Are HIV care providers talking with patients about safer sex and disclosure?: A multi-clinic assessment. Gary Marks, Jean L. Richardsona, Nicole Crepaz, Susan ...
CONCISE COMMUNICATION
Are HIV care providers talking with patients about safer sex and disclosure?: A multi-clinic assessment Gary Marks, Jean L. Richardsona , Nicole Crepaz, Susan Stoyanoffa , Joel Milama , Carol Kemperb, Robert A. Larsenc , Robert Boland, Penny Weismullere, Harry Hollanderf and Allen McCutchang Objectives: To examine HIV-positive patients’ reports of whether HIV care providers ever talked with them about practicing safer sex and disclosing seropositive status to sex partners. Design: Cross-sectional survey (1998–1999) of HIV-positive men and women sampled randomly at six public HIV clinics in California. Methods: Participants were interviewed and asked whether applicable clinic providers (physician, physician assistant, nurse practitioner, nurse, social worker, health educator, psychologist, psychiatrist) ever talked with them about safer sex or disclosure. Responses were analyzed by clinic site, HIV medical status (viral load), demographic, and behavioral variables (unprotected intercourse, non-disclosure). Results: The sample (n ¼ 839) included heterosexual men (n ¼ 127), men who have sex with men (MSM; n ¼ 607), and women (n ¼ 105). Thirty-nine percent were white, 36% Hispanic, 17% black, and 8% other/mixed ethnicity. Overall, 71% reported that an applicable provider had talked with them at least once about safer sex (range across clinics, 52–94%); 50% reported discussion of disclosure (range across clinics, 31–78%). Discussion of safer sex was more prevalent with physicians than with other clinic staff. In multivariate analyses, in addition to significant clinic differences, MSM (versus heterosexual men) and whites (versus blacks or Hispanics) were less likely to receive prevention messages on these topics. Patients’ behaviors (unsafe sex, nondisclosure) and HIV medical status were not independently associated with provider communication. Conclusions: HIV clinics differed substantially in the percentage of patients who reported that they received prevention messages from clinic staff. Care providers should assess and overcome barriers to providing prevention messages to patients. & 2002 Lippincott Williams & Wilkins
AIDS 2002, 16:1953–1957 Keywords: HIV/AIDS, HIV-positive persons, safer sex, disclosure, HIV care providers From the Division of HIV/AIDS Prevention, Centers for Disease Control and Prevention, Atlanta, Georgia, the a Department of Preventive Medicine, University of Southern California, Los Angeles, the b HIV Positive PACE Clinic, Santa Clara Valley Medical Center, San Jose, the c Department of Medicine, University of Southern California, the d Department of Family Medicine, University of Southern California, Los Angeles, e Orange County Health Care Agency, Santa Ana, the f University of California at San Francisco, San Francisco, and the g University of California at San Diego, La Jolla, California, USA. Requests for reprints to: G. Marks, Centers for Disease Control and Prevention, Division of HIV/AIDS Prevention, 1600 Clifton Rd., Mailstop E-45, Atlanta, Georgia, 30333 USA. Received: 15 February 2002; revised: 27 May 2002; accepted: 10 June 2002.
ISSN 0269-9370 & 2002 Lippincott Williams & Wilkins
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AIDS 2002, Vol 16 No 14
Introduction Most adults who learn they are HIV-positive remain sexually active [1–4]. Some engage in unprotected sexual behaviors that place others at risk for infection and place themselves at risk for contracting secondary infections (e.g., syphilis, gonorrhea) that may promote transmission of HIV [5,6]. With recent improvements in HIV therapy, more persons are seeking testing for HIV and, if infected, medical care [7]. Thus, HIV clinics have become an increasingly important setting for delivering prevention messages to HIV-positive patients. Relatively little is known about the extent to which HIV care providers are giving prevention messages to their patients [8–10]. A recent study of HIV-positive men who have sex with men (MSM), recruited at public venues (e.g., bars, sex clubs, parks), found that 24% of those who had a ‘current doctor or health-care provider’ reported that their provider never talked with them about safer sex [11]. That investigation, however, was limited by a narrowly defined sample and by a definition of health-care provider that may have missed communication from providers in clinic settings. We sampled HIV-positive men and women in care at HIV clinics and examined their reports of whether clinic providers talked with them about practicing safer sex and disclosing their seropositive status to sex partners.
