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Computerized HIV intervention is effective
It takes nothing away from MD time
HIV clinicians continually are reminded to use prevention for positives (P4P) strategies with patients, yet these often are time-consuming and costly.
Now there's a strategy that appears to be effective, inexpensive, and easy to implement. This P4P approach uses computer technology to deliver nonjudgmental HIV prevention information to patients.
When researchers compared the computerized intervention with a similar provider-delivered intervention, they found that the computerized intervention had better results.
"The inception of this intervention was based on a conversation I had with clinician colleagues who were frustrated with having patients who continued to present in the clinic with sexually-transmitted diseases (STDs)," says Marguerita Lightfoot, PhD, an associate professor in the school of medicine at the University of California San Francisco. Lightfoot also is the co-director for the Center for AIDS Prevention Studies, also in San Francisco, CA.
"We were discussing what kinds of prevention strategies could be done in a way that is feasible, sustainable, and integrated into clinical care," she explains. "I heard from colleagues that they didn't have a lot of time to ask another question and delve deeply into the sexual risk behavior of patients."
So Lightfoot and co-investigators created an intervention that did not impact physicians' time. Then they compared it to standard care and to a similar intervention that required providers' assistance.
The results were surprising. The computer intervention had better results than both of the other study arms.
"We found that patients who received the intervention were more likely to report fewer HIV-negative, unknown sexual partners than the control group, who received nothing but a risk assessment," Lightfoot says. "And they were more likely to report a fewer number of unprotected sex acts."
The provider intervention did not show a significant improvement, and investigators suspected this was because providers may have returned to their usual interactions with patients after a period of time.
With the computerized intervention, providers did not have any P4P discussions with patients unless the patient brought up the topic of sexual risk behaviors.
The interventions were fairly short with the risk assessment portion taking 10 to 15 minutes and the computerized intervention or the provider intervention lasting 5-10 minutes.
Here is how the computerized intervention worked:
Integrate intervention in regular clinic visits: Generally, patients would come in for their regularly scheduled appointment, and the intervention was delivered to them during this check-up visit.
They would answer questions on the computerized intervention while waiting to see their doctors or while visiting a community-based agency, such as while waiting at a food bank, Lightfoot says.
Patients answered the computerized questions every three or six months when they made a clinic visit for an average of three times, she says.
"The more of these they did, the more likely they were to change their behavior over time," Lightfoot says. "This helped people reflect on their behavior on their own, and for some that encouraged behavior change."
Use self-reported answers on risk assessment to customize P4P suggestions: The computerized risk assessment asks patients these kinds of questions:
How many sexual partners have you had in X number of months?
How many times have you had unprotected sex?
What is the likelihood that you have transmitted HIV to someone else?
Do you value being kind to others?
Then the computerized intervention tailors feedback based on the patient's answers. This added element made a significant difference in outcomes.
"If clinics have the time and flexibility to do more, then they could sit patients at the computer every three to six months and program the computer to go into the intervention.
The intervention could give patients encouraging messages when their behavior shows improvement. For instance, an encouraging message might say, "You say you use a condom with every partner and you value being kind," Lightfoot says. "You really are being kind."
Clinics could program the intervention to be initiated when patients reach a certain threshold of unsafe behaviors, or it could be used to provide both positive and instructional feedback to all patients.
Just repeating patients' reported behavior can have some positive impact.
For instance, the program will let the patient know how many times the person has had unprotected sex in the past month, Lightfoot says.
"The patient might think, 'Wow! I never really thought about it,'" she explains. "Most of the time patients were not reflecting on their behavior."
Or a patient might indicate that kindness is something he or she values highly. But the person's report also shows that he or she might have transmitted HIV to other people.
"The program would say, 'You say you are a kind person, but you also say it's highly likely you gave HIV to someone else; That's not very kind,'" she adds. "It would add, 'Have you thought about what you could do to make your values congruent with your actions,' and the computer might suggest some goals."
Patients who received this intervention were more likely to report fewer HIV-negative, unknown sexual partners and fewer unprotected sex acts than the control group, she says.
One advantage of the computerized P4P program is that patients tend to be more honest with a computer since it doesn't hold judgments or values, Lightfoot says.
"It just provides facts, not the emotional aspect to it," she explains.
So patients might not have the emotional reactions of denial, discomfort, and feeling judged to being questioned as they would if the doctor were the one asking questions, she adds.
"The computer gives them a targeted experience so they feel the message is tailored to them individually," Lightfoot adds. "Patients overwhelmingly said they'd rather give this information to a computer."
The study of the P4P intervention enrolled an ethnically diverse population, including African Americans, and other people of color. The average age was in the early 40s, and most study participants were men who have sex with men (MSM).
The next step for the P4P intervention is to be selected as one of the evidence-based interventions disseminated to clinics by the Centers for Disease Control and Prevention of Atlanta, GA. Once this occurs, clinics could obtain a DVD that would be installed on office computers.
"The only cost is for the materials and the only material is a DVD, so it's not expensive," Lightfoot says.