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Prevention with HIV-Infected Persons Seen in Primary Care Settings

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HIV prevention efforts have focused primarily on reducing the risk of infection among HIV infected individuals, concentrating on those individuals who engage in "high risk" sexual and drug using activities.  However, less attention has been given to prevention efforts targeting people already infected with HIV.  Research suggests that people living with HIV continue to engage in risky activities, demonstrating a need for interventions targeting HIV positive individuals in clinical care.

The SPNS Prevention with Positives Initiative was designed to address the need for interventions targeting HIV-positive individuals in clinical care; to prevent transmission to uninfected persons; and to prevent re-infection among people already infected with the virus.  This SPNS Initiative awarded grants to one Evaluation and Support Center and 15 demonstration sites.  The evaluation center conducted a multisite evaluation of the interventions, assessing their effectiveness, feasibility and costs.  Fifteen clinical demonstration sites were funded to implement and evaluate prevention interventions with HIV-infected persons seen in primary care settings.  Research questions included:

  1. Are provider-driven interventions in clinical settings effective, and what specific models are most effective with different target populations, such as MSM of color, heterosexual women, substance users, and others?
  2. How can clinicians effectively assess risk and produce behavior change, given time constraints?
  3. Do clinicians have the skills needed to effectively conduct prevention interventions?
  4. What can be done to strengthen clinician skills?
  5. What tools are effective as providers conduct risk assessments and prevention interventions?
  6. What are the obstacles to conducting HIV prevention activities with HIV infected individuals in a clinical setting and how can they be overcome?
  7. Can an integrated approach that includes physician assessment and referral improve behavioral outcomes?
  8. What roles can multi-disciplinary teams play in risk assessment and producing behavior change?
  9. What types of referral links are used and how effective are they?
  10. How can integration of referral resources and clinician-delivered risk assessment and behavior change interventions be achieved?



Grants for this initiative were awarded to the applicants listed below. The abstract provides both contact information and a brief description of the project. 

  • DeKalb County Board of Health
  • Drexel University School of Public Health
  • El Rio Santa Cruz Neighborhood Health Center
  • Fenway Community Health Center
  • Johns Hopkins University School of Medicine
  • Los Angeles County Department of Health Services
  • Mount Sinai Hospital
  • St. Luke's Roosevelt Hospital Center
  • University of Alabama at Birmingham
  • University of California, Davis
  • University of California, San Diego
  • University of Miami School of Medicine
  • University of North Carolina at Chapel Hill
  • University of Washington
  • Whitman-Walker Clinic
  • University of California, San Francisco (Evaluation and Support Center)


    DeKalb County (GA) Board of Health
    Decatur, GA

    Prevention with HIV Positives in the Clinical Setting

    This project tested the feasibility and impact of three different models of interventions.  Their target population was urban African-American patients living with HIV infection being seen at an existing early care clinic.  The first model was prevention counseling and education conducted solely by existing clinical providers.  All providers are trained before the project is initiated.  The second model provided prevention counseling conducted by an HIV prevention specialist. The third model was a small group intervention. The evaluation of the project compared the impact of each model with regard to development of individualized plans for behavior change; self-reports of behavior change sustained over time; and decreases in secondary transmission of HIV.  Collaborating partners included the Southeast AIDS Training and Education Center and the AIDS Research Consortium of Atlanta.


    Drexel University School of Public Health
    Philadelphia, PA

    The Protect and Respect Program for Women Living with HIV or AIDS

    This project sought to reduce high risk sexual behavior among HIV-infected women being seen at the Partnership Comprehensive Care Practice (PCCP) of the Drexel University College of Medicine.  The project provided prevention-oriented small group skill-building sessions and peer support activities to existing prevention counseling provided by clinical providers. Their evaluation focused on clinical outcomes, self-reports of behavior, reports from providers, and economic analyses. Cost effectiveness analysis was performed by faculty in the Business School, and training was provided by the Pennsylvania Mid-Atlantic AETC.  Collaborating Organizations included the PCCP, the Business College at Drexel University, and the Pennsylvania Mid-Atlantic AIDS Education and Training Center (AETC).


    El Rio Santa Cruz Neighborhood Health Center
    Tucson, AZ

    Supporting Healthy Alternatives through Patient Education (SHAPE)

    This project implemented a prevention specialist educational intervention to complement prevention counseling already provided by HIV primary care clinical providers.  A specialist intervention developed by Kalichman et al. was modified to be culturally and linguistically matched to the target population, which consisted of HIV-infected persons being seen in clinical primary care services, many of whom were Latino.  The intervention focused on high-risk unprotected sex and disclosure of HIV status to sexual partners.  For the evaluation, patients receiving the prevention specialist intervention were compared to those receiving only the clinical provider counseling.  The evaluation also examined outcomes of reducing HIV transmission and re-infection risks, and increasing efficacy for self-disclosure of serostatus. Process data regarding project reach and fidelity, and client satisfaction were also examined.


