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

1. Incorporating HIV Prevention into the Medical Care of Persons Living with HIV Ask Screen Intervene

2. 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

3. 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

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

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

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

7. Incorporating HIV Prevention into the Medical Care of Persons Living with HIV Ask Screen Intervene

8. 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

9. Background: Advancing HIV Prevention (AHP) • Rationale for AHP • AHP primary goal: reduce HIV transmission • AHP’s 4 priority strategies • Recommendations address strategy 3

10. 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 transmission—but often relapse. • Providers: unique opportunity to influence prevention practices of HIV-positive patients during medical visits.

11. 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

12. What’s Stopping Us? • Responsibility • Time • Privacy • Comfort Level • Skills • Scope • Resources • Impact • Reimbursement • Beliefs/perceptions

13. 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

14. How to Ask

15. 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

16. Tools Available to Start Risk Assessment Conversations

17. How to Screen

18. Screen: Identify and Treat Other STDs • Diagnostic testing vs. screening • Who do you screen? • Everyone one time per year • Everyone who discloses risk behavior

19. 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

20. How to Intervene

21. 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

22. Intervene: Deliver Brief, TailoredPrevention 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

23. 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

24. Address Common Misconceptions: Risk of Acquiring HIV Based on Specific Sexual Behaviors

25. 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?

26. 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

27. 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

28. 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

29. 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

30. 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

31. 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 85% of patients don’t fully understand what the doctor tells them OVER50% of patients leave the office unsure of what they are supposed to do Source: Kaplan SH, et al. Med Care. 27(3 Suppl):S110-S127.

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

33. 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

34. 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/partnercounsel.htm • State STD Program Managers

35. 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

36. Patient Perspective Keith Rhoades HIV-Positive for 4 Years Torrance, CA

37. My HIV Diagnosis Experience • Initial symptoms • Request for an HIV Test • Physician delivery of diagnosis • Search for new physician x2

38. 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

39. Today: During Every Visit • Medication • Prevention messages • Overall health Keeping me healthy in ALL aspects of my life ~ Constant reminders

40. 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

41. 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

42. 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

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