AIDS Education and Prevention, 24(4), 295308, 2012

2012 The Guilford Press

HIV PREVENTION INTERVENTIONS
KOESTER ET AL.

PEOPLE LIVING WITH HIV ARE RECEPTIVE

TO HIV PREVENTION INTERVENTIONS
IN CLINICAL SETTINGS: A QUALITATIVE
EVALUATION
Kimberly A. Koester, Andre Maiorana, Stephen F. Morin,
Carol Dawson Rose, Starley Shade, and Janet J. Myers

In the United States, HIV prevention services are increasingly being offered
in the context of healthcare settings. This includes prioritizing prevention
services for people living with HIV (PLWH), otherwise known as prevention with positives. We conducted sixty in-depth interviews to explore
patients perceptions of clinic-based HIV prevention interventions targeting people living with HIV. The majority of patients were receptive to the
prevention interventions. Patients described experiencing feeling fulfilled by
communicating about issues related to HIV prevention when the conversations were specific to their situation and with an interventionist who was
objective, yet empathic and non-judgmental. Provider-delivered interventions opened up new areas of prevention discussions with patients. Specialist-delivered interventions, specifically group-level interventions, provided
opportunities to integrate participants into social networks that in turn
provided social support and a reduction in social isolation. HIV prevention
counseling benefited patients regardless of risk status.

In the United States, HIV prevention services are increasingly being offered in the
context of healthcare settings. This includes prioritizing prevention services for people living with HIV (PLWH), otherwise known as prevention with positives or
PwP. While the movement towards PwP began in the late 1990s, interest intensified
in 2003 when the Centers for Disease Control (CDC) published recommendations
to incorporate HIV prevention education into the care of PLWH together with emKimberly A. Koester, Andre Maiorana, Stephen F. Morin, Carol Dawson Rose, Starley Shade, and Janet
J. Myers are all affiliated with the AIDS Policy Research Center, Center for AIDS Prevention Studies,
Department of Medicine, at the University of California in San Francisco.
This publication is supported by the Health Resources and Services Administration (HRSA) Special Projects of National Significance (SPNS) Program. The publications contents are solely the responsibility of
the authors and do not necessarily represent the official view of HRSA or the SPNS program.
We would like to express our appreciation to the following people for the support and guidance given to
us over the course of the project and during the drafting of this paper: the women and men participating
in our study, principal investigators, project directors, and project staff in the 15 demonstration sites,
Jennifer Bie, Dan Ciccarone, Megan Comfort, Alberto Curotto, Stuart Gaffney, Karen Mccready, Jay
Newberry, and Karen Vernon.
Address correspondence to Kimberly A. Koester, Center for AIDS Prevention Studies, University of CaliforniaSan Francisco, 50 Beale Street, Suite 1300, San Francisco, CA 94105. E-mail: kimberly.koester@
ucsf.edu.

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phasizing the importance of detecting new cases of HIV (Centers for Disease Control, 2001). The shift in priorities of HIV prevention from the uninfected to the
infected (Schlitz & Sandfort, 2000) occurred swiftly and placed responsibility to
prevent and detect new cases of HIV on healthcare providers.
The degree to which HIV prevention has been effectively and sustainably incorporated into HIV care settings per the CDC recommendations is unknown. Initial
research on the prevalence of HIV prevention discussions indicated that only about
half of patients reported receiving safer sex messages in the past six months (Morin
et al., 2004). Discussions about how to avoid HIV transmission and STD acquisition
consistently occurred during a new patient intake and included a risk assessment,
but any further HIV prevention counseling occurred intermittently during subsequent visits (Morin et al., 2004). More recently, a study of physicians found similar
results: less than 40% of physicians reported routinely discussing HIV prevention
(Gardner, Metsch, Strathdee, del Rio, Mahoney, & Holmber, 2008). Multiple factors appear to influence whether ongoing prevention counseling occurs, including
providers communication style, perceived amount of time required for counseling,
whether specific clinic policies were in place, and comfort level discussing sex and
drug use with patients (Gerbert, Caspers, Linkins, & Burack, 1999; Morin et al.,
2004; Myers et al., 2004; Steward, Koester, Myers, & Morin, 2006).
Research on the effectiveness of PwP is on-going; to date there are a number
of proven effective PwP interventions (Fisher & Smith, 2009; Gilbert et al., 2008;
Myers et al., 2010). The study of PwP in clinical settings remains an area of research
of considerable importance (Drainoni, Dekker, Lee-Hood, Boehmer, & Reif, 2009;
Fisher & Smith, 2009; Fisher et al., 2006; Gilliam & Straub, 2009; Grodensky et al.,
2008; Illa et al., 2010; Richardson et al., 2004) in order expand our understanding
of whether PwP in clinical settings is a sustainable HIV prevention strategy. In particular, HIV care providers need evidenced-based information on how to best intervene with patients on the topic of HIV prevention. With the publication of numerous
quantitative studies, we aim here to explore patient narratives on their experiences
in HIV prevention interventions.

