Need for Further Education
The educational curriculum of the IMPACT initiative addressed gaps and disparities in HIV infection rates and prevention services, identified barriers to care, and outlined evidence-based strategies for prevention. While these teachings resulted in measurable improvements in participants’ knowledge, competence, and practice, there remains a need for further education as barriers to optimal practice persist.
In the aggregate analysis, 80% of learners acknowledged the need to make changes in their practice, but 6 months later 24% said they still didn’t have enough knowledge to make those changes. Approximately 34% said that patient adherence had proved to be a barrier; 28% cited a lack of time and resources to consider making changes; and 27% identified insurance, reimbursement, or legal issues as substantial challenges.
On average, at the conclusion of the activities, half of the participants said they were “very comfortable” discussing sexual health issues with their patients. Some concerns about PrEP remain: the possible development of resistant HIV strains and less frequent use of condoms or other safer sexual practices in patients taking PrEP.
Next Steps for Improving HIV Prevention
Applying the learnings and eliminating disparities in access to HIV prevention services involves talking candidly and comfortably about HIV with patients, assessing the individual’s risk for infection, discussing available prevention methods, and prescribing or referring as appropriate.11 Assessing HIV risk requires conversations about sensitive topics (ie, sexuality, drug use) with patients who may be reticent to discuss such information. Clinicians can help by taking measures to eliminate stigma and facilitate relationships that can normalize discussions about sexual activity and its consequences. To begin, clinicians should ask their patients if they have had sex within the past 12 months. If so, follow-up questions can include how many partners they had sex with, the gender(s) of their partners, and in what type(s) of sexual behavior did they engage. The CDC has published a guide to taking a sexual history43 and a set of specific instructions for taking a sexual history from transgender people.44
Other questions may include the role of the influence of alcohol on recent sexual encounters, the use of drugs to get high before or during sex, condom use/nonuse, and whether patients had been in a detention center, jail, or prison for more than 24 hours during the last 12 months. Clinicians can delve further into questions about alcohol, tobacco, and other substance use in the recent past, whether use led to legal or financial trouble, whether a friend or relative expressed concern about substance use, and if patients have tried without success to curtail their substance use. Notably, no additional financial resources are required to make sure patients are asked about sex; drugs; and social, economic, cultural, and psychological issues that may affect HIV risk and access to HIV prevention and treatment services.
Targeting barriers related to the availability and access of HIV prevention and treatment services can help eliminate disparities. To do so, it is important to combat the stigma linked to societal and cultural factors associated with HIV and to increase cultural competence and patient literacy. For example, providers can learn basic medical Spanish to help improve clinician-patient relationships in Hispanic/Latino communities. Using tools for health literacy, providing outreach, and engaging in community-specific messaging to patients in various languages may also improve these relationships. Cultural competence has been associated with “higher quality of care, better patient self-management, and better health outcomes among minority patients.”30
A Pivotal Role for Primary Care
Primary care physicians write the majority of prescriptions for PrEP. This makes them ideally positioned to identify individuals at risk for HIV infection and to provide HIV prevention services for these individuals. The CDC’s guidelines for PrEP, first developed in 2014 and updated twice since then, emphasize that (1) many people at very high risk for HIV infection are not getting PrEP, and (2) any prescribing healthcare provider can provide PrEP care.31,32,45 (See box, CDC Guidelines on PrEP — and Other Helpful Resources.)
Thus, it is critical that healthcare providers receive education about HIV prevention strategies and interventions for overcoming barriers to the uptake of and adherence to services. A fairly significant proportion of IMPACT learners (4%) were emergency medicine clinicians, 4% were pediatricians, and an additional 4% were obstetrician-gynecologists. Therefore, future educational activities on HIV prevention could be extended to these audiences.
From this foundation, the optimization of HIV prevention and treatment will be expanded to move closer toward the goal of eliminating disparities in HIV care.
CDC Guidelines on PrEP–and Other Helpful Resources
The CDC published guidelines on the use of HIV pre-exposure prophylaxis (PrEP) in 2014, updated them in 2017, and published the revised document online in March 2018.
PrEP Clinician Helpline: 855-448-7737 or 855-HIV-PrEP
CDC. Complete Listing of Risk Reduction Evidence-based Behavioral Interventions.
CDC. HIV Risk Reduction Tool.
NASTAD. Pharmaceutical Company Patient Assistance Programs and Co-Payment Assistance Programs for Pre-exposure Prophylaxis
(PrEP) and Post-exposure Prophylaxis (PEP).
The Body. Assess Your Risk for HIV.
