Can Healthcare Workers Help in HIV Prevention?
Are healthcare providers important in prevention?
Yes. Healthcare providers have many opportunities to help foster the behavior changes needed to stem the spread of HIV infection. In the US in 1996, the average adult visited a physician 3 times a year. Overall, 82% of visits were in physician offices and 10% in emergency departments.1 Visits with healthcare providers or other encounters with the healthcare system are “teachable moments”-opportunities for discussing sexual and drug-use risks in a manner relevant to individual patients’ lives. Healthcare providers in environments with large numbers of high-risk patients such as emergency departments, sexually transmitted disease (STD) clinics, methadone maintenance clinics and prison or jail clinics, can be crucial for HIV prevention. For example, men, women and adolescents who have been incarcerated have high rates of HIV, STDs and tuberculosis, as well as substance abuse problems, and would benefit from preventive information and medical services.2 In a nationwide survey of adults, only 20% of patients had discussed HIV risks with their doctors in the previous five years. Only 21% of those who did talk to a physician said the physician initiated the discussion. And only 23% of those who reported a behavioral risk for HIV had spoken to their physician about AIDS.3
What are barriers to discussing HIV?
HIV prevention requires the ability to talk about sexuality and drugs in an open manner, which may be uncomfortable. Healthcare providers need training in initiating discussions, negotiating awkward moments, responding to fears and expectations, encouraging patient feedback and being empathic. Ways to help foster these skills include instructors acting as patients for role-play and videotaped feedback on clinical performance.4 Lack of time can be a huge barrier to discussing HIV risks for healthcare providers. Many hospitals, clinics and health maintenance organizations (HMOs) require healthcare providers to address prevention in many other areas such as diet and exercise, smoking, depression, diabetes, heart disease and cancer. With a limited amount of time allotted each patient, healthcare providers may feel there is not enough time to also discuss sensitive issues such as sexuality and drug use.
What can healthcare providers do?
Assessing HIV risk behaviors should be a standard part of new patient intake. In-depth AIDS prevention education is not necessary for each and every patient. However, healthcare providers should ask all patients about condom use, number of sexual partners, sexual orientation and injection drug use to assess a patient’s risk for HIV. These quick questions may lead to longer discussions and counseling about safer sex or drug use practices. Healthcare providers who don’t have the time or comfort for these discussions can refer patients to toll-free hotlines or community-based public health programs. Healthcare providers can provide HIV counseling and testing to patients who request it, and recommend testing to patients at high risk for HIV. These include patients with STDs, especially adolescents, injection drug users (IDUs), women whose partners may be IDUs and patients who are unsure of their partner’s HIV status.5 Helping patients get into drug treatment can be an effective HIV prevention tool. Healthcare providers can have a profound effect on patients’ lives by showing an interest in drug-using patients and encouraging willing patients to enter a drug or alcohol treatment program. Because relapse is common in treating addictions, healthcare providers should use a non-judgmental attitude.6 Healthcare providers who work with HIV+ patients can help prevent HIV transmission by assessing patients’ risky sexual and needle-use behaviors and counseling them to reduce those unsafe behaviors.7 This is especially important with the advent of more effective treatments for HIV. For example, HIV+ patients may believe that if they have a low or undetectable viral load, they cannot transmit HIV. Opportune moments for counseling are: at diagnosis, at onset of symptoms and when beginning drug treatment.8
Can treatment promote prevention?
Yes. Diagnosing and treating STDs such as syphilis and gonorrhea can help protect against HIV transmission. Early detection and treatment of STDs can be crucial, as STD infections make it easier to both get HIV and transmit it to others. In areas and populations with high rates of STDs and low rates of HIV infection, treating STDs is an effective means to prevent HIV infection.9 In recent years, great advances have been made in preventing HIV transmission from mother to infant. Healthcare providers should offer HIV testing to all pregnant women. Treating HIV+ mothers and their babies with AZT has been shown to reduce transmission by two-thirds. HIV+ mothers should also be counseled on the risk of breastfeeding and provided with alternates to breast milk if needed.10 Post-exposure prophylaxis (PEP) is a method for potentially preventing HIV transmission by administering AZT and other anti-HIV drugs within 72 hours of an accidental exposure to HIV. Studies of occupational PEP have found that HIV transmission can be prevented by post-exposure treatment, and PEP is now recommended by the Centers for Disease Control and Prevention (CDC) for occupational exposure among healthcare workers.11 PEP is currently being piloted for exposure via sexual or drug use activities, including sexual assault. The CDC has not yet endorsed this due to lack of research data directly from drug and sexual exposure.12
What’s being done?