STUDY BACKGROUND
In 2003, Health Resources and Services Administration (HRSA) funded 15 demonstration sites and an evaluation center under the HIV Prevention with Positives in
Clinical Settings Initiative. The purpose of the Initiative was to test whether behavioral interventions in HIV care settings helped PLWH reduce the risk HIV transmission. The 15 demonstration sites developed interventions tailored to their particular
patient population and clinical practice settings. Although each intervention was
unique, three general models emerged: provider-delivered, specialist-delivered, and
specialist + providerdelivered. Providers included medical doctors, nurse practitioners, and physician assistants; and specialists included health educators, peers living with HIV, and social workers. The interventions differed according to mode of
delivery: group level intervention versus individual level intervention; interventions
varied in their content and focus as well as their dose or duration. See Table 1 for a
brief overview of the interventions and the AIDS and Behavior supplement 2007 for
a full description of the interventions (Koester et al., 2004).
In about half of the provider-delivered interventions, patients completed a risk
assessment prior to the clinical encounter. The results were included in the patients

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TABLE 1. Brief Overview of Prevention Interventions
Intervention Model

Brief Description of Intervention Components

Provider-Delivered
Johns Hopkins University, Baltimore

Computerized behavioral risk assessment generates stage-based profile

for provider. Brief counseling by primary care provider during routine
medical visit.

University of Alabama, Birmingham

Computerized behavioral risk assessment generates stage of change-based

brief message and prescription printed for primary care provider delivery
during routine clinic visit.

UC Davis

Self-administered written risk assessment info is used by primary care

provider to conduct brief stage-based counseling using elements of motivational interviewing during routine clinic visit.

County of Los Angeles

Provider administers sexual health risk assessment to determine brief HIV

prevention loss-frame messages and a behavioral prescription delivered by
primary care during routine clinic visit.

Specialist-Delivered
St. Lukes Roosevelt Hospital, New York

Social worker administers brief risk assessment during first session, 4 motivational interviewing sessions in total which may or may not coincide
with primary care visits and are in addition to routine case management.

University of Washington, Seattle

Intervention group received minimum of 4 counseling sessions with specialist using motivational interviewing and 6 peer support group sessions.

El Rio Health Center, Tucson

Group views film clips to initiate discussion on relevant topics such as

stress and HIV, disclosure, relationships and safer sex/risk reduction. 5
sessions, 120 minutes each, over 5 weeks.

Provider + Specialist-Delivered
DeKalb County, GA, Health Educators

PCP gives brief prevention message every 6 months. Targeted risk behaviors are assessed by the health specialist, and tailored stage-based counseling is provided in conjunction with regularly scheduled primary care visits
every 3 months.

Whitman Walker Clinic, Washington, DC, PCP provides brief risk reduction message. Specialist conducts risk assessHealth Educator
ment and tailored stage-based counseling during 3 30-minute counseling
sessions within 45 days of baseline.
Drexel University, Philadelphia, Health
Educator

PCP determines risk and stage of change based on a personalized discussion

of risk and delivers a stage based prevention message. Intervention group
receives additional five facilitated specialist-led group sessions and two
peer-led support sessions.

University of North Carolina, Chapel Hill, PCP delivers a brief prevention message based on a computerized risk
Social worker
assessment during regularly scheduled primary care visits. Intervention
group receives in addition: 3 40-minute motivational interviewing sessions w/social worker over three months.
Owen Clinic, UC San Diego, Health
Educator

Intervention group received brief loss frame message from provider based
on computerized risk assessment during primary care visits. Intervention group receives additional stage of change assessment and targeted
counseling with health educator in 4 one-hour sessions.

Peer-Delivered
Fenway Community Health Boston

9 sessions (intake, 4 module sessions, 4 booster sessions) based on computerized modular workbook guided by peer interventionist. Client chooses
modules. Sessions last 50 minutes.

