Brief report on ecological momentary assessment: everyday states predict HIV prevention behaviors.

BACKGROUND: Prevention behaviors help persons living with HIV (PLWH) to avoid transmitting HIV, and psychological variables have been found to predict HIV prevention behaviors. These variables have typically been measured using retrospective questionnaires about average psychological states over a period of time, which are likely to be biased by selective recall and interpretation. Measuring the same variables as momentary states, in the day-to-day context where they actually occur, may reveal different relationships to behavior. FINDINGS: 21 PLWH completed daily surveys about momentary states and prevention behaviors. Brief, validated measures were used to assess control beliefs, mood, stress, coping, social support, stigma, knowledge, and motivation. We used multilevel models to predict prevention behaviors from momentary states the previous day, while controlling for the effect of multiple observations from the same person over time. Participants reported a moderate overall level of HIV prevention behaviors during the 6-month study. Although lapses in prevention were infrequent, there was room for improvement. Control beliefs, mood, and motivation had significant prospective effects on HIV prevention behaviors, rs = 0.07-0.21. Stress and coping had effects approaching significance. CONCLUSIONS: Some momentary states predicted prevention behaviors, providing partial support for the motivational model. This finding supports past research showing effects of momentary states on behavior, and advances the science by testing multiple predictors. High within-sample diversity strengthened generalizability, but the overall sample size was small and the findings require replication. Future research should continue to examine the everyday experiences of PLWH as influences on their behavior.

Enhanced personal contact with HIV patients improves retention in primary care: a randomized trial in 6 US HIV clinics.

BACKGROUND: The aim of the study was to determine whether enhanced personal contact with human immunodeficiency virus (HIV)-infected patients across time improves retention in care compared with existing standard of care (SOC) practices, and whether brief skills training improves retention beyond enhanced contact. METHODS: The study, conducted at 6 HIV clinics in the United States, included 1838 patients with a recent history of inconsistent clinic attendance, and new patients. Each clinic randomized participants to 1 of 3 arms and continued to provide SOC practices to all enrollees: enhanced contact with interventionist (EC) (brief face-to-face meeting upon returning for care visit, interim visit call, appointment reminder calls, missed visit call); EC + skills (organization, problem solving, and communication skills); or SOC only. The intervention was delivered by project staff for 12 months following randomization. The outcomes during that 12-month period were (1) percentage of participants attending at least 1 primary care visit in 3 consecutive 4-month intervals (visit constancy), and (2) proportion of kept/scheduled primary care visits (visit adherence). RESULTS: Log-binomial risk ratios comparing intervention arms against the SOC arm demonstrated better outcomes in both the EC and EC + skills arms (visit constancy: risk ratio [RR], 1.22 [95% confidence interval {CI}, 1.09-1.36] and 1.22 [95% CI, 1.09-1.36], respectively; visit adherence: RR, 1.08 [95% CI, 1.05-1.11] and 1.06 [95% CI, 1.02-1.09], respectively; all Ps < .01). Intervention effects were observed in numerous patient subgroups, although they were lower in patients reporting unmet needs or illicit drug use. CONCLUSIONS: Enhanced contact with patients improved retention in HIV primary care compared with existing SOC practices. A brief patient skill-building component did not improve retention further. Additional intervention elements may be needed for patients reporting illicit drug use or who have unmet needs. CLINICAL TRIALS REGISTRATION: CDCHRSA9272007.

A low-effort, clinic-wide intervention improves attendance for HIV primary care.

BACKGROUND: Retention in care for human immunodeficiency virus (HIV)-infected patients is a National HIV/AIDS Strategy priority. We hypothesized that retention could be improved with coordinated messages to encourage patients' clinic attendance. We report here the results of the first phase of the Centers for Disease Control and Prevention/Health Resources and Services Administration Retention in Care project. METHODS: Six HIV-specialty clinics participated in a cross-sectionally sampled pretest-posttest evaluation of brochures, posters, and messages that conveyed the importance of regular clinic attendance. 10,018 patients in 2008-2009 (preintervention period) and 11,039 patients in 2009-2010 (intervention period) were followed up for clinic attendance. Outcome variables were the percentage of patients who kept 2 consecutive primary care visits and the mean proportion of all primary care visits kept. Stratification variables were: new, reengaging, and active patients, HIV RNA viral load, CD4 cell count, age, sex, race or ethnicity, risk group, number of scheduled visits, and clinic site. Data were analyzed by multivariable log-binomial and linear models using generalized estimation equation methods. RESULTS: Clinic attendance for primary care was significantly higher in the intervention versus preintervention year. Overall relative improvement was 7.0% for keeping 2 consecutive visits and 3.0% for the mean proportion of all visits kept (P < .0001). Larger relative improvement for both outcomes was observed for new or reengaging patients, young patients and patients with elevated viral loads. Improved attendance among the new or reengaging patients was consistent across the 6 clinics, and less consistent across clinics for active patients. CONCLUSION: Targeted messages on staying in care, which were delivered at minimal effort and cost, improved clinic attendance, especially for new or reengaging patients, young patients, and those with elevated viral loads.