    Fenway Community Health Center
    Boston, MA

    HIV Prevention in Primary Care Settings

    This project conducted a randomized trial of a four-session behavioral intervention to reduce high-risk sexual practices among HIV-infected men who have sex with other men.  Particular attention was given to engaging men who are receiving HIV-oriented primary care at the Fenway Community Health Center.  Individualized interventions were provided by a medical social worker, which included education, motivational and behavioral skills enhancement, in addition to standard prevention case management (PCM).  Control group participants received only PCM. Once screened, patients who engaged in unprotected sex with anyone except a monogamous seroconcordant partner during the previous 3 months were enrolled into the study.


    Johns Hopkins University
    Baltimore, MD

    Improving Provider Counseling Interventions in HIV Practice

    This project evaluated the impact of a prevention counseling protocol to be used by existing clinical providers.  Participating patients were asked to complete an audio-computer assisted self-interview (ACASI) upon arrival at clinical appointments.  A randomly-selected group of those presenting with high-risk profiles were given prevention counseling as part of their scheduled visit.  The ACASI risk assessment with counseling by providers (according to assignment to an intervention or control group) continued at standard 3 month visits for the following year.  All providers were being trained by a staff person from the Rochester Center for Health and Behavioral Training before the project is initiated.  The evaluation compared changes in self-reported transmission behavior at 12-month follow-up in the intervention group, compared to the control group. The project also assessed patients' intent to change behavior, as captured by the ACASI; improvements in health service counseling during clinical encounters;  and patients' perception of the intervention's impact on interactions with clinical providers.  The Rochester (NY) Center for Health and Behavioral Training was a collaborating partner in the project.


    Los Angeles County Department of Health Services
    Los Angeles, CA

    HIV Prevention in Primary Care Settings

    This project first studied the impact of existing prevention counseling offered by clinical providers in the context of ongoing clinical care, establishing impact baselines.  The project then evaluated the effectiveness of enhanced provider-based prevention services using motivational interviewing and loss-framed messages.  Project goals included improving the patient-provider relationship, improving the ability of providers to implement prevention counseling, and reducing high-risk sexual behaviors.  The evaluation assessed the extent to which the enhanced intervention met project goals; identified patient characteristics that are covariates of outcomes and/or that act as moderators in the intervention; and the extent to which high-risk sexual behaviors were related to demographic characteristics and co-occurring behaviors such as substance abuse.  The target population was sexually active HIV-infected patients being seen at HIV-oriented primary care sites, and collaborating partners included the Keck School of Medicine at the University of Southern California; Children's Hospital of Los Angeles; AltaMed Health Services; and Northeast Valley Health Corporation.


    Mount Sinai Hospital
    Chicago, IL

    HIV Prevention in Treatment Settings

    This project evaluated the impact of a 12 month-behavioral intervention consisting of multiple individualized educational sessions with a peer advocate using computer-assisted technology. Intervention participants were stratified by length of time from diagnosis (newly diagnosed vs. diagnosed for more than 18 months) and were compared to persons who only received prevention counseling from primary care providers according to current protocols.  The target Population was HIV-infected low-income persons of African-American or Mexican-American ethnicity.  The evaluation examined the impact of each intervention on coping ability, adherence to treatment regimens, elimination of high-risk sexual behaviors, and adoption of lower risk practices with regard to drug use (particularly injection drug use).  The evaluation also assessed the effectiveness of the intervention with newly diagnosed persons vs. persons who have been infected for some time, and the extent to which participant impacts vary by HIV risk factor and demographic characteristics.


    St. Luke's Roosevelt Hospital Center
    New York, NY

    Positive Prevention

    This project implemented an individualized, non-judgmental, and culturally competent prevention specialist intervention with HIV infected persons being seen at the Center for Comprehensive Care.  Staff nurses at the Center were trained in behavioral risk assessment and theories and techniques of behavior change.  Patients were periodically assessed for risk and recruited into the intervention based upon risk profile. Motivational interviewing techniques and peer support groups were then employed.  Specific behavioral outcomes sought by the intervention included increased condom use during sexual activity; decreased high-risk needle use when injecting substances; decreased substance use; and improved treatment adherence. The evaluation also examined patient demographic variables;  activity process data; the impact of the intervention on self-reported risk behaviors and service utilization; and clinical outcomes.