Mt. Sinai Hospital, Chicago

4 educational sessions focusing on medication adherence, safer sex practices, mood management, communication skills, alcohol/drug use over 6
months.

University of Miami

Group sessions facilitated by a peer focusing on building skills and increasing knowledge and motivation 4 sessions in total, 2 sessions a week.

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chart and in some cases, accompanied by a scripted prevention message. The remaining provider-delivered interventions relied on the provider to elicit risk information
from the patient and to deliver a brief prevention message. The specialist-delivered
interventions typically did not include a risk assessment. The curriculum included
such topics as: safer sex, drug use, relationships, taking medication, disclosure, emotional well-being, and assertiveness training and, in some cases, allowed for patientdirected topics.
Results from the quantitative evaluation indicated that interventions delivered
by either providers or specialists were effective in reducing sexual risk behavior (Myers et al., 2010). In particular, messages delivered by specialists influenced behavior
change in the shorter term, while provider-delivered messages were effective and
durable (Myers et al., 2010). The number of HIV infections averted depended on the
type of intervention, but ranged from 2 cases averted in the assessment-only condition to 6 cases averted in the provider-delivered interventions. This article reports on
qualitative data collected with a subset of the survey respondents.

METHODS
THE EVALUATION
Our qualitative study was a part of the larger evaluation center funded to determine the effectiveness of the interventions and was designed to explore patients
perceptions of the interventions. Our implicit hypothesis was that patients would
not necessarily perceive HIV prevention interventions conducted in clinic settings to
be acceptable because of the emphasis on the individual as well as the medical context of those interventions. Methods included in-depth interviews with patients. The
University of California San Franciscos Committee on Human Research approved
this study, and all participants provided informed consent.

SAMPLING AND RECRUITMENT

Demonstration site staff recruited patients on our behalf; this form of secondary
recruitment is commonly used in settings where researchers are unable to directly
conduct recruitment. We instructed site staff to purposefully sample patients that
were neither outstanding intervention successes nor notable intervention failures
(Patton, 2002). Our eligibility criteria included patients who were exposed to the
intervention condition and had completed all intervention sessions. Among sites
with more than one interventionist, we sampled patients seen by multiple interventionists; among sites employing group-level interventions, we sampled patients who
attended different groups. The sample size for this project was designed to yield findings about patients experiences of the HIV prevention interventions across and not
within the demonstration sites.

PROCEDURES
All interviews were digitally recorded after securing patient informed consent.
Our research team of three professional qualitative researchers conducted the interviews and performed the analysis. The interview guide was intentionally broad and
covered the following areas: patient motivation to participate in the intervention;
perceptions of and experiences with the intervention; expectations, reactions, and
changes made due to intervention; and communication about sex and HIV with

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TABLE 2. Intervention Model and Qualitative Patient Sample
Intervention Model

Patient n

Provider-Delivered

12

Specialist-Delivered

23

Provider - + Specialist-Delivered

25

Total n

60

clinic staff prior to the intervention. Numerous probes were included to elicit information that was not spontaneously offered by participants.

ANALYSIS
We utilized Ritchie and Spears framework analysis approach (Ritchie, Spencer,
& OConner, 2003). We independently read a selected subset of interviews, noting
initial reactions and assigning preliminary thematic codes. In subsequent meetings,
we discussed areas of emerging importance and reached agreement on a set of preliminary codes. We divided the remaining data between dyadic teams consisting of a
primary and secondary reader. Dyads met weekly to review the coded interviews and
to reconcile any discrepancies. The first author reviewed all of the coded interviews.
Our team met bi-weekly over the course of 6 months to expand or refine code definitions and to discuss emerging patterns in the data. We used Atlas.ti to facilitate
the organization of the data. For this analysis, we had a priori questions related to
acceptability and summarized the segments of text associated with code reaction
to the intervention. We also examined all text that was assigned a code called
what did the intervention do for you, as well as all text associated with the code
changes made because of the intervention. Further analyses of these data included
charting cases within these code categories that allowed us to identify patterns and
then to refine the recurring narratives into themes.

FINDINGS
We interviewed 60 patients enrolled in the interventions over a 10-month time period (FebruaryDecember 2006). Table 2 outlines the sample size according to the
intervention; Table 3 provides the demographic information on the participants
quoted. All names are pseudonyms selected by the research team.

