed-on standard regarding the riskiness of oral sex, the riskiness of “strategic positioning” (when HIV-infected individuals may assume that they are less likely to transmit HIV if they are the receptive partner), and the current lack of data about the specific risks of unprotected seroconcordant sex.
Given these multiple variables that need to be discussed to provide a scientifically correct discussion that helps the patient to understand the limitations of the available data, providers may think that it is less problematic to avoid a discussion of HIV transmission altogether. Fortunately, resources to assist providers in discussing HIV and other STD transmission are increasing, because US Public Health Service Guidelines have been developed that contain graphs, charts, and talking points for clinicians, based on the best available evidence.24
MISSED OPPORTUNITIES FOR HIV PREVENTION
Medical providers continue to be highly respected by their patients as important sources of health care information. Despite all the impediments described previously, many HIV-infected patients continue to look to their primary providers for information above and beyond the management of their antiretroviral therapy. If a patient senses provider willingness to engage in discussions about HIV risk-taking behavior, the clinical encounter may be able to be used as an “educable moment.” At present, there is no simple formula for how providers should promote HIV prevention among their infected patients. Several studies in this issue discuss innovative programs for HIV prevention, and readers will be able to incorporate the features of each that make the most sense for their clinical setting. Some of the interventions described in this issue are provider based (eg, Fisher et al, Richardson et al), whereas others may involve triage to affiliated counselors (eg, Wingood et al). The National Institutes of Health (NIH), Centers for Disease Control and Prevention (CDC), and Health Resources and Services Administration (HRSA) are currently funding additional studies and initiatives to evaluate the best methodologies to enhance HIV prevention services for HIV-infected patients in care. Although the long-term efficacy of these interventions in decreasing HIV transmission is as yet unknown, the importance of providers in making their best efforts to address this latest wave of the epidemic is manifestly clear, given that 40,000 Americans are likely to become newly infected with HIV in the next year.
The dedication of the Research Department staff at Fenway Community Health and the Miriam Hospital Immunology Center is gratefully acknowledged, and discussions with Rodney VanDerwarker, Timothy Flanigan, and Martha Powers have been invaluable in helping the first author think about the challenges of HIV prevention in clinical settings. Ms. Lola Wright for assistance in the preparation of this manuscript.
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