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Shifting the Focus

Health care providers at the Los Angeles County Medical Center outpatient HIV clinic expected to find higher than average rates of HIV infection when they added a testing clinic for the sexual partners of patients. But just how high was a surprise, according to Debra Johnson, NP, a researcher and provider at the clinic. "The results have been astounding," she says.

According to Johnson, standalone HIV testing centers average seropositive rates of 3% to 5%, but at the testing center connected to the Los Angeles County Medical Center outpatient HIV clinic, seropositive rates are around 30%.

These figures have led Johnson and her colleagues to conclude that HIV testing should be routinely offered to the sexual partners of patients who receive their HIV care in a treatment center. "Public health campaigns need to intensify efforts to encourage HIV-positive patients to practice safe sex and to bring their partners in for counseling and testing," she says.

The Centers for Disease Control and Prevention's recently issued HIV guidelines echo Johnson's point of view. Published in the July 18, 2003, issue of Morbidity and Mortality Weekly Report, the guidelines are intended to help health care professionals communicate with their HIV-infected patients about what they can do to prevent transmitting the virus to others. They are based on the assumption that health care providers who care for HIV-infected people can play a vital role in helping patients to continue practicing safe sex and to cut down on risky behaviors.

Steady Rates of HIV Infection
For more than 10 years, the number of annual new HIV infections in the United States has failed to fall, remaining steady at around 40,000, with new infections rising by 2.2% in 2002. In addition, 2003 marked the third consecutive year in which new HIV diagnoses among gay and bisexual men in some states increased, according to CDC figures.

Studies suggest that HIV patients who know of their positive status generally cut down on the kinds of high-risk behaviors through which they could infect others with HIV. Recent reports show that a considerable number of HIV-positive patients nonetheless eventually return to behaviors that put others at risk for HIV infection, such as unprotected sex and needle sharing (see sidebar). In addition, health care professionals working with HIV-positive patients have not had clear guidance on how to speak to patients about maintaining safe behaviors and protecting their HIV-negative partners from becoming infected.

These factors prompted the CDC to conclude that reducing rates of HIV transmission will require a shift in focus, from helping people who are HIV-negative to avoid infection to educating people who are HIV-positive on preventing transmission to others.

"It's time we merge prevention services for HIV-infected persons into the mainstream of medical care," CDC director Julie L. Gerberding, MD, MPH, said in a press release. "These guidelines provide a much-needed roadmap for medical professionals that allows them to work more closely with their HIV-infected patients to reduce HIV transmission."

The guidelines call for:

  • Screening patients for the risk of HIV transmission. The guidelines recommend screening practices such as using questionnaires and interviews to evaluate risk behaviors and testing for sexually transmitted diseases when appropriate. Discussing the possibility of pregnancy to help prevent mother-to-child HIV transmission with women patients is also suggested.
  • Delivering prevention interventions. Health care providers can help lessen patients' risk of transmitting HIV by delivering prevention messages, supplying condoms and printed information and, when relevant, referring patients to outside prevention services and agencies.
  • Partner counseling and referral services. Health care professionals are urged to ask patients whether they have informed their partners of their HIV status and to help patients contact their local health departments to arrange for partners who have not been informed to be told. The guidelines especially stress the importance of reaching the partners of HIV-positive patients with counseling and testing services.

Funding and Exclusion
Some health care professionals view the new guidelines warily. "I don't see this as a positive development," says Carl Stein, a physician assistant who has been volunteering and working with HIV and AIDS patients since the 1980s. Stein, a board member of Physician Assistants AIDS Network and a co-founder and member of the steering committee of the San Francisco Bay Area Physician Assistants Association, is now in private practice with the Owen Medical Group in San Francisco. He strongly believes that the CDC's decision to issue these new guidelines was motivated by what he feels is the conservative agenda of the Bush administration.

"They don't want to work with prevention in the general population, just prevention within the positive community, because to do effective HIV prevention work with people who are HIV-negative and at risk, the message must be sex-positive," he says. "I believe that to the Bush administration and its conservative supporters, a sex-positive message to gay or straight people who are having sex outside a heterosexual marriage is abhorrent."

Stein fears that the new guidelines' focus will cause federal funding for education and prevention in the general population to dry up, resulting in a loss of services for many people who are at risk for HIV. "I'm all for funding prevention education within the positive community but not to the exclusion of funding education for the negative population," he says.

Funding for community-based organizations and testing centers may also be affected by the new guidelines, according to Shana Krochmal, director of communications and public affairs for the Stop AIDS project, which works to prevent HIV transmission among gay and bisexual men in San Francisco through multicultural, community-based organizing. Shifting money to health care providers' offices and treatment centers and away from behavioral interventions, education, standalone testing centers and community-based organizations is problematic, according to Krochmal, because many HIV-positive patients do not see a provider on a regular basis. "Many don't have insurance and get their primary care at emergency rooms," she says. "Where would this leave them?"

CDC officials acknowledged this shift in focus but argue that it is necessary because the current HIV-prevention model has not succeeded in decreasing the number of new U.S. HIV infections per year. "We wouldn't want all of our efforts targeted on the general population because that would not result in an effective program," Dr. Ronald Valdiserri, MD, a CDC deputy director, has said.

Zeroing In
Johnson agrees with the CDC's point of view. "The treatment centers, as they are, aren't doing a good job, or we wouldn't have ongoing reported cases of HIV" she says.

She feels that some funding should be available for HIV education and prevention efforts geared toward people who are HIV-negative, but she stresses that the lion's share of funding should be spent improving treatment centers by equipping them with testing facilities and additional clinicians. "You're talking about a state and federal government that have less and less access to money each year," she says. "Budgets are getting cut and we need to use health care dollars in the most effective way."

To Johnson, it has always made sense that controlling the spread of HIV means zeroing in on the people who have the highest risk of infecting others - those with multiple exposures to HIV, those who are not taking medication and those who have developed a drug-resistant form of the virus.

She draws an analogy to illustrate her point: "If you had an infectious disease break out, say Ebola, would you ignore the town where the virus came from and just concentrate on all the surrounding towns? Or would you try to get into the town that was ground zero and try to block the virus from spreading? To me, the latter just makes much more sense."

Time and Reimbursement
Whether or not the guidelines make political or clinical sense, many health care providers worry that they do not have the resources to incorporate CDC's recommendations into their already full schedules.

According to CDC, providers can follow the guidelines "with a feasible level of effort, even in constrained practice settings." The report urges managed care plans to incorporate its recommendations into their practice guidelines, educate their providers and enrollees and provide condoms and educational materials.

The report goes on to acknowledge providers' concerns that reimbursement often is not provided for prevention services and notes that improving reimbursement for such services might enhance the adoption and implementation of these guidelines.

But unlegislated suggestions, recommendations and urgings are not the stuff that HMO reform is made of, according to Stein. "I can't see HMOs recognizing that HIV care requires adequate payment and time for preventive services," he says. Stein is concerned that health care providers who follow the guidelines will not be paid for the added time they spend with patients.

"Giving our patients good HIV care is not a matter of following guidelines as much as it's a matter of having enough time," he says.

Lena Fleminger is on staff at ADVANCE.


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