Despite the several just-reviewed studies showing the value of clinician-provided prevention counseling, at least one study identified a counselor who did better than clinicians in getting HIV-positive people to cut back on risky sex: a computer.13 This trial randomized 566 HIV-positive people in six Los Angeles clinics to (1) a 10-minute interactive computer program (two clinics), (2) a provider-delivered prevention interaction (two clinics), or (3) standard care (two clinics). Compared with people randomized to provider delivery or standard care, those who pointed and clicked their way through a prevention program reported a significant drop in number of HIV-negative or HIV status-unknown partners. And compared with the standard-care group, computer users claimed a significant drop in vaginal or anal sex without condoms.
Another interactive laptop prevention program, the Positive Steps "Video Doctor," yielded significant declines in illicit drug use, average days of ongoing drug use, unprotected sex, and number of casual sex partners compared with standard care.14 This randomized trial focused on 476 HIV-positive people who reported substance use or sexual risk when attending five HIV outpatient clinics in San Francisco. Results for the first two outcomes were statistically significant both 30 and 60 days after the intervention.
An advantage of both of these digital strategies is that they require 0 up-front provider time.13,14 The Video Doctor gives the flesh-and-blood doctor a "cuing sheet" on risks reported by each patient so the provider can follow-up with appropriate questions and, if necessary, referral.
All three positive-prevention experts interviewed in this issue of RITA! stress the value of these time-saving approaches for busy HIV practices. And, no doubt, when it comes to intimate questions about sex and drugs, many people with HIV would rather respond to a computer than to a clinician. The table between the two interviews in this issue outlines these and other patient-administered prevention strategies and provides links for more information.
If people with HIV respond to simple HIV prevention counseling from providers -- and waiting room laptops -- as part of their regular check-up, why do physicians and other practitioners skip this facet of HIV care so often?3-8 One HIV clinician/researcher told RITA! he could think of four reasons: "Time. Time. Time. Time." Another four reasons are money, money, money, and money. As the CDC delicately notes in its positive prevention guidelines, "Some clinicians have expressed concern that reimbursement is often not provided for prevention services and note that improving reimbursement for such services might enhance the adoption and implementation of these guidelines."1
The survey of 317 HIV physicians in Atlanta, Baltimore, Miami, and Los Angeles underlined the importance of time in determining whether clinicians paused to stress positive prevention.7 Physicians who strongly agreed they had enough time "to provide care and information to patients" were over 3 times more likely to discuss prevention than physicians who said they didn't have enough time (OR 3.4, 95% CI 1.9 to 6.1, P < 0.001). Every additional 20 patients seen monthly lowered chances of always discussing transmission almost 10% (OR 0.92, 95% CI 0.84 to 0.99, P = 0.05).
Three studies reviewed above suggest another important reason -- provider discomfort in discussing sex with gay or bisexual men,4,5,12 though research reviewed below indicates these men pose the biggest transmission risk among HIV-positive people in the United States.
Another already-mentioned study uncovered a nearly nihilistic reason why providers don't talk to HIV-positive people about prevention -- the belief that people with HIV won't change their behavior.6 Besides surveying 618 HIV-positive people about prevention counseling, these researchers conducted 144 interviews with providers, administrators, and patients in 16 publicly funded US clinics. Then they summed pessimistic comments (described as "provider fatalism") and assigned each clinic a "fatalism score."
People in high-fatalism clinics proved less likely to report prevention counseling than those in low-fatalism clinics, even after statistical adjustment for clinic characteristics, patients' sexual risk, and patients' health status. People in high-fatalism clinics were more likely to be white, gay, educated, and older -- a finding that also suggests providers in these clinics assume their patients are sophisticated or disciplined enough to avoid transmission risk on their own.6
A separate analysis of these patients found that people in their first year of care were twice as likely to hear from their provider about safer sex and transmission as people in care for more than 1 year (OR 2.35, 95% CI 1.60 to 3.44, P < 0.001).8 Interviews with these providers confirmed an array of familiar reasons for shunning prevention reminders: lack of time, specialized training, and dedicated funding for staffing. Interviews with some providers evinced a "conflict over their role and responsibility" when they described themselves "as advocates for their patients' health, rather than as guardians of the public health." Providers who agreed that HIV clinics should talk to patients about positive prevention did not agree on exactly who should do the talking.