Methods We report baseline data from a clinic-based behavioral intervention trial. The baseline interviews were conducted in 1998–1999 at six public HIV clinics in California. The approximate number of active patients at the clinics ranged from 500 to 2500 per clinic.
Recruitment Project staff implemented a standardized set of recruitment procedures. Patients were randomly selected during time blocks from each clinic’s daily appointment schedule or from patient registration lists. Sampling of female patients was given priority because of their limited numbers. At least 20 females were enrolled at each clinic. Criteria for entry were: 18 years of age or older, tested HIV seropositive at least 3 months prior to participation, sexually active during the previous 3 months (mutual masturbation, oral, vaginal, anal sex), and English or Spanish speaker of any ethnicity. Overall, we approached 2027 patients and 187 (9%) declined to be screened. Of those screened, 562 (30%) were ineligible. Of those eligible, 886 (69%) were
enrolled (approximately 150 patients per clinic). All participants provided written informed consent and were paid US $10.
Questionnaire administration and measures Interviewers administered the questionnaire in private rooms at the clinics. Participants were shown three categories of clinic providers: (i) physician, (ii) physician assistant, nurse practitioner, or nurse, and (iii) social worker, health educator, psychologist, or psychiatrist. A category was applicable if a participant had ever interacted at the clinic with one or more persons in the category. Participants indicated whether any provider in an applicable category had ever talked with them about using safer sex and disclosing their seropositive status to sex partners. Participants reported on sexual behaviors with, and disclosure to, HIV-negative or status-unknown sex partners in the past 3 months. Sexual orientation was defined behaviorally (sex with men only, men and women, women only). Participants reported the length of time since testing HIV-positive and the number of previous clinic visits. Current disease status (AIDS, not AIDS) and the most recent viral load were obtained from medical charts.
Statistical analyses Forty-seven participants were omitted from analysis (16 incomplete data, 15 had not attended the clinic prior to the survey, five women who had sex with women only, 11 transgendered men). The analytic sample (n ¼ 839) focused on MSM, heterosexual men, and women who had sex with men. For each provider category, we calculated the percentage of participants reporting that a provider(s) ever talked with them about safer sex. A composite index was calculated as the percentage reporting that a provider from any applicable category ever talked with them about safer sex. The same scores were calculated for disclosure. Differences in communicating about safer sex versus disclosure were tested (dependent proportions). Chi-squared analysis examined the composite index by clinic site, demographic, medical, and behavioral factors. Significant bivariate correlates (P < 0.05) were retained in multivariate logistic regression models conducted with and without clinic site in the equation, because patient demographic characteristics varied from clinic to clinic.
HIV care providers Marks et al.
Results Demographic characteristics of participants Seventy-two percent were MSM, 15% heterosexual men, and 13% women who had sex with men. The ethnic breakdown was 39% white, 36% Hispanic, 17% black, and 8% other/mixed ethnicity. Educational attainment varied widely (23% had a college degree), and most had low annual household income (50% had annual income , $10 000). Approximately 45% had AIDS, and 56% reported they had been to the clinic more than 20 times. Patients’ reports of provider communication Across all clinics, 71% of the participants (range across clinics, 52–94%) reported that at least one applicable clinic provider had talked with them about safer sex. Overall, 67% said that a physician discussed safer sex, whereas only about half said that clinic staff in the other two provider categories discussed that topic. Discussion of disclosure was significantly (P , 0.05) less likely than discussion of safer sex. Fifty percent of the participants (range across clinics, 31–78%) reported that an applicable clinic provider had ever talked with them about disclosing their seropositive status to sex partners. Discussion of disclosure was comparably prevalent for the three provider categories. A clinic-level analysis (n ¼ 6) confirmed that clinics with a low prevalence of discussion about safer sex also had a low prevalence of discussion about disclosure (r . 0.90; P , 0.01 for each provider category).
Tests of association In addition to substantial clinic differences, discussion of these prevention issues was more likely with heterosexual men and women, patients of non-white ethnicity, patients who were less well educated, had lower annual household income, and had been to the clinic more than 20 times (disclosure only) (Table 1). Patients who withheld disclosure from an at-risk partner were less likely than their counterparts to report that any applicable clinic provider had talked with them about disclosure. Discussion of safer sex did not differ between those who engaged in unprotected anal or vaginal intercourse with at-risk partners compared with those who had not. None of the HIV disease status variables including viral load were significant bivariate correlates. Two independent effects emerged in multivariate logistic regression models (Table 1). Clinics differed in the likelihood that providers discussed safer sex or disclosure with patients. Black and Hispanic patients were more likely than white patients to say that any applicable provider had talked with them about these topics. When clinic site was not in the model, discussion about
safer sex was less likely to be reported by MSM than heterosexual men, and discussion of disclosure was more likely to be reported by those who had attended the clinic many times.
