Stephen F. Morin, Ph.D.
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Dr. Morin was among the first scientists to undertake behavioral research on HIV prevention. Besides his ongoing investigation of HIV prevention -- much of which focuses on prevention in positives -- he has helped recommend structural changes in the AIDS Drug Assistance Program and has studied racial and ethnic disparities in access to HIV medication. From 1987 through 1997, Dr. Morin worked as principal legislative assistant to Representative Nancy Pelosi, then on the Labor-HHS-Education Appropriations Subcommittee, which funds most of the federal response to AIDS.
Mascolini: What does your research and others' tell us about which HIV-positive people in the United States have the highest risk of transmitting their virus sexually or by needle sharing?
Morin: The greatest transmission risk continues to be sexual transmission, even among injectors. In the United States, being a man who has sex with men (MSM) is the greatest predictor of HIV transmission risk. Most sexual transmissions occur among MSM, and MSM have the highest probability of transmission.
Much of my research has looked at how clinical settings can be used to reach men who have sex with men and other HIV-positive people who may be at risk of transmitting to others. We've been looking at everything from very simple communications from providers to very complicated multisession interventions delivered by prevention specialists. (See "What Are Effective HIV Prevention Models for Use in Health Care Settings?")
Mascolini: Your work shows that prevention interventions delivered in clinical care settings can be effective in reducing HIV transmission risk.1-3 But clinicians say they don't have enough time or they're uncomfortable talking about sex or they don't think they can change patient behavior. How can clinicians get beyond these negative perceptions?
Morin: We started examining this issue by looking at the opportunity for prevention in clinical settings.4,5 Those early studies found that prevention interventions in clinical settings were unusual, and we found that there was considerable difference of opinion among providers about their role in prevention.4 Some providers argued that they were advocates for their patients, that their primary responsibility was improving health outcomes, and that they did not play a significant role in public health, which was other peoples' responsibility. Other providers argued that of course sexual health was part of taking care of any patient and that frank discussions about sexual risk and transmission were part of their responsibility in improving health outcomes. You had a range of provider attitudes on this issue.
We found that in order to get providers more involved, one has to start by working to minimize the burden on providers and to simplify the process of conducting the risk assessment. The most useful and efficient provider-based interventions last about a minute and a half. You have to structure the situation so the provider is comfortable and has some guidance about how to deliver a prevention message in a very brief amount of time.
Mascolini: And do your findings show that such brief interventions can be effective?
Morin: Yes, we actually found it to be the most effective and most cost-effective of various interventions that we looked at.2
Mascolini: Your work indicates that people with acute HIV infection don't understand the high transmission risk associated with their new infection.6 You also found that newly infected MSM cut back on sex and risky sex in particular.7 Do HIV clinicians see acutely infected people often enough to have an impact on prevention at this critical juncture?
Morin: Yes, providers see acutely infected patients often enough to have an impact. Among all their patients, the proportion of people with acute infection is very low. Even in those low numbers, however, they can still have an impact because diagnosing acute infection -- when the viral load is so high -- can have such a big impact on transmission outcomes.
We find that many providers do not have sufficient information about sexual history or risk in their HIV-negative patients. If they did, they would probably do more screening for acute infection. One of the interventions we've recommended is a provider awareness campaign that encourages providers to screen for HIV and STIs [sexually transmitted infections] in clinical settings when people present with certain symptoms.
Mascolini: Who would mount such campaigns?
Morin: It could be done through specialty organizations, though any of the professional groups, or through networks at the local level. Most of these campaigns have been done in discrete jurisdictions, like New York City.
Mascolini: A study you coauthored found complex and evolving interactions between mental health and HIV transmission risk.8 Can you summarize the clinically relevant take-home findings?
Morin: The important takeaway messages from that study are that there is a high prevalence of mental disorders in the population of people with HIV, and if clinicians treat depression and other mental health issues they can improve antiretroviral adherence and improve clinical outcomes. The relation between the mental health issues and substance abuse issues is very significant as well.
In terms of prevention in positives, these findings point to a need to screen for both mental health and substance abuse in the course of treating people with HIV. These kinds of brief screenings can be done in waiting rooms, the same way you can screen for transmission risk on handheld devices in waiting rooms. If you make it efficient and don't put the burden on the provider, you greatly increase the likelihood that it will get done as part of routine clinical business. [See the table following this interview for a summary of four patient self-administered interventions.]
Depending on patient responses on the handheld device, the provider can be alerted to the need for intervention. If there's no problem, the provider is not cued. If there is a problem, there's a prompt in the electronic medical records to raise the issue. That may mean directly intervening with a message or it may mean referral for specialty care.
Mascolini: Are clinical practices adopting this approach?
Morin: It depends on how technology-savvy the practice is. Practices that have electronic medical record prompts tend also to be more flexible in terms of screening procedures that cue providers when to intervene and when not to.
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