    University of Alabama at Birmingham
    Birmingham, AL

    HIV Prevention in the Primary Care Setting

    This project conducted a randomized trial evaluating the effectiveness of an enhanced provider-delivered, client-centered intervention seeking to increase motivation, facilitate positive decision-making, and increase self-efficacy for changing sexual risk behaviors among HIV-infected MSM.  Provider-delivered messages and strategies were based on the conceptual framework of the Transtheoretical Model of Change, and matched to each patient's level of motivation to change.  Computer-assisted self-interviewing (CASI) technology was used to collect data from participants.  The evaluation’s principal behavioral outcome measures included  increases in condom use with primary and any secondary casual partners; decreases in number of sexual partners among those reporting multiple partners; and increases in the frequency of HIV serostatus disclosure to all sexual partners.  Patients receiving the intervention were compared to those receiving only standard prevention counseling according to existing clinical protocols.


    University of California, Davis
    Sacramento, CA

    Prevention Intervention Strategies with HIV-infected Persons Seen in Four Different Primary Care Settings

    This project trained primary care providers in existing clinics, and then added an HIV specialist health educator to promote behavior change among HIV-infected patients.  The project’s target population was HIV-infected persons seen in clinics primarily serving low-income populations, mostly people of color.  The project included two intervention models: a brief intervention from a primary care provider during a regularly scheduled clinic appointment, and a brief intervention by a primary care provider, immediately followed by an educational session with an HIV specialist health educator.  All clinical providers were trained in HIV prevention counseling before the project began.  The evaluation examined the extent to which the sole clinical provider counseling and the combined provider-health education specialist models were effective in reducing the prevalence of high risk behavior among patients being seen.  It also compared the impacts of each model, assessing their relative costs and cost-effectiveness.  Collaborating partners included the Center for Health Services Research in Primary Care, and the Northern California HIV Primary Care Providers Consortium.


    University of California, San Diego
    San Diego, CA

    Primary Prevention for Positives

    This project implemented an enhanced intervention using individualized prevention specialist counseling sessions with HIV-infected persons currently being seen in primary care services who were identified as at high risk for transmitting infection to others.  Participants were referred to the enhanced intervention, which consisted of a minimum of six hour-long sessions.  Audio-computer assisted self-interviewing (ACASI) was used to assess risk and progress toward behavioral change.  The patient, primary care provider, and prevention specialist periodically reviewed data provided by the ACASI system with regard to patient knowledge, skills, motivation, resources, and support, and then identified opportunities for further change. The project’s overall goal was reduction of HIV transmission risk from patients to sexual and/or needle sharing partners. The evaluation examined the percent change in reported high risk sexual and/or drug using behaviors; intervention effects on estimates of potentially transmitting HIV to others; percent change in STD rates as measured by laboratory screening tests and client self-report; costs of implementing the intervention; and potential for reproducing the intervention.


    University of Miami School of Medicine
    Miami, FL

    Project Road Map

    This project is adapting an intervention model developed in the NIMH Multi-site Prevention Trial, Project LIGHT, to include issues related to secondary prevention of HIV infection, disclosure of HIV status to others, and addressing unique life needs of older adults.  Participants were HIV-infected individuals 50 years of age and older, and were recruited via referrals from primary care providers, and randomly assigned to an intervention group or a control group.  The intervention group received four 90 - 120 minute small group intervention addressing prevention and risk reduction issues. Specific groups were formed based upon language (Spanish vs. English) and gender. The evaluation assessed HIV knowledge, risk reduction problem solving, and self-reported lower risk sexual behaviors.  The Adult Special Immunology Clinic at the University of Miami's Jackson Memorial Hospital collaborated in the project.


    University of North Carolina, Chapel Hill
    Chapel Hill, NC

    UNC HIV Prevention Demonstration Project

    This project introduced enhanced prevention services into an existing Title III Early Intervention program for HIV care serving HIV-infected persons living in non-urban areas.  The enhanced services provided included patient risk assessment using a web-based risk screening tool; counseling by primary care providers based upon screening results; patient education via an educational tool linked to the web-based screening tool; and motivational interviewing by a health behavior specialist.  Primary care providers were trained before the enhanced intervention began.  The evaluation examined behavioral and health outcomes, including self-reported risk behaviors, disclosure of HIV status to others, and incidence of sexually transmitted infections.  It also assessed intervention dose (frequency and duration) and cost.


