Shilpa N. Patel, MPH University of North Carolina, Chapel Hill Division of Infectious Diseases

1. Prevention in Clinical Settings (PICS) Program in the United States: Receipt of Prevention Counseling and Satisfaction with Care Shilpa N. Patel, MPH University of North Carolina, Chapel Hill Division of Infectious Diseases Department of Medicine

2. Acknowledgements • A heartfelt thanks to the participants of this project and their contribution to prevention research. • Thank you to all the authors at the University of North Carolina Chapel Hill: Carol Golin MD, MPH, and Hsiao Tien PhD, Eva Lu MS, Kathy Ramsey BS, and Byrd Quinlivan MD • Thank you to authors at participating PICS sites: Melanie Thompson MD, Jacquel Clemons MPH, Mark Thrun, MD, Tracey Wilson PhD, April Timmons MS, Andrew Yale, and Julie Wright Pharm.D. • Thank you to Gary Marks, PhD, Lytt Gardner PhD, and Christine O’ Daniels RN with the Centers for Disease Control and Prevention • This research was supported by: CDC contract number: 200-2003-02721 and the UNC CFAR: P30 AI50410. General Clinical Research Center grant #RR00046. Dr. Golin’s salary was supported in part by K23 MH01862-01.

3. Background • 40,000 new cases of HIV occur in the United States each year. • Some (20-30%) people living with HIV and AIDS (PLWHA) continue to engage in high risk sexual activity.2 • As PLWHA live longer, healthier lives, interventions to help them practice safer sex are needed. • Few studies have evaluated such programs among individuals already infected with HIV. 1Janssen and Valdesser, 2004, Marks et al, 2Kalichman et al., 2002

4. Background • 2003 guidelines recommended HIV prevention services be provided in medical care settings to PLWHA. • Guidelines suggested screening, counseling and tailored referrals. • Little is known of the extent to which providers follow the recommendations to discuss prevention or how prevention counseling affects patients’ satisfaction with medical care. • There might be some concern that prevention discussions might interfere with patients’ satisfaction with providers and healthcare. • Prevention in Clinical Settings (PICS) evaluates the effectiveness of these guidelines when implemented in HIV clinics throughout the United States.

5. Study Objectives • To assess patients’ perceptions of the extent to which medical providers deliver prevention services (counseling). • To assess patients’ perceptions of satisfaction with prevention services • To compare these perceptions before and after implementation of the PICS prevention program. • To assess differences in perceptions among subgroups of patients.

6. Methods

7. Approximately 150 patients from each of 7 academic and public health HIV clinics in 6 US cities. Participants were: 1) 18 years or over, 2) diagnosed with HIV > 6 months ago, 3) sexually active and/or had used injected illicit drugs in the past 6 months, 4) planned to attend their respective HIV care clinic at least 1 year 1050 patients enrolled, 915 (87%) completed 6 month surveys. Methods: Sample

8. Methods: The PICS Program Prevention in Care Guidelines for all PLWHA based on CDC recommendations: • Structural prevention messages (posters and brochures) • Standardized training for providers • Brief Risk assessment survey & brief provider-delivered risk reduction counseling • In depth specialist-delivered prevention counseling for high risk patients

9. Methods: The PICS Program Structural Prevention Messages

10. Methods: Survey • Audio-computer assisted self-interviews (ACASI) • Patients surveyed before and six months after program implementation. • Prevention survey items asked how frequently care providers had discussed prevention issues in the last six months. • The ACASI also assessed general health care satisfaction and satisfaction with specific prevention services, and demographics.

11. Methods: Survey Items • How often during the last 6 months did your provider in this clinic talk to you about: • The topic of safer sex ? • Telling your sex partners that you have HIV? • Telling your needle sharing partner that you have HIV? • Responses were on five point ranging from “every clinic visit” to “never”

12. Methods: Survey Items Cont. • In the last 6 months, how satisfied are you with the discussions you have had with your provider in this clinic about: • The topic of safer sex? • Telling your sex partners that you have HIV? • I am satisfied with my relationship with my provider. • I am satisfied with the healthcare provided.

13. Methods: Statistical Analyses • We compared the percent of participants at baseline versus six months for responses to specific prevention and satisfaction items. • We calculated the percent mean change score for specific prevention and satisfaction items by: • Subtracting the baseline score from the 6 month score for each individual, • Dividing this difference by the baseline score for the individual, • Multiplying by 100%, • Calculating mean for percent change scores. • We conducted bivariate analyses (Wilcoxon sign rank test; McNemar Chi Square ). • We stratified selected analyses by demographics.

14. Results

15. Results: Socio-demographics N=915

16. Results:Patients’ Perceptions of Receipt of Prevention Counseling (N=915)

17. Results:Patients’ Perceptions of Receipt of Prevention Counseling (N=915)

18. Results:Patients’ Perceptions of Prevention Counseling (HIV Disclosure Discussions) N=915

19. Results:Patients’ Perceptions of Disclosure Discussion (N=915)

20. Results: Patient Perceptions of Safer Sex Discussions Stratified by Socio-demographic Categories

21. Results: Patients’ Satisfaction with Care & Prevention Discussions N=915

22. Results:Patients’ Satisfaction with Care & Prevention Discussions N=915

23. Conclusions • Over 6 months, the percentage of patients who perceived that their care providers had discussed safer sex, recreational drug use, alcohol use, and HIV disclosure with them increased slightly six months after program implementation. • Patients’ general satisfaction and satisfaction with prevention discussions did not worsen but rather increased slightly from baseline to 6 months.

24. Conclusions Cont. • When we stratified the analyses by socio-demographics we found that from baseline to six months: • the greatest increases in safer sex discussions occurred among the older PLWHA, men, MSM, and those with only one partner. • There were slight increases in satisfaction about safer sex discussions.

25. Dedication In memory of Dr. Andrew Kaplan, a brilliant man who inspired us all with his enthusiasm for science, love for humanity, and commitment to social justice.

26. Thank You

27. Results: Patient Satisfaction with Prevention Stratified by Socio-demographic Categories

28. Stratified by Socio-demographic Categories

29. Stratified by Socio-demographic Categories

30. The risk screening… • We want to ask you some questions about your sex and drug practices that will help us take better care of you. Please take a few minutes to answer the questions on this page. Thank you! • Why are you here today? ______________________ • 2. Thinking over the last 3 months, did you have sex with anyone? (oral, anal, or vaginal sex) • □ No □ Yes if no, go to #7 • 3. How many different sex partners did you have in past 3 months • _____#males _____#females • 4. Have you had any main sex partners in the past 3 months? (someone you are committed to) • □ No □ Yes If yes, how many_________ • 5. Have you had any occasional sex partners in the past 3 months? • □ No □ Yes If yes, how many_________ • 6. Were you told you had a sexually transmitted infection other than HIV in the past 3 months ? □ No □ Yes • 7. Did you smoke any crack or use crystal in the past 3 months? □ No □ Yes • 8. Have you injected any recreational drugs in past 3 months? □ No □ Yes • 9. Is there anything about sex or drugs that you want to talk to your provider about today? □ No □ Yes