As AIDS Cases Increase, Health Experts Warn Against Missed Prevention Opportunities
October 1, 2003
At CDC's National HIV Prevention Conference in Atlanta in July, Mark Thrun, M.D., of Denver spoke about missed opportunities for HIV prevention counseling in which physicians ask patients about specific behaviors that increase their risk of transmitting HIV or being reinfected with a different strain. A key theme of the conference focused on the need for strengthening a "do ask, do tell" relationship between physicians and their HIV patients, especially since the United States has recently experienced its first increase in AIDS cases in a decade.
New US AIDS cases rose by 2.2 percent from 2001 to 2002, for a total of 42,136, according to CDC preliminary figures. New diagnoses among gay and bisexual men rose by 7.1 percent from 2001 to 2002. Since 1999, HIV infections in this group have increased by 17.7 percent, while HIV rates in other risk groups have remained stable since 2001, and AIDS-related deaths declined by 5.9 percent last year to 16,371.
"These findings suggest that the dramatic progress against AIDS following the introduction of highly active antiretroviral treatment [HAART] in the mid-1990s is beginning to plateau," said Ronald O. Valdiserri, M.D., M.P.H., deputy director of CDC's National Center for HIV, STD, and TB Prevention. "The only truly effective protection against the consequences of AIDS is to prevent HIV infection in the first place," he remarked. Shortly before the conference, CDC released new recommendations advising physicians to ask their HIV-positive patients specific questions about their risk for transmitting HIV or being reinfected.
New studies presented at the conference indicate that although clinicians currently miss opportunities to counsel patients on secondary HIV prevention, brief training sessions can help quell unease that may prevent physicians from asking patients intimate questions about sex and drug use.
At the Denver Public Health Department, Thrun and colleagues conducted an informal survey of 27 health care workers after they recognized they had been unaware that some of their male HIV patients were being treated for other STDs in a clinic in the same building. Initially, 60 percent of the 27 people surveyed said they were comfortable discussing risk behavior with patients. After a one-day workshop -- in which health care workers received a checklist of basic question to ask -- and follow-up "booster" sessions, the proportion of clinic workers who asked patients about current risk behaviors had increased to 82 percent.
Researchers from the University of California-San Francisco interviewed 618 HIV-positive patients leaving office visits at 16 clinics funded through the Ryan White CARE Act. Lead investigator Stephen Morin, PhD, said that 25 percent of participants said they had talked to someone at the clinic about safer sex practices. "But when you get down to the detailed kind of risk assessment recommended by the CDC guidelines," he said, "only 6 percent said they had discussed specific sexual activities at that day's visit." Morin noted that compared to counseling for other HIV issues such as medication adherence and emotional issues, HIV prevention came up short: 42 percent of patients were counseled on medication adherence, 37 percent on emotional issues, but only 25 percent reported having received prevention counseling. Morin found "very little in the way of specific or organized prevention activities."
Morin's study also found that clinics and physician practices with written procedures on prevention interventions were twice as likely to offer patients prevention counseling. Morin noted that confusion abounds among health care workers about how to counsel HIV-infected patients and whose responsibility it is to do it -- primary care physicians or specially trained counselors. Still, both Morin and Thrun emphasized, existing evidence shows that interventions as brief as five minutes can help change patients' behavior. "We talk about changing patients' behavior, but this is about changing workers' behavior, too," Thrun said.
CDC has announced accelerated efforts to diagnose HIV and to determine the rate of new infections. By next year, CDC will expand its Serologic Testing Algorithm for Recent HIV Seroconversion to 35 locations nationally. This technology adds a detuned assay to conventional antibody testing to identify recently infected individuals. With a more accurate estimate of new infections, "We can tell where the epidemic is headed, and we can use that improved information to target services for those now being infected," said Robert Janssen, M.D., director of CDC's HIV prevention programs.
Other research presented at the conference demonstrated the value of the OraQuick Rapid HIV-1 Antibody Test in reaching high-risk individuals outside medical settings, and also showed that health care workers do not need extensive training to perform the test correctly.
Journal of the American Medical Association
09.10.03; Vol. 290; No. 10: P.1304-1306; Rebecca Voelker
This article was provided by U.S. Centers for Disease Control and Prevention. It is a part of the publication CDC HIV/Hepatitis/STD/TB Prevention News Update. Visit the CDC's website to find out more about their activities, publications and services.