Fatalistic attitudes impact prevention

Providers play a critical role in prevention

A recent study found a relationship between provider fatalism and HIV prevention counseling, suggesting a possible obstacle to having providers provide prevention for positives.

Fatalism among providers was a strong predictor of patients perceiving less HIV prevention counseling at 16 publicly funded clinics.1

"This finding wasn't something we set out to have in the study," says Wayne Steward, PhD, MPH, a researcher for the Center for AIDS Prevention Studies at the University of California, San Francisco.

Investigators visited federally funded clinics to examine what facilitators and barriers existed to the clinics providing prevention for positives services, Steward says.

Researchers conducted qualitative interviews with providers, patients, clinic administrators, and all different key players who might be affected by prevention for positives programs. They also did a quantitative survey of patients as they were leaving their appointments at the clinics, Steward says.

"In the qualitative interviews, one of the findings that emerged was this idea of fatalism, and this is how the paper got its start," Steward says. "In some clinics a number of providers expressed a rather profound sense of what we ultimately labeled as fatalism," he explains. "It was a sense that there wasn't a lot they could do to change their clients/patients' behavior."

Some providers thought their patients knew what the HIV risks were and they knew how their own behaviors increased the risks, and they didn't think they could meaningfully affect their behavior, Steward says.

"We were interested in how fatalism might relate to the HIV prevention services a clinic provided," Steward says. "So we did a study with an unusual mixed-message design."

Since it was impractical to ask patients about their perceptions of providers' fatalism, they took the qualitative data and quantified the number of fatalistic comments, ranking these in order of how much fatalism was expressed by providers, he says.

Then researchers looked at the HIV prevention services that patients reported and found a correlation between fatalism expressed and prevention services reported by patients, Steward says.

"In clinics with a lot of fatalism, you had patient reports of less frequent receipt of HIV prevention services," Steward says.

"It's a complicated correlation," he adds. For example, there is no measure of how much the provider gives out prevention counseling.

However, the correlation tended to be robust against all challenges, including the amount of time patients reported that they spent in their sessions, Steward says.

"You frequently hear providers say they don't have a lot of time, and that definitely is true," Steward says. "But we put time into the model and the predictor line for fatalism remained significant."

Investigators looked into clinic-level procedural variables, such as the length of the appointment and the size of the clinic, and these also did not account for the fatalism finding, he adds.

The correlation between fatalism and prevention services remained even when patients' health history, length of time since diagnosis, and length of time as a patient at the clinic were examined, Steward says.

"Even when accounting for sexual risk and other health history variables, fatalism remained an independent risk factor," Steward adds.

However, when researchers included demographic data, including race, sexual orientation, age, gender, and education, the association between fatalism and HIV prevention counseling changed, he says.

"The clinics with a fatalism and HIV prevention counseling association tended to be the ones that had large gay, white male populations," Steward explains. "We weren't seeing fatalism in the other clinics."

After running a new model, the data confirmed that finding, he notes. Although the data couldn't be divided between the various demographic materials, anecdotal evidence suggested that the chief factor was sexual orientation, Steward says.

"In qualitative interviews, it seemed more tied to a patient's sexual orientation," he says. "One provider statement I recall was about fatalism within the gay community and how the gay community itself had a feeling that HIV infection was inevitable."

A new study will look at how clinics implement prevention for positives programs, and the investigators are including questions about fatalism to see if that will explain the outcomes found in the interventions, Steward says.

"What we found with this study is people weren't discussing HIV prevention topics with their patients, so the current, ongoing study will look at something slightly different," Steward explains. "It will examine whether or not the quality of services or outcomes differ in any way."

What the study suggests is that HIV providers who work with white, older, gay patients have pre-conceived notions about the gay community's knowledge of HIV and willingness to act on that knowledge, Steward says.

"In a lot of places it's very true that the gay community is well-educated about HIV and has been very active in taking steps to prevent HIV," Steward says. "Gay men are educated early on that they're at risk for HIV infection."

So the result is that providers, who believe a white gay patient already knows a great deal about HIV risk behaviors, will view continued risk behaviors as a sign that the patient is not willing to make the changes he knows are necessary to prevent HIV transmission, Steward says.

"Whereas with other populations, they believe there is a lot of misinformation, and they feel they can correct the misinformation and provide HIV education as a part of prevention efforts," Steward says.

In another study, related to this one, investigators found that clinics which had written procedures tended to do better overall in terms of HIV prevention, Steward notes.

"What written procedures did was knock out any sort of effect of race or sexual orientation because everyone in the clinic got some amount of HIV prevention counseling, and there was no subjective judgment about who needed it," he adds.

Success at prevention for positives might require neutrality and uniformity in the prevention intervention, Steward suggests.

Step one is to just do it, provide prevention services regardless of whether you personally feel they are needed or will succeed, he says.

Then, the more fatalistic providers might be surprised and find their attitude change if some patients begin to make changes that previously seemed highly unlikely, Steward says.

“There will be a set of patients for whom you do make an effort and they don’t respond,” Steward says. “And those are the ones that the providers have to go back to time and time again to keep reinforcing prevention messages.”

The other thing for providers to consider is that prevention for positives gives them the opportunity to follow-through on prevention messages with a specific and recurring population, he says.

With prevention messages aimed at HIV-negative people, the prevention intervention might be administered once or in a series that ends and typically is not repeated to the same people.

Prevention for positives, however, gives clinicians the opportunity to repeat prevention messages at each clinic visit to the same patients they might see for a decade or longer.

“You have the advantage of a sustained relationship over time that you don’t get with prevention for negatives,” Steward says. “This gives providers a unique opportunity to help a person because they understand the other challenges in the person’s life.”

Prevention messages need constant repetition because each individual’s life circumstances change and might result in a person becoming more or less likely to engage in risky behaviors, he says. “Risk behaviors are not static and immutable, and this is why people move in and out of risk behavior,” Steward says. This is why long-term prevention efforts are extremely important, and to think you can provide a prevention intervention one time and everything is great is overly optimistic, Steward says.

“People who seem like they are not willing to make a change may move into a patch in life where they are willing to change,” Steward says.

So providers could wait for an opportunity to discuss prevention again and not close the door because of a fatalistic attitude that this opportunity will never arise, Steward adds.