Because research on this question is lean, RITA! asked an impromptu panel of clinician/researchers to offer their insights on why providers don't spend more time stressing positive prevention (see box). Almost all 18 ticked off the same reasons disclosed in studies outlined above -- the (flattering but perhaps unfounded) assumption that patients are avoiding risk without coaching, the belief that primary care doesn't carry a public health mandate, and too little time:
"My patients often come with lists of issues to deal with and we attend to those first, often leaving little time for issues that would be on my list," explained Ann Collier. "Other issues of care often seem more important, more pressing, or more rewarding," David Margolis noted, acknowledging that "this is a problem." Indeed, too little time may soon become a time-worn excuse for shunning prevention counseling. The forthcoming CDC update on prevention with positives will stress interventions that require little or no clinician time, as discussed in the two interviews in this issue, in the table between those interviews, and in the second review article.
Providers probably also look beyond the time taken for prevention counseling itself to what might follow: If a tricky concern does arise during counseling, clinicians may fear they will have little time to deal with it meaningfully. Along the same lines, John A. Bartlett suggested that hearing patients say they haven't backed away from risky sex creates a "burden" for the provider, "and we might wish that we didn't have this information." But that fear, he stressed, does not excuse clinicians from talking about risky sex.
Carl Fichtenbaum underlined the futility some clinician feel in getting patients to avoid transmission-risk behaviors, the "provider fatalism" seen in the 16-center study discussed above.6
David Wohl emphasized provider discomfort in talking explicitly about sex. "Even HIV providers used to doing anal paps and hearing about sex toys and meth-fueled nights on the town can get shy when it comes to talking dirty," he offered. "We are also busy and sex talk takes time."
Some providers, Ian Frank suggested, fear that hammering on consistent condom use may send a pejorative message to the patient, as if the clinician is saying, "You are doing something you know you shouldn't be doing!" He sees value in "getting beyond the condom conversation, which is important, but not the only way to counsel patients about transmission risk."
Paul Sax also stressed that providers must not seem judgmental: "For newly diagnosed patients, or patients seeing you for the first time, it's critically important not to imply blame for the patient being HIV positive," he explained. "Consciously or subconsciously, we may feel that discussing prevention sends that message -- that if only you had followed this prevention advice, you wouldn't be infected."
TB may jump from one person to the next more readily than HIV makes that leap, but odds of blood-borne or sexual transmission of HIV are not long when one considers (1) the consequences and (2) how often people embrace the risk in a lifetime. Getting transfused with HIV-tainted blood -- though rare today -- almost always results in HIV infection, with chances estimated at 95-in-100.3 Children born to HIV-positive mothers without antiretroviral prophylaxis stand a 1-in-4 chance of HIV infection. From there, odds drop in people sharing drug-injecting equipment or having condom-free sex (Figure 2).
But compared with other risks, sexual HIV transmission chances should inspire caution -- if not awe -- in people who let HIV near a nick, sore, or porous mucosal wall. For example, the 1-in-150 chance of picking up HIV while sharing injecting equipment exceeds the 1 in 167 risk of dying from heart disease or from an accident in the next 10 years among 45-year-old US men who never smoked15 and far exceeds the 1-in-1000 risk of dying from pneumonia in the next 10 years among 45-year-old US men who do smoke.15 The high estimate for acquiring HIV during rubber-free male-to-male anal intercourse, 1-in-10, is about the same as the 1-in-10 to 1-in-25 chance of miscarriage in the United States16 and far exceeds the 1-in-36 chance of rolling snake eyes (one and one) in craps.
Figure 2. Risk of HIV transmission is generally higher with needle sharing or needlestick injuries than with condom-shirking male-to-male anal intercourse or heterosexual coitus.3 But some research suggests that unprotected receptive anal sex may be riskier than needle sharing or needlestick and that for women unprotected vaginal sex may be as risky as needle sharing or needlestick.
Lifetime chances of HIV infection in the US are downright awful. For the years 2004-2005, CDC researchers estimated that white men in 33 of the United States ran a 1 in 104 chance of getting infected, Hispanic men a 1 in 35 chance, and black men a 1 in 16 chance.17 Estimated lifetime infection rates for US women were 1 in 588 for whites, 1 in 114 for Hispanics, and 1 in 30 for blacks. If you told people they had a 1 in 16 to 1 in 104 lifetime chance of dying in a plane crash, how many people would fly?