TOOLS IMPROVE PWP COMMUNICATION: ACCEPTABILITY OF THE

PROVIDER-DELIVERED INTERVENTIONS
The quantitative survey results indicated that provider-delivered interventions
were the most robust in terms of averting new HIV infections (Myers et al., 2010).
In about half of the provider-delivered interventions, patients completed a computerized risk assessment prior to the clinical encounter. Providers then utilized the assessment information to deliver a prevention message. The risk assessment tool provided a structured prompt to remind providers to address PwP. It also presented the
providers with pertinent risk information that may not have been available to them
in the absence of the intervention. Patients preferred responding to sexual and drug
use behavior questions on a computerized assessment prior to seeing their provider.

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TABLE 3. Demographic Information of Participants Quoted

Patient*

Gender

Sexual Orientation

Length of Diagnosis Sexually Active

Intervention Type

Chris

Male

Gay

18 years

Yes

Provider

James

Male

Gay

18 years

Yes

Provider

Roger

Male

Gay

13 years

No

Provider

Patrick

Male

Heterosexual

15 years

Yes

Provider

Gary

Male

Gay

7 years

Yes

Specialist (group)

Julia

Female

Heterosexual

5 years

Yes

Specialist (group)

Scott

Male

Heterosexual

13 years

Yes

Specialist (group)

Mark

Male

Gay

12 years

Yes

Specialist (group)

Glenn

Male

Heterosexual

20 years

No

Specialist

Ted

Male

Gay

6 years

Yes

Specialist

Margaret

Female

Heterosexual

6 years

Yes

Specialist

Maria

Female

Heterosexual

10 years

Yes

Specialist (group)

Philip

Male

Gay

Unknown

Yes

Provider

James

Male

Gay

18

Yes

Provider

Note. *Pseudonym

Responding in advance of the clinical encounter allowed patients to reflect on their

behaviors. Once face to face with their provider, discussions about risk were more
focused and somewhat relaxed, whereas in the past both parties may have superficially addressed risk and prevention in an effort to avoid engaging in an awkward
conversation. The excerpt below was preceded by the question: Lets see, you said
that it helped. In what way did it help?
The questions were formulated in a way that elicited responses that were easier for me
to deal with. I knew exactly what they were saying, and [its] easier for me to respond to
written than to verbal. And this way, it was already in my mind, and the answers were
easily forthcoming, and it was easier for the doctor, it was easier for me. (Chris)

Patients appreciated having their provider devote time to HIV prevention issues,
assuming it was not a perfunctory discussion. Patients suggested having specific opportunities to discuss issues such as disclosure, sex preferences, and being sexually
active in a personalized way as key to engendering change. Below James attributes
his participation in the study to facilitating becoming open, a term frequently used
when patients described their intervention experiences.
Im open about my life more than Ive ever been. And thats because of the study. Im
not just able to talk to my doctors about my sex life, Im able to stand up in front of
someone and feel that Im not gonna get judged for what I tell them. It has helped me
considerably. And tell them when Ive done something or Ive had unprotected sex, and
without feeling guilty about it. (James)

Despite the fact that some patients were accustomed to provider inquiries about risk,
the interventions introduced either new questions or new ways of asking questions,
which prompted openings for prevention discussions as depicted below.
At one point, I found that after doing my survey and going into the doctor, it made me
a little more ready to talk to him about it than I would have normally. The questions
from the study helped me prepare for what I was gonna ask him and how I was gonna
ask it. And a lot of it will come from answering the questions on the survey [risk assess-

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ment]. (Roger)

A handful of patients described not benefiting at all from the interventions. Notably,
most of these patients were enrolled in the provider-delivered interventions. Patients
reported that conversations about HIV prevention were not out of the ordinary since
prior to the intervention, their providers periodically addressed prevention. One patient described the offer of prevention counseling as ridiculous since he had been
living with HIV for over 15 years:
Theyre trying to tell me that I shouldnt do this, that, and the other thing. I guess if Id
been more of a selfish person and didnt care about anybody else around me that might
have been a different thing. Ive been doing this for years. I mean, basically, it just tells
you what should be common sense. (Patrick)

Among provider-delivered interventions where the change in clinical practice was

distinct (i.e., brand-new procedures including the computerized risk assessment followed by counseling), patients appeared to respond well to the conversations generated due to the PwP interventions. In the clinics with interventions that had no noticeable tools or distinct shift on the part of the providers behaviors, many patients
found the PwP messages unnecessary.