Feasibility of a daily electronic survey to study prevention behavior with HIV-infected individuals.

The daily experiences of persons living with HIV (PLWH) are important but under-studied as predictors of HIV prevention behavior. Ecological momentary assessment (EMA) is an intensive within-subjects data collection method that can be used to examine daily experiences. To determine whether PLWH would participate in EMA, we conducted a feasibility study with 21 PLWH. The method was acceptable to men and women from diverse backgrounds, with 81% (17/21) completing 2 months of daily surveys, and 67% (14/21) completing 6 months. Measures were completed on 72% of study days. Only 6% of records had missing data. Daily survey completion decreased over time. Participants reported that EMA was easy and did not influence their behaviors. Results suggest EMA is feasible with PLWH.

Improved prevention counseling by HIV care providers in a multisite, clinic-based intervention: Positive STEPs.

The Centers for Disease Control and Prevention have recommended that HIV care clinics incorporate prevention into clinical practice. This report summarizes HIV care providers' attitudes and counseling practices before and after they received training to deliver a counseling intervention to patients. Providers at seven HIV clinics received training in delivering a counseling intervention (Positive STEPs) to their patients and completed baseline and follow-up questionnaires to measure changes in prevention parameters. A cohort of patients at each clinic was independently surveyed about counseling experiences. Compared with the pretraining period, providers' self-ratings collected after they initiated the intervention showed significant (p < .05) positive changes in attitudes, comfort, self-efficacy, and frequency of delivering prevention counseling. Patients reported an increase in prevention counseling received from providers after training. The findings indicate that the training and delivery of the Positive STEPs intervention was associated with positive changes in providers' attitudes and HIV prevention counseling to patients.

Outcomes of multimodal training for healthcare professionals at an AIDS education and training center.

There is an ongoing need for continuing professional education (CPE) in the rapidly changing field of HIV care, but the best instructional methods remain a subject of debate. This study assessed the effects of training at an AIDS Education and Training Center (AETC) over an 18-month period. Health care professionals (HCP) who attended more than one training event showed small but significant improvements over time in HIV-related clinical practice behaviors. The type of training also predicted self-reported practice behavior, with interactive trainings and individual consultations associated with greater change, and intensive clinical training activities associated with a faster rate of change but not better scores on the self-reported behavior measure. Participants also reported high levels of satisfaction, knowledge improvement, and intention to change after each training event; however, these results were unrelated to whether trainees actually reported improved practice behavior.

Changes in clinician ability to assess risk and help patients determine the need for hiv testing: a comparison of three teaching methods.

An estimated one of four people with HIV in the United States do not know they have the infection. The Centers for Disease Control and Prevention encourages HIV testing in clinical settings, but there is evidence that this is not done on a regular basis. The purposes of this study were to (a) compare two less traditional teaching methods with a classroom method to determine whether the less traditional methods resulted in greater improvement of clinician knowledge, skill, and willingness to perform HIV risk assessment as the basis for recommending HIV testing; and (b) find out whether there were significant differences in convenience, cost, learner preference, or learner acceptance that would make one method more desirable than the others. Findings from participants in the standardized patient interaction with facilitator feedback (FB) and the case-based self-study module (SSM) were not different from those of participants in the interactive classroom education method (CL). Generally, there were positive changes in knowledge, attitudes, and behaviors over time. Participants preferred standardized patient interaction (FB) and interactive classes (CL) to self-study modules (SSM).

Prevention with HIV-infected men: recommendations for practice and research.

In the United States in 2004, 74% of the new AIDS cases and 70% of the new HIV cases were in men; in addition, 75% of the cases of HIV in women were classified as heterosexually acquired. These numbers make it clear that expanded prevention efforts for men who are infected with HIV would make a large contribution to containing the epidemic. This report explores epidemiologic and psychosocial issues related to prevention in men with HIV and compares how those variables relate to prevention efforts. The report ends with a discussion of a method to approach HIV risk reduction in clinical care settings.