Abstract
BackgroundReducing substance use and unprotected sex by HIV-positive persons improves individual health status while decreasing the risk of HIV transmission. Despite recommendations that health care providers screen and counsel their HIV-positive patients for ongoing behavioral risks, it is unknown how to best provide “prevention with positives” in clinical settings. Positive Choice, an interactive, patient-tailored computer program, was developed in the United States to improve clinic-based assessment and counseling for risky behaviors.Methodology and FindingsWe conducted a parallel groups randomized controlled trial (December 2003–September 2006) at 5 San Francisco area outpatient HIV clinics. Eligible patients (HIV-positive English-speaking adults) completed an in-depth computerized risk assessment. Participants reporting substance use or sexual risks (n = 476) were randomized in stratified blocks. The intervention group received tailored risk-reduction counseling from a “Video Doctor” via laptop computer and a printed Educational Worksheet; providers received a Cueing Sheet on reported risks. Compared with control, fewer intervention participants reported continuing illicit drug use (RR 0.81, 95% CI: 0.689, 0.957, p = 0.014 at 3 months; and RR 0.65, 95% CI: 0.540, 0.785, p<0.001 at 6 months) and unprotected sex (RR 0.88, 95% CI: 0.773, 0.993, p = 0.039 at 3 months; and RR 0.80, 95% CI: 0.686, 0.941, p = 0.007 at 6 months). Intervention participants reported fewer mean days of ongoing illicit drug use (-4.0 days vs. -1.3 days, p = 0.346, at 3 months; and -4.7 days vs. -0.7 days, p = 0.130, at 6 months) than did controls, and had fewer casual sex partners at (−2.3 vs. −1.4, p = 0.461, at 3 months; and −2.7 vs. −0.6, p = 0.042, at 6 months).ConclusionsThe Positive Choice intervention achieved significant cessation of illicit drug use and unprotected sex at the group-level, and modest individual-level reductions in days of ongoing drug use and number of casual sex partners compared with the control group. Positive Choice, including Video Doctor counseling, is an efficacious and appropriate adjunct to risk-reduction efforts in outpatient settings, and holds promise as a public health HIV intervention.Trial RegistrationClinicaltrials.gov NCT00447707
Highlights
Advances in HIV treatment have dramatically increased patients’ duration and quality of life [1,2]
The Positive Choice intervention achieved significant cessation of illicit drug use and unprotected sex at the group-level, and modest individual-level reductions in days of ongoing drug use and number of casual sex partners compared with the control group
Because HIV-positive individuals are living longer and may continue to engage in risky behaviors, new prevention strategies address the role of HIV-positive persons; an approach called ‘‘prevention with positives.’’ To address prevention with HIV-positive individuals, the US Centers for Disease Control (CDC) recommends that providers screen for and intervene on transmission-related risk behaviors, monitor behaviors that increase the risk of disease progression, and counsel patients on how they can protect their own health [3]
Summary
Advances in HIV treatment have dramatically increased patients’ duration and quality of life [1,2]. Reducing substance use is another important strategy to reduce transmission and protect the health of HIV-positive individuals [7,8]. Both illicit drug and excessive alcohol use are associated with highrisk sexual behaviors [9,10,11]. Reducing sexual risk and substance use can be reframed as lifestyle changes supporting the patient’s own health while avoiding conceptualizing the HIV-infected person as a vector of disease [17]. Reducing substance use and unprotected sex by HIV-positive persons improves individual health status while decreasing the risk of HIV transmission. Positive Choice, an interactive, patient-tailored computer program, was developed in the United States to improve clinic-based assessment and counseling for risky behaviors
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