Discussion Twenty-nine percent of the full sample (33% of MSM) reported that no applicable HIV clinic provider had ever talked with them about safer sex. Providers were less likely to talk with patients about disclosure to sex partners than about practicing safer sex. Given limited time per patient, providers may focus more on sexual behavior because it is the ‘bottom line’ in transmission risk. Alternatively, some providers may not feel fully prepared to deal with the issue of disclosure [12]. It is encouraging that two clinics reached over 90% of their patients with safer-sex messages. Another clinic reached 76% of patients, but the situation at three other clinics was less encouraging. Apparently some clinics have been more successful than others in integrating prevention into the routine care of HIV patients. The successful clinics were not those with the fewest active patients; there was no correlation (data not shown) between number of patients at a clinic and reports of provider communication about prevention. Barriers to communication may involve structural factors (e.g., lack of training opportunities or resources, lack of time, lack of referral mechanisms) as well as attitudinal or motivational factors on the part of clinic personnel. Staff at HIV clinics may need to assess and overcome barriers to patient–provider communication so that more HIV-positive patients receive prevention messages. After statistically adjusting for other variables, black and Hispanic patients were more likely than white patients to report that an HIV provider had talked with them about safer sex or disclosure. One hypothesis is that HIV providers may be giving more attention to prevention in the ethnic groups that are increasingly affected by the HIV/AIDS epidemic. Further, some providers may (mistakenly) believe that whites are better informed and practice safer sex more often than blacks or Hispanics. Alternatively, minority patients may have been more likely than white patients to initiate conversations about prevention with their providers, although we do not have any confirming data. A smaller percentage of MSM than heterosexual men or women reported that providers had talked with them about safer sex, which may indicate that some providers feel uncomfortable talking about homosexual behavior [13] or that they may (mistakenly) assume that MSM already know about the importance of prevention and thus do not need additional information.
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Provider discussion about safer sex
Provider discussion about disclosure
Adjusted OR (95% CI) Reporting discussion (%)b
Clinic in equation
Sexual orientation/sex Heterosexual men (n ¼ 127) Women (n ¼ 105)c MSM (n ¼ 607)
83 82 67
Ethnicity White (n ¼ 328) Hispanic (n ¼ 303) Black (n ¼ 141) Other (n ¼ 67)
Adjusted OR (95% CI)
Clinic out of equation
Reporting discussion (%)b
Clinic in equation
Clinic out of equation
1.00 1.17 (0.55–2.48) 0.65 (0.37–1.16)
1.00 0.93 (0.46–1.86) 0.48 (0.28–0.81)
60 62 45
1.00 1.19 (0.67–2.11) 0.94 (0.60–1.48)
1.00 1.12 (0.65–1.94) 0.71 (0.47–1.09)
62 77 79 73
1.00 1.28 (0.83–1.98) 2.02 (1.19–3.44) 1.41 (0.74–2.67)
1.00 1.79 (1.23–2.60) 1.83 (1.11–3.00) 1.64 (0.90–2.98)
40 57 59 40
1.00 1.52 (1.03–2.21) 2.17 (1.38–3.42) 1.01 (0.57–1.79)
1.00 1.77 (1.26–2.49) 1.82 (1.18–2.80) 1.02 (0.59–1.76)
Education High school or less (n ¼ 215) High school grad (n ¼ 185) Some college (n ¼ 241) College graduate (n ¼ 198)
80 71 68 66
1.00 0.85 (0.50–1.42) 1.10 (0.65–1.86) 0.97 (0.55–1.71)
1.00 0.77 (0.48–1.25) 0.85 (0.52–1.37) 0.87 (0.52–1.45)
60 51 42 46
1.00 0.86 (0.56–1.33) 0.86 (0.55–1.34) 0.94 (0.58–1.53)
1.00 0.81 (0.54–1.23) 0.71 (0.47–1.10) 0.88 (0.56–1.39)
Annual household income , $5000 (n ¼ 158) $5000–9999 (n ¼ 266) $10 000–19 999 (n ¼ 204) > $20 000 (n ¼ 211)
78 72 74 64
1.00 1.00 (0.60–1.67) 1.07 (0.62–1.86) 0.79 (0.45–1.40)
1.00 0.84 (0.52–1.36) 1.06 (0.63–1.77) 0.76 (0.45–1.28)
58 47 52 44
1.00 0.81 (0.53–1.26) 1.10 (0.69–1.76) 0.90 (0.55–1.48)