    University of Washington
    Seattle, WA

    Prevention for Positives

    This project added an enhanced prevention specialist intervention into an existing HIV primary care clinic. Working closely with primary care providers and case managers, a trained nurse specialist conducted risk-assessments with patients using an audio-enhanced, computer-assisted self-interview.  HIV-infected patients with high risk profiles seen at the Madison Clinic of the Harborview Medical Center were recruited into a 12-month individualized intervention by the nurse specialist.  Motivational interviewing and small group peer interventions were also employed.  Evaluation examined changes in patient behaviors at 12 and 24 month intervals.  Intervention patients were compared to patients referred to the intervention but who choose not to enroll or who delayed enrollment.  Provider behavior change was also be assessed through reviews of medical records.


    Whitman-Walker Clinic
    Washington, DC

    Prevention with HIV-infected Persons Seen in Primary Care

    This project implemented an intervention that combined primary care provider counseling with focused behavioral interventions by health educators.  The target population was HIV-infected men seen in HIV-oriented primary care facilities.  Outcome measures of the evaluation included awareness of sexual risk, openness and trust with primary care providers regarding high risk behaviors, and self-reports of engagement in high-risk behaviors.  A quasi-experimental design with a longitudinal time dimension was used.  The evaluation also included duration and intensity of the intervention, patient demographics, and comparison of risk assessment scores.  Collaborating partners included the Georgetown University School of Nursing and Health Studies, and Boston University School of Public Health.


    University of California, San Francisco, Center for AIDS Prevention Studies
    San Francisco, CA

    Evaluation and Support Center

    The Evaluation and Support Center led the design and implementation of the multisite evaluation of the prevention with positive interventions.  Their specific aims were to facilitate and conduct rigorous evaluation research across multiple demonstration sites that will have maximum impact on practice and policy of HIV prevention with positives, and to provide methodological (both quantitative and qualitative) research design and evaluation consultation and support to the demonstration projects.  The Center provided technical assistance on the development of behaviorally based interventions, assisting the sites in design of state-of-the-art data collection and management systems, and maintaining a central database for measurement outcomes.  It also synthesized and disseminated findings from demonstration projects for optimum impact on further prevention research, practices and policies.


    Journal Articles 

    Marseille E, Shade SB, Myers J, & Morin S. The cost-effectiveness of HIV prevention interventions for HIV-infected patients seen in clinical settings.  Journal of Acquired Immune Deficiency Syndromes, March 2011; 56 (3): e87-e94. PubMed Abstract

    Myers JJ, Shade SB, Rose CD, Koester K, Maiorana A, Malitz FE, Bie J, Kang-Dufour MS, & Morin SF.  Interventions Delivered in Clinical Settings are Effective in Reducing Risk of HIV Transmission Among People Living with HIV: Results from the Health Resources and Services Administration (HRSA)'s Special Projects of National Significance Initiative.  AIDS and Behavior, June 2010; 14 (3): 483-492.  PubMed Abstract

    Estes LJ, Lloyd LE, Teti M, Raja S, Bowleg L, Allgood KL, & Glick N. Perceptions of Audio Computer-Assisted Self-Interviewing (ACASI) among Women in an HIV Positive Prevention Program.  PLoS ONE, 5 (2): e-published February 10, 2010. Full Text Exit Disclaimer

    Iverson EF, Balasuriya D, García GP, Sheng M, Richardson JL, Stoyanoff S, & King JB.  The Challenges of Assessing Fidelity to Physician-Driven HIV Prevention Interventions: Lessons Learned Implementing Partnership for Health in a Los Angeles HIV Clinic.  AIDS and Behavior, November 2008; 12 (6): 978-988.  PubMed Abstract

    Grodensky CA, Golin CE, Boland MS, Patel SN, Quinlivan EB, & Price M.  Translating concern into action: HIV care providers' views on counseling patients about HIV prevention in the clinical setting.  AIDS and Behavior, May 2008; 12 (3): 404-411. PubMed Abstract

    Malitz FE and Eldred L. Evolution of the special projects of national significance prevention with HIV-infected persons seen in primary care settings initiative.  AIDS and Behavior, September 2007; 11 (5 Supplement):  S1-S5.  No abstract available.

