HIV prevention efforts mired in patient denial, physician discomfort

Some 'HIV doctors still have a little discomfort talking about sex.'

New research shows that despite nearly three decades of safe sex and clean needle messages and HIV prevention work, a large proportion of people at risk for HIV infection continue to engage in high-risk behaviors. The result is a new infection rate that has not improved in years and an estimated 1.1 million people living with HIV in the United States.1

One of the issues is that many of the people who are at risk for HIV infection are convinced they are not at risk, even when they continue to engage in unsafe sex behaviors. Some of those in denial already are infected and have not learned their HIV status.

"So much of my research is with men who don't consider they are at risk, but they're very much at risk and are transmitting the virus unknowingly," says Lisa Bowleg, PhD, an associate professor in the department of community health and prevention in the School of Public Health at Drexel University in Philadelphia, PA.

"They don't know their status or think they're at risk and will say, 'We're not like those down-low brothers,'" she adds. "But when you look at the behaviors they're engaged in, you can see they are at risk."

Despite increased public health efforts to increase HIV testing, an estimated 75% to 80% of Americans with HIV infection are unaware of their serostatus.2

Also, there have been many studies conducted showing some success in HIV prevention strategies, but few of these continue after the research grant funding ends. The interventions often require more resources than HIV clinics and organizations have available.

One problem might be in the way HIV prevention interventions work. Strategies targeting entire populations in which individuals are known to engage in risky behaviors are very resource intensive and beyond the financial reach of most non-governmental organizations.

P4P approach holds promise

A seemingly more pragmatic strategy of focusing on changing the risk behaviors of people who already are HIV positive was not even on the prevention radar screen until this past decade. And even now there are very few prevention for positives (P4P) interventions included in the list of evidence-based prevention strategies compiled by the Centers for Disease Control and Prevention (CDC).2

The P4P approach is consistent with how other public health issues are handled, Bowleg says.

"You go where the infection is and attempt to curb it there," she says.

Then there are obstacles to making prevention for positives (P4P) strategies succeed. For instance, it makes sense to have HIV clinics provide these prevention interventions since they see HIV patients multiple times a year. But HIV providers often fail to embrace this role, particularly when it requires discussions about behavioral changes to reduce risk, experts say.

"I'd like to see more prevention interventions happen in the clinical care setting," says Kees Rietmeijer, MD, PhD, a professor of community and behavioral health at the Colorado School of Public Health at the University of Colorado in Denver, CO. Rietmeijer is retired from the position of director of the STD Prevention Program at the Denver Public Health Department.

HIV providers have the opportunity to provide brief prevention interventions and reinforce these when patients return every few months. But providers sometimes have engrained resistance to fulfilling this role, he notes.

"The HIV physician's traditional role is to support patients and make them feel better," Rietmeijer explains. "For them to start asking sensitive questions about what's going on in their lives sexually and whether they're doing drugs is something a lot of care providers do not feel all that comfortable doing."

This discomfort on the part of the provider can undermine their work on a prevention for positives strategy or even prevent them from starting a discussion that patients might want and need to have about their risk behaviors.

Rietmeijer was involved in a study in which care providers and HIV patients were each asked separately how important it is to talk about patients' current sexual behaviors.

"Both care providers and patients said, 'This is very important,'" he says. "Then we asked who should bring up this subject, and patients said care providers should bring it up, and providers said patients should bring it up."

These findings suggest that providers should be trained to take the lead on asking about HIV patients' risk behaviors. Their training could include giving them methods for incorporating the discussion in their daily encounters with patients.

Ask, Screen, Intervene

For instance, one training program, called Ask, Screen, Intervene, teaches doctors, nurses, social workers, nurse practitioners, and others working with HIV patients how to ask patients about their risk behaviors, screen them for sexually-transmitted diseases (STDs), and provide prevention interventions as needed, Rietmeijer says.

