Efavirenz and Methadone Interaction Tashima K, et al, 9th European Congress of Clinical Microbiology

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Inserting Prevention Into the Clinical Care
Setting
Gerald Friedland, MD
G Friedland, MD.Presented at IASUSA/RWCA
Clinical Conference, August 2004.
The International AIDS SocietyUSA
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The Need For Prevention in HIV Positives

• Prevention has focused on HIV negatives staying
  negative or have been serostatus neutral
• Prevention in HIV until recently largely
  ignored
• Number of people living and capable of
  transmitting drug sensitive and resistant HIV ??
• Addressing prevention needs for HIV is key in
  HIV prevention agenda

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HIV Transmission Risk Behaviors in HIVs

• Continued risk behaviors among all groups of
  HIVs (MSM, IDUs, heterosexuals) in community
  samples
• Rates 25-35
• Risk behaviors may increase in pts on HAART
• Subjectively improved feelings of well-being
• Belief that treatment and ND VL make risk
  behaviors safe
• Ineffective prevention efforts prevention
  fatigue

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Emergence of Drug-Resistant HIV

• Estimated 10-40 of patients on potent ART for
• six months have detectable VL, gt50 of these
  have resistant virus
• Super infection with resistant virus increasingly
  reported
• Source of new resistant infections are patients
  in clinical care with detectable virus who are
  receiving HAART

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HIV Prevention in the Clinical Care Setting

• Clinical care setting provides is a unique and
  and underutilized opportunity for medical and
  behavioral interventions to reduce HIV
  transmission
• Access to HIV population with and without
  resistance
• Repeated encounters over time
• TRUST-unique feature of physician-patient
  relationship
• Behavior changes by physicians are effective
• Can we do it???-Can providers also be
  preventers???

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HIV Prevention in the Clinical Care Setting

•  Behavioral interventions
• Screen for risk behaviors at initial and
• subsequent visits
• Assess and discuss sex and injection drug
  -related behaviors
• Use motivational interviewing to develop plan to
  reduce risk or maintain safe behavior

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Why clinicians do not discuss HIV prevention

• Information Factors
• Many have minimal knowledge
• ongoing risk behaviors among HIV individuals
• Sexual and drug use risk practices
• Risk reduction strategies
• Motivation Factors
• Many lack time, are uncomfortable in this area,
  and are concerned about confidentiality,
  reimbursement, and clinician role conflict.

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Why health clinicians do not discuss HIV
prevention

• Behavioral Skills Factors
• Many lack the necessary counseling skills to
  effectively promote HIV risk reduction
• Communication barriers to providers engaging in
  HIV risk reduction include lack of a good
  opening line, vague language, and the
  provider-centered interview style

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Options Project Overview

• Define the frequency, patterns and correlates of
  HIV transmission risk behaviors among HIV pts in
  clinical care
• Develop and test a controlled trial of a
  physician delivered intervention to reduce HIV
  patient risk behaviors
• Intervention and control site
• Explore relationship between risk behavior and
  antiretroviral resistance

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Options-encounter

• Setting the agenda to discuss safer sex and safer
  drug use
• Assessing risk behavior
• Summarize risky behaviors, and ask the patient to
  choose one behavior on which to focus
• Determine how to proceed by first having patients
  rate the importance of changing the risk
  behavior they chose, and then their confidence
  that they could change it.

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Options-encounter

• 5. Based on Importance and Confidence scores and
  the Options algorithm, further explore either
  Importance OR Confidence
• 6. Summarize the patients responses, and then
  elicit a menu of specific strategies from the
  patient for raising his or her score
• 7. Negotiate a goal or action plan with the
  patient by having the patient select a goal for
  the next clinic visit from a menu of goals
• 8. Record the goal or action plan on the Options
  Prescription Pad and give the behavioral
  prescription to patient.

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Options-feasibility

• Feasibility 71 of the patient-provider meetings
  that took place involved implementation of the
  intervention protocol.
• Fidelity Based on documentation provided by the
  providers, the vast majority of meetings included
  implementation of at least 7 of the 8
  intervention protocol steps.
• Efficacy Patients in the intervention group
  reported a greater reduction in sexual risk
  behaviors at 6-month follow-up than the control
  group.

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Options-Results

• Feasibility
• 71 of the patient-provider meetings that took
  place involved implementation of the intervention
  protocol.
• Fidelity
• Based on documentation provided by the providers,
  a large majority of meetings included
  implementation of at least 7 of the 8
  intervention protocol steps.
• Efficacy
• Patients in the intervention group reported a
  significantly greater reduction in sexual risk
  behaviors at 6-18 months follow-up than the
  control group.

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Results

• Overall
• HIV transmission risk sexual behavior
  significantly reduced in the intervention group(
  plt.001),
• Total events
• Intervention group decreased ( p.02)
• No change in standard of care control group
  (p.51)
• Difference in total events over time between
  intervention and control (p.02).
• Partners exposed
• Intervention group decreased ( p.06),
• No change in standard of care control ( p.40)
• Difference number of partners exposed in
  intervention and control groups (p.06)

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Conclusions

• A minority of patients in clinical care continue
  to engage in transmission risk sexual and IDU
  behaviors.
• Although the percentage of patients is small,
  the number of potential transmission events and
  at partners exposed is large.
• Clinical care setting is an ideal and untapped
  setting for the implementation of prevention
  practices to reduce transmission of both HIV
  sensitive and resistant HIV
• Behavioral traditional medical prevention
  interventions should and can be successfully
  incorporated into clinical care