Healthcare providers need access to training and medical updates. One program trained rural healthcare providers in HIV/AIDS information, how to conduct risk assessments, advances in treatments, and sensitivity to diverse populations. The most effective training was achieved with a self-study booklet which helped increase prevention, early intervention and health promotion among rural health care providers. This booklet is now available free of charge on the Internet. Interactive teleconference training and personal training from visiting educators were also effective.13 Healthcare providers need to address the multiple needs of patients. In Bangalore, India, the Well Woman Clinic was established as part of an HIV control program. Poor women, especially commercial sex workers, had been underserved, had high rates of STDs and were at high risk for HIV. Because women are conditioned to ignore or tolerate health problems, patients at the Clinic are automatically screened for STDs without having to admit to any symptoms.14 Healthcare providers need to take advantage of community-based services. Children’s Hospital Los Angeles teamed with community-based prevention organizations to provide an integrated care model for youth with and at high risk for HIV infection. The model offers a general medical clinic for youth and psychosocial services such as counseling and case management. Peer educators also conduct extensive street outreach where high-risk youth congregate. The program developed a computerized referral system for local youth services available on the Internet.15
Will enhancing healthcare providers’ involvement be enough?
Enhancing healthcare providers’ involvement is only one aspect of a broad prevention policy. A comprehensive HIV-prevention strategy uses multiple elements to protect as many people at risk of HIV infection as possible. HIV prevention is not a “one-shot” effort; it is an ongoing process that demands the involvement of many sectors of society. This includes the physicians, nurses, health educators, therapists, dentists and other healthcare providers to whom people look for advice on how to stay healthy.
1. Schappert SM. Ambulatory care visits to physician offices, hospital outpatient departments, and emergency departments: United States, 1996 . Vital and Health Statistics. 1998;134:1-37. 2. Hammett TM, Gaiter JL, Crawford C. Reaching seriously at-risk populations: health interventions in criminal justice settings . Health Education and Behavior. 1998;25:99-120. 3. Gerbert B, Bleecker T, Bernzweig J . Is anybody talking to physicians about acquired immunodeficiency syndrome and sex? A national survey of patients. Archives of Family Medicine. 1993;2:45-51. 4. Epstein RM, Morse DS, Frankel RM, et al. Awkward moments in patient-physician communication about HIV risk. Annals of Internal Medicine. 1998;128:435-442. 5. American Medical Association. Physician Guide to HIV Prevention. June 1996. 6. Herman M, Gourevitch MN. Integrating primary care and methadone maintenance treatment: implementation issues . Journal of Addictive Diseases. 1997;16:91-102. 7. Gerbert B, Brown B, Volberding P, et al. Physicians’ transmission assessment and counseling practices with their HIV-seropositive patients. AIDS Education and Prevention. In press. 8. Gerbert B, Love C, Caspers N et al. “ Making all the difference in the world”: how physicians can help HIV-seropositive patients become more involved in their healthcare . AIDS Patient Care and STDs. 1999;13:29-39. 9. Centers for Disease Control and Prevention. HIV prevention through early detection and treatment of other sexually transmitted diseases-United States . Morbidity and Mortality Weekly Report. 1998;47(RR-12):1-25. 10. Centers for Disease Control and Prevention. Update: perinatally acquired HIV/AIDS-United States, 1997 . Morbidity and Mortality Weekly Report. 1997;46:1086-1092. 11. Centers for Disease Control and Prevention. Management of health-care worker exposures to HIV and recommendations for postexposure prophylaxis . Morbidity and Mortality Weekly Report. 1998;47(RR-7):1-33. 12. Centers for Disease Control and Prevention. Management of possible sexual, injecting drug-use, or other non-occupational exposure to HIV, including considerations related to antiretroviral therapy . Morbidity and Mortality Weekly Report. 1998;47(RR-17):1-14. 13. Martin SJ. HIV/AIDS prevention, early intervention and health promotion: results of training for rural health care providers. Presented at the 9th National AIDS Update Conference, San Francisco, CA. March 19, 1997. Contact: Sara Martin (303) 315-2516. www.uchsc.edu/sm/aids/begin.htm 14. Baksi CM, Harper I, Raj M. A `Well Woman Clinic’ in Bangalore: one strategy to attempt to decrease the transmission of HIV infection . International Journal of STDs & AIDS. 1998;9:418-423. 15. Schneir A, Kipke MD, Melchior LA, et al. Children’s Hospital Los Angeles: a model of integrated care for HIV-positive and very high risk youth. Journal of Adolescent Health. 1998;23(2Suppl):59-70. Computerized referral system:www.caars.net
Prepared by Pamela DeCarlo*, Barbara Gerbert, PhD** and the Center for Health Improvement and Prevention Studies** *CAPS, **Division of Behavioral Sciences, UCSF April 1999. Fact Sheet #6ER
Reproduction of this text is encouraged; however, copies may not be sold, and the Center for AIDS Prevention Studies at the University of California San Franciso should be cited as the source of this information. For additional copies of this and other HIV Prevention Fact Sheets, please call the National Prevention Information Network at 800/458-5231. Comments and questions about this Fact Sheet may be e-mailed to [email protected]. © April 1999, University of California