"The nice thing about an HIV care setting is you see these patients come back every six months, so you can have this relationship where you say, 'How's it going? What's happening? We talked about your risks, so what has happened since we last talked about it?'" he explains. "And you can see if they've moved along the stages of behavioral change."

The Ask, Screen, Intervene strategy focuses on prevention for positives, and it is intended to be a brief intervention that is incorporated into the clinical encounter, Rietmeijer says.

The key question, which is similar for all prevention strategies, is how to scale up the intervention and make it a part of routine practice, he notes.

"We know people with HIV will access care services and other types of services, so that is an interface we can capitalize on for prevention messages," he adds. "But how do we do that?"

Clinicians should be trained and taught that HIV P4P interventions are similar to doctors discussing diet and exercise with obese patients or monitoring blood sugar levels with diabetic patients.

"It's not all that different," Rietmeijer says. "You can use the same kind of techniques that you use in those kinds of interventions."

Rietmeijer has noticed a shift in provider interest in prevention interventions, but studies continue to show some obstacles.

For instance, physician resistance to having risk behavior discussions was evident in the results of one recent study aimed at HIV positive patients who engaged in sexual risk behaviors.

This prevention for positives intervention had one arm that included a physician-delivered intervention and another with a similar approach delivered by a computer. Investigators found that the computer-delivered intervention worked better than both the standard care and the physician-delivered strategy.3

Researchers trained providers to discuss patients' specific risk behaviors, while encouraging them to act in accordance with their own values. But the study's results showed no significant impact in this arm. By contrast the computerized-delivery was so successful, the intervention is now being considered for the CDC's effective prevention intervention list. It's likely the physician-delivered arm failed to have an impact because the providers did not follow the intervention's script, the study's principal investigator suggests.

"I suspect providers reverted into what they normally did which was just giving advice and not using the techniques they were taught," says Marguerita Lightfoot, PhD, an associate professor in the School of Medicine at the University of California – San Francisco.

"HIV doctors are some of the most caring and committed folks, and some still have a little discomfort with talking about sex," she says. "They have issues around opening Pandora's box."

Protect and Respect for women

Most prevention for positives strategies involve at least some clinician direction. One recent study found that a P4P intervention, called Protect and Respect and directed toward women living with HIV/AIDS, was successful with a three-pronged approach that included a brief provider-directed risk reduction conversation plus a group-level intervention and a peer-led support group.4

The provider component, which proved in the Protect and Respect study, to be not as effective when used by itself, still is an important part of a P4P strategy, says Michelle Teti, MPH, DrPH, an assistant professor in the School of Health Professions at the University of Missouri in Columbia, MO.

"HIV patients who are in care rely on their providers and trust their providers for information," Teti says. "They come to see their providers on a regular basis, so HIV clinicians are in a perfect position to engage with their patients on a variety of health issues, including HIV prevention over time."

This Protect and Respect intervention focuses on increasing condom use after addressing the reality of these HIV-infected women's lives, Bowleg says.

"One thing we've learned is simply talking to women about using condoms while ignoring the context of their lives is madness," she says. "These women are unemployed, poor, dealing with substance use issues, and they are in so many violent relationships, so that to just focus on condom use is to not really understand their lives."


  1. Lansky A, Brooks JT, DiNenno E, et al. Epidemiology of HIV in the United States. J Acquir Immune Defic Syndr. 2010;55(2):S64-S68.
  2. Fisher JD, Smith LR, Lenz EM. Secondary prevention of HIV in the United States: past, current, and future perspectives. J Acquir Immune Defic Syndr. 2010;55(2):S106-S115.
  3. Lightfoot M, Rotheram-Borus MJ, Comulada WS, et al. Efficacy of brief interventions in clinical care settings for persons living with HIV. J Acquir Immune Defic Syndr. 2010; 53(3):348-356.
  4. Teti M, Bowleg L, Cole R, et al. A mixed methods evaluation of the effect of the protect and respect intervention on the condom use and disclosure practices of women living with HIV/AIDS. AIDS Behav. 2010;14(3):567-579.