Richard A. Elion, MD, is associate clinical professor of internal medicine at George Washington University in Washington, DC, and medical director of CAPE. Mesfin Fransua, MD, is a professor of medicine in the Infectious Diseases Section of Morehouse School of Medicine in Atlanta, Georgia. H. Gene Stringer Jr, MD, is associate professor of medicine and chief of the Infectious Diseases Section of the Department of Medicine of Morehouse School of Medicine in Atlanta, Georgia. Krista Sierra, MA, is director of grant and content development at Haymarket Medical Education in Paramus, New Jersey.
Acknowledgements: The educational activities for the IMPACT curriculum were supported by unrestricted grants from Gilead Sciences Inc. Writing assistance was provided by Jeremy Pagirsky of Haymarket Medical Education.
- Centers for Disease Control and Prevention (CDC). Diagnoses of HIV infection in the United States and dependent areas, 2017. HIV Surveillance Report, 2017, vol. 29. Published November 2018. Updated May 25, 2018. Accessed March 27, 2019.
- CDC. HIV in the United States and dependent areas. Accessed March 28, 2019.
- CDC. Estimated HIV incidence and prevalence in the United States 2010-2016. HIV Surveillance Supplemental Report. 2019;24(1):1-89.
library/reports/surveillance/cdc-hiv-surveillance-supplemental-report-vol-24-1.pdf. Published February 2019. Accessed March 25, 2019.
- CDC. CDC Fact Sheet. HIV incidence: estimated annual infections in the U.S., 2010-2016. Reviewed February 27, 2019. Accessed March 24, 2019.
- CDC. CDC Fact Sheet. Today’s HIV/AIDS Epidemic. https://www.cdc.gov/nchhstp/newsroom/docs/factsheets/todaysepidemic-508.pdf. Published August 2016. Accessed March 20, 2019.
- CDC. CDC Fact Sheet. New HIV infections in the United States. Published February 2016.
- Purcell D, Johnson CH, Lansky A, et al. Estimating the population size of men who have sex with men in the United States to obtain HIV and syphilis rates. The Open AIDS Journal. 2012;6(suppl 1:M6):98-107.
- CDC. Lifetime risk of HIV diagnosis. Half of black gay men and a quarter of Latino gay men projected to be diagnosed within their lifetime. CDC Press release, February 23, 2016. Accessed March 25, 2019.
- CDC. HIV and young men who have sex with men. https://www.cdc.gov/healthyyouth/sexualbehaviors/pdf/hiv_factsheet_ymsm. Accessed March 24, 2019.
- Bauermeister JA, Meanley S, Pingel E, et al. PrEP awareness and perceived barriers among single young men who have sex with men. Curr HIV Res. 2013;11:520-527.
- Hujdich B, Kirchner JT, Lubin-Johnson N, Mitchell EP, Rios EV, Streed CG Jr. The Need for HIV Prevention in Diverse Populations: Eliminating Health Disparities. Paramus, NJ: Haymarket Medical Education LP; 2017.
- Hosek SG, Rudy B, Landovitz R, et al. An HIV preexposure prophylaxis demonstration project and safety study for young MSM. J Acquir Immune Defic Syndr. 2017;74(1):21-29.
- World Health Organization. Consolidated Guidelines on HIV Prevention, Diagnosis, Treatment and Care for Key Populations: 2016 Update. Geneva, Switzerland: WHO Press; 2016.
- James SE, Herman JL, Rankin S, et al. Report of the 2015 U.S. Transgender Survey. Washington, DC: National Center for Transgender Equality; 2016. Page numbers from exec summary Published December 2016; Updated January 2017.
- CDC. Evidence of HIV treatment and viral suppression in preventing the sexual transmission of HIV. Accessed March 22, 2019.
- CDC. CDC Fact Sheet. HIV Prevention Today. Accessed March 24, 2019.
- CDC. CDC Fact Sheet. Proven HIV prevention methods. Published May 2016. Accessed March 22, 2019.
- Cohen MS, Chen YQ, McCauley M, et al. Prevention of HIV-1 infection with early antiretroviral therapy. N Engl J Med. 2011;365(6):493-505.
- Rodger AJ, Cambiano V, Bruun T, et al. Sexual activity without condoms and risk of HIV transmission in serodifferent couples when the HIV-positive partner is using suppressive antiretroviral therapy. JAMA. 2016;316(2):171-181.
- Dominguez KL, Smith DK, Vasavi T, et al; CDC. Updated Guidelines for Antiretroviral Postexposure Prophylaxis After Sexual, Injection Drug Use, or Other Nonoccupational Exposure to HIV—United States, 2016 [2016 nPEP Guidelines Update]. Atlanta, GA: CDC, US Department of Health & Human Services; 2016.
- Grant RM, Lama JR, Anderson PL, et al. Preexposure chemoprophylaxis for HIV prevention in men who have sex with men. N Engl J Med. 2010;363(27):2587-2599.
- Baeten JM, Donnell D, Ndase P, et al. Antiretroviral prophylaxis for HIV prevention in heterosexual men and women. N Engl J Med. 2012;367(5):399-410.