CDC number jugglers offer another way to weigh the risk of getting HIV from a sex partner (Figure 3).1 Starting with the premise that insertive penile-oral sex is the least likely way to pick up the retrovirus, the CDC team uses study data to estimate the relative risk of receptive penile-oral sex (twice as likely), insertive vaginal sex (10 times more likely), receptive vaginal sex (20 times more likely), insertive anal sex (13 times more likely), and receptive anal sex (100 times more likely). Compared with using a condom, the CDC figures, shunning condoms hikes the risk of HIV acquisition 20 times.
Figure 3. Using data from published studies (and a "best-guess estimate"), the CDC figured the likelihood of getting HIV during sex compared with insertive fellatio as the reference. (Source: CDC. Incorporating HIV prevention into the medical care of persons living with HIV: recommendations of CDC, the Health Resources and Services Administration, the National Institutes of Health, and the HIV Medicine Association of the Infectious Diseases Society of America. MMWR. 2003;52(No. RR-12).)
Needle sharing and needlestick HIV transmission risk varies according to how much blood gets under the stuck person's skin. And anal or vaginal transmission risk depends on viral load in the already-infected person and sexually transmitted diseases or open wounds in either partner. A landmark study of 415 HIV-discordant Ugandan couples -- one partner positive, one negative -- established the tight link between HIV load in plasma and transmission risk in this antiretroviral-naive group.18 Viral load averaged 90,254 copies/mL in people whose partner got infected with HIV versus 38,029 copies/mL in those whose partners stayed HIV-free (P = 0.01). Multivariate analysis accounting for other transmission risk factors determined that every 10-fold higher viral load more than doubled transmission risk (OR 2.45, 95% CI 1.85 to 3.26).
A more recent analysis of 235 monogamous Ugandan couples in this same population confirmed the intimate link between transmission risk and viral load (as well as genitourinary disease) in the positive partner.19 These researchers examined the impact of disease stage, viral load, and other factors on transmission risk in the years before any of these people took antiretrovirals. They established HIV transmission by HIV sequence analysis.
The HIV transmission rate was about 8 per 1000 coital acts in the first 5 months of HIV infection, when viral load is highest (median 30,000 copies/mL in this cohort).19 Six to 35 months after infection, the rate fell to about 1.5 per 1000 coital acts as the viral load waned (median 2600 copies/mL 15 months after infection). During chronic HIV infection, transmission rates varied from about 0.5 to 1.0 per 1000 coital acts (median viral load 10,300 copies/mL at study entry and 15,000 copies/mL after 30 months of follow-up). In late-stage infection (median viral load 112,600 copies/mL), transmission rates climbed back above 1 per 1000 coital acts, reaching about 3.5 per 1000 in the 6 to 25 months before death.
Multivariate analysis determined that, compared with a viral load in the lowest quartile, a load in the next-higher quartile tripled the risk of HIV transmission per coital act (rate ratio [RR] 3.31, 95% CI 1.01 to 10.80), a load in the next-higher quartile upped the risk more than 6 times (RR 6.39, 95% CI 2.10 to 19.42), and a load in the highest quartile inflated odds 7 times (RR 7.06, 95% CI 2.29 to 21.81). In a model that also included viral load, genitourinary disease in the initially infected partner doubled the risk of transmission (RR 2.05, 95% CI 1.02 to 4.14).
A recent longitudinal study of 1381 initially HIV-negative gay men in Sydney, Australia figured a per-sex-act HIV risk of 14.3-in-1000 for men who practiced unprotected receptive anal intercourse with ejaculation in the rectum versus 6.5-in-1000 for unprotected receptive anal intercourse with withdrawal before ejaculation.20 The latter rate came close to the 6.2-in-1000 for uncircumcised men who practiced unprotected insertive anal intercourse, much higher than the 1-in-1000 rate for circumcised men taking the insertive role. The 1.43-in-100 infection rate for receptive partners whose mates ejaculated in their rectum looks big when one considers that the 663 men who took that role reported 56,514 such encounters in 6 years of total follow-up, or 85 per man. Also, these findings underline the iffy protective value of withdrawal during anal sex.
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