    Morin SF, Myers JJ, Shade SB, Koester K, Maiorana A, & Rose CD.  Predicting HIV transmission risk among HIV-infected patients seen in clinical settings.  AIDS and Behavior, September 2007; 11 (5 Supplement): S6-S16.  PubMed Abstract

    Koester KA, Maiorana A, Vernon K, Myers J, Rose CD, & Morin S.  Implementation of HIV prevention interventions with people living with HIV/AIDS in clinical settings: challenges and lessons learned.  AIDS and Behavior, September 2007; 11 (5 Supplement): S17-S29. PubMed Abstract

    Myers JJ, Rose CD, Shade SB, Koester KA, Maiorana A, Malitz F, Steward WT, & Morin SF. Sex, risk and responsibility: provider attitudes and beliefs predict HIV transmission risk prevention counseling in clinical care settings. AIDS and Behavior, September 2007; 11 (5 Supplement): S30-S38.  PubMed Abstract

    Grimley DM, Bachmann LH, Jenckes MW, & Erbelding EJ. Provider-delivered, theory-based, individualized prevention interventions for HIV positive adults receiving HIV comprehensive care.  AIDS and Behavior, September 2007; 11 (5 Supplement): S39-S47.  PubMed Abstract

    Callahan EJ, Flynn NM, Kuenneth CA, & Enders SR. Strategies to reduce HIV risk behavior in HIV primary care clinics: brief provider messages and specialist intervention.  AIDS and Behavior, September 2007; 11 (5 Supplement): S48-S57.  PubMed Abstract

    Zúñiga ML, Baldwin H, Uhler D, Brennan J, Olshefsky AM, Oliver E, & Mathews WC. Supporting Positive Living and Sexual Health (SPLASH): a clinician and behavioral counselor risk-reduction intervention in a university-based HIV clinic.  AIDS and Behavior, September 2007; 11 (5 Supplement): S58-S71.  PubMed Abstract

    Golin CE, Patel S, Tiller K, Quinlivan EB, Grodensky CA, & Boland M. Start Talking About Risks: development of a Motivational Interviewing-based safer sex program for people living with HIV. AIDS and Behavior, September 2007; 11 (5 Supplement): S72-S83. PubMed Abstract

    Nollen C, Drainoni ML & Sharp V. Designing and delivering a prevention project within an HIV treatment setting: lessons learned from a specialist model. AIDS and Behavior, September 2007; 11 (5 Supplement): S72-S83. PubMed Abstract

    Estrada BD, Trujillo S, & Estrada AL. Supporting Healthy Alternatives through Patient  Education: a theoretically driven HIV prevention intervention for persons living with HIV/AIDS. AIDS and Behavior, September 2007; 11 (5 Supplement): S95-S105.  PubMed Abstract

    Teti M, Rubinstein S, Lloyd L, Aaron E, Merron-Brainerd J, Spencer S, Ricksecker A, & Gold M.  The Protect and Respect program: a sexual risk reduction intervention for women living with HIV/AIDS. AIDS and Behavior, September 2007; 11 (5 Supplement): S106-S116.  PubMed Abstract

    Knauz RO, Safren SA, O’Cleirigh C, Capistrant BD, Driskell JR, Aguilar D, Salomon L, Hobson J, & Mayer KH.  Developing an HIV-Prevention Intervention for HIV-Infected Men Who Have Sex with Men in HIV Care: Project Enhance.  AIDS and Behavior, September 2007; 11 (5 Supplement): S117-S126.  PubMed Abstract

    Raja S, McKirnan D, & Glick N. The Treatment Advocacy Program--Sinai: a peer-based HIV prevention intervention for working with African American HIV-infected persons.  AIDS and Behavior, September 2007; 11 (5 Supplement): S127-S137.  PubMed Abstract

    Steward WT, Koester KA, Myers JJ, & Morin SF.  Provider fatalism reduces the likelihood of HIV-prevention counseling in primary care settings.  AIDS and Behavior, January 2006; 10 (1): 3-12.  PubMed Abstract

    Myers JJ, Steward WT, Charlebois E, Koester KA, Maiorana A, & Morin SF. Written clinic procedures enhance delivery of HIV "prevention with positives" counseling in primary health care settings.  Journal of Acquired Immune Deficiency Syndromes, 37 (Supplement 2): S95-S100. PubMed Abstract

    Morin SF, Koester KA, Steward WT, Maiorana A, McLaughlin M, Myers JJ, Vernon K, & Chesney MA. Missed opportunities: prevention with HIV-infected patients in clinical care settings.  Journal of Acquired Immune Deficiency Syndromes, 36 (4): 960–966.  PubMed Abstract


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The SPNS program began with some of the first Federal grants to target adolescents and women living with HIV, and over the years, initiatives have been developed to reflect the evolution of the epidemic and the health care arena.

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