1.00 0.71 (0.47–1.08) 1.03 (0.66–1.61) 0.86 (0.54–1.38)
Number of clinic visits 2–5 times (n ¼ 132) 6–10 times (n ¼ 115) 11–20 times (n ¼ 120) 21 times or more (n ¼ 472)
64 73 75 72
1.00 1.37 (0.76–2.47) 1.21 (0.66–2.21) 0.83 (0.52–1.33)
1.00 1.45 (0.83–2.55) 1.56 (0.89–2.73) 1.30 (0.85–2.00)
39 52 47 53
1.00 1.50 (0.86–2.59) 1.01 (0.59–1.75) 1.09 (0.70–1.70)
1.00 1.51 (0.90–2.54) 1.28 (0.76–2.14) 1.54 (1.02–2.32)
52 44
1.00 0.77 (0.56–1.07)
1.00 0.78 (0.57–1.06)
78 52 31 39 60 36
1.00 0.25 (0.15–0.43) 0.13 (0.07–0.23) 0.19 (0.11–0.34) 0.42 (0.24–0.72) 0.20 (0.11–0.36)
Withheld disclosure of HIV-positive status to at-risk partnerd in past 3 months No (n ¼ 570) Yes (n ¼ 269) Study sites Clinic 3 (n ¼ 144) Clinic 1 (n ¼ 143) Clinic 2 (n ¼ 147) Clinic 4 (n ¼ 133) Clinic 5 (n ¼ 142) Clinic 6 (n ¼ 130) a
94 76 58 52 90 56
1.00 0.15 (0.07–0.35) 0.08 (0.03–0.17) 0.06 (0.03–0.14) 0.52 (0.21–1.31) 0.09 (0.04–0.20)
Applicable clinic provider is physician, physician assistant, nurse practitioner, nurse, social worker, health educator, psychologist, or psychiatrist that participants had seen at least once at the clinic. Unadjusted prevalence. All stratification variables in the table were significantly (P , 0.05) associated with discussion of safer sex and disclosure (chi-square). The one exception was for number of clinic visits, which was not significant for discussion of safer sex. c Five women who have sex with women only were omitted. d HIV-negative or unknown serostatus partner. P , 0.05. OR, Odds ratio; CI, confidence interval. b
AIDS 2002, Vol 16 No 14
Table 1. Multivariate logistic regression analyses of participants’ reports that any applicable clinic providera ever talked with them about practicing safer sex or disclosing seropositive status to sex partners.
HIV care providers Marks et al.
Consistent with Margolis et al. [11], patients whose viral load was above the median in the sample and those who reported unprotected anal or vaginal intercourse with at-risk partners were no more likely than their counterparts to report that clinic providers talked with them about safer sex. These findings prompt concern, because HIV-positive patients who have high viral loads (compared to low or undetectable levels) and engage in unprotected sex with at-risk partners pose a greater risk for transmitting HIV. We suggest that providers give prevention messages to all HIV patients, regardless or their viral load level, because some patients who presently are engaging in safer sexual behaviors may relapse to risky sex. More patients indicated that a physician talked with them about safer sex, compared with reports of communication from other applicable providers. However, a higher frequency of interaction with a provider (e.g., physician) may increase the probability of receiving a prevention message from that provider. Further, some providers may not discuss prevention with patients because those providers may assume that other clinic staff has done so. Our study prompts questions for future research, including who initiates the discussion (patient or provider), under what circumstances, and how well is the discussion received by the patient? The HIV clinic setting affords the opportunity to integrate prevention efforts with routine medical care across time. Studies conducted in other health-behavior domains (tobacco use [14–18,19], alcohol use [20–21], physical activity [22], eating habits [23]) have shown that health-care providers can play a significant role in helping their patients adopt and maintain healthy behaviors. We believe that HIV care providers, given adequate resources and training, can play the same beneficial role with their HIV-positive patients. It is imperative to identify efficacious prevention messages and interventions that can be used in HIV clinic settings. Sponsorship: Supported by NIH grant R01 MH 57208 and by the Centers for Disease Control and Prevention.
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