- Truvada [Prescribing Information]. Gilead Sciences, Inc., Foster City, CA, 2018.
- Hall HI, Tang T, Espinoza L. Late diagnosis of HIV infection in metropolitan areas of the United States and Puerto Rico. AIDS Behav. 2016;20(5):967-972.
- O’Connor BB. Promoting cultural competence in HIV/AIDS care. J Assoc Nurses AIDS Care. 1996;7(suppl 1):41-53.
- Scott KD, Gilliam A, Braxton K. Culturally competent HIV prevention strategies for women of color in the United States. Health Care Women Int. 2005;26(1):17-45.
- McNeil JI. A model for cultural competency in the HIV management of African American patients. J Natl Med Assoc. 2003;95(2 suppl 2):3S-7S.
- Acevedo V. Cultural competence in a group intervention designed for Latino patients living with HIV/AIDS. Health Soc Work. 2008;33(2):111-120.
- Keiswetter S, Brotemarkle B. Culturally competent care for HIV-infected transgender persons in the inpatient hospital setting: the role of the clinical nurse leader. J Assoc Nurses AIDS Care. 2010;21(3):272-277.
- Saha S, Korthuis PT, Cohn JA, et al. Primary care provider cultural competence and racial disparities in HIV care and outcomes. J Gen Intern Med. 2013;28(5):622-629.
- CDC. Vital Signs. Daily pill can prevent HIV. Reaching people who could benefit from PrEP. Accessed March 26, 2019.
- CDC. HIV prevention pill not reaching most Americans who could benefit—especially people of color. Press release based on CDC presentation at the annual Conference on Retroviruses and Opportunistic Infections, March 6, 2018. Accessed April 5, 2019.
- Kuhns LM, Hotton AL, Schneider J, et al. Use of pre-exposure prophylaxis (PrEP) in young men who have sex with men is associated with race, sexual risk behavior and peer network size. AIDS Behav. 2017;21(5):1376-1382.
- Golub SA, Gamarel KE, Surace A. Demographic differences in PrEP-related stereotypes: implications for implementation. AIDS Behav. 2017;21(5):1229-1235.
- Koester K, Amico RK, Gilmore H, et al. Risk, safety and sex among male PrEP users: time for a new understanding. Cult Health Sex. 2017:19(12):1301-1313.
- Grant RM, Anderson PL, McMahan V, et al. Uptake of pre-exposure prophylaxis, sexual practices, and HIV incidence in men and transgender women who have sex with men: a cohort study. Lancet Infect Dis. 2014;14(9):820-829.
- Mugwanya KK, Donnell D, Celum C, et al. Sexual behaviour of heterosexual men and women receiving antiretroviral pre-exposure prophylaxis for HIV prevention: a longitudinal analysis. Lancet Infect Dis. 2013;13(12):1021-1028.
- Liu AY, Vittinghoff E, Chillag K, et al. Sexual risk behavior among HIV-uninfected men who have sex with men participating in a tenofovir preexposure prophylaxis randomized trial in the United States. J Acquir Immune Defic Syndr. 2013;64(1):87-94.
- Barreiro P. Hot news: sexually transmitted infections on the rise in PrEP users. AIDS Rev. 2018;20(1):71.
- Traeger MW, Cornelisse VJ, Asseklin J, et al; for the PrEPX Study Team. Association of HIV preexposure prophylaxis with incidence of sexually transmitted infections among individuals at high risk of HIV infection. JAMA. 2019;321(14):1380-1390.
- Nguyen VK, Greenwald Z, Trottier H, et al. Incidence of sexually transmitted infections before and after preexposure prophylaxis for HIV. AIDS. 2018;32:523-530.
- Liu AY, Cohen SE, Vittinghoff E, et al. HIV pre-exposure prophylaxis integrated with municipal and community based sexual health services. JAMA Intern Med. 2016;176(1):75-84.
- CDC. A Guide to Taking a Sexual History. Accessed March 28, 2019.
- CDC. Taking a sexual history from transgender people. Accessed March 28, 2019.
- CDC. Preexposure prophylaxis for the prevention of HIV infection in the United States—2017 Update: a clinical practice guideline. Accessed April 15, 2019.
- Molina JM, Capitant C, Spire B, et al; ANRS IPERGAY Study Group. On-demand preexposure prophylaxis in men at high risk for HIV-1 infection. N Engl J Med. 2015;373(23):2237-2246.
- Choopanya K, Martin M, Suntharasamai P, et al; Bangkok Tenofovir Study group. Antiretroviral prophylaxis for HIV infection in injecting drug users in Bangkok, Thailand (the Bangkok Tenofovir Study): a randomized, double-blind, placebo-controlled phase 3 trial. Lancet. 2013;381(9883):2083-2090.