SPECIALIST INTERVENTIONS GO DEEP; ACCEPTABILITY

OF THE SPECIALIST-DELIVERED INTERVENTIONS
The specialist-delivered interventions had a significant advantage over the provider-delivered interventions: more time to engage patients. In contrast to the provider-delivered interventions where the patients reported experiencing improvements
in communication with their providers, patients in the specialist-delivered projects
described their experiences as therapeutic. Most patients described experiencing
increased ability to implement healthy behavior changes, such as negotiating for
and using condoms, decreased feelings of isolation, building self-confidence, and
feeling more comfortable about living with HIV. Participants discourse explicitly
emphasized feeling better about themselves: I think its helped me to accept who I
am and like who I am better. It made me more comfortable in my own skin. Or I
didnt hold back. I said everything, and I felt like I benefited as well, just to be able to
talk about things. Patients appeared to welcome the opportunity to be candid and
expressive about intimate aspects of their lives, either in a one-on-one situation or
in group settings. Gary, a gay man enrolled in a group-level intervention, articulated
his experience as expansive and novel:
The intervention allowed me to be open; it allowed me to be vulnerable with other
clients that are citizens of this community. It served as a debut, sort of like a new awakening, because I had never been so open and I had never seen any other gay members
in this community be as open and sharing their personal stories and feelings about the
scenarios that were presented to us and the topics of HIV prevention, so for me it was
extremely therapeutic. (Gary)

In contrast to the provider-delivered interventions, the specialist-delivered interventions allowed participants extended time periods to process with others and encouraged self-reflection. Patterns in the data suggested that patients often described
somatic and/or attitudinal changes, such as feeling wholer, lighter, stronger,
more grown up, more self-confident. In some instances this was due to skill-build-

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ing activities, such as condom demonstrations or role playing disclosure scenarios.

Julia describes her experiences:
We (PLWH) are some of the loneliest people in the world. And we think that were not
going to ever have sex again. So we pay our damned attention if somebody can tell us
how we can make love. And get love in return. Of course youre going to listen and learn
and ask questions on how to do it. And youre going to listen. (Julia)

Despite the range of approaches and topics, the intervention activities appeared to
overwhelmingly fulfill a majority of patients unmet emotional needs.
I was able to talk about some stuff that I never talked about before. And it was really
positive to me. I liked it. Because you know, I have a lot of thoughts in my head but I
never express them, and I never share them. So theyre just there. But you know, that
very first initial meeting with [the interventionist], I was able to hear me say those things.
And that I could really process those things, those thoughts, see. It was positive to me.
(Scott)

A number of patients enrolled in specialist interventions described living in socially

isolated conditions because of their HIV status and, in some cases, because of their
same sex sexual preferences. For these patients, having a place to discuss issues
related to living with HIV without fear of judgment was described as a great relief.
Participants routinely described the opportunity to openly express themselves as a
welcome outlet, as depicted in the following quote:
Well for me, it was that I felt comfortable enough to be honest. For so much of my life,
I kept myself hiddennobody really knew anything. . .This group accepted me the way
I was and I was able to be very comfortable and thats what I liked about it. I could say
whatever I was thinking, whatever I was feeling, I didnt have to be careful, of what am
I or what am I getting myself into. Or you know, what would be the repercussions. Ive
never felt that way, so it made a big difference. (Mark)

Glenn, a patient who was diagnosed with HIV 15 years earlier, had not disclosed
to anyone but his mother. He described his relationship with the specialist as trusting. He discussed issues with her that he would not talk to his doctor about. For
example, his low sex drive meant that his desire to have sex seldom occurred, but his
doctor would not prescribe Viagra, telling him, you dont need that. This caused
him to feel pissed off and not entitled to be human again. He said this about
the peer specialist:
Well, then I got to trust and we went deep. I could tell her things, secrets and stuff and
I did. It sometimes is good to talk to other people with it, you know? Sometimes you
do want to talk about it, but you just dont want to talk to supposedly your friends and
stuff. You know, they dont understand? Where Im from they wont. Its like outcasts.
You know, like symptoms and diseases and sores. You know, those things, personal
things. I mean, we talk about stuff like that. Things you wouldnt really talk, sometimes
you dont talk to your doctor about things like that. (Glenn)

In group-level interventions, patients benefited from comparing themselves to others and providing or receiving feedback. Participants described the camaraderie and
freedom to discuss topics ordinarily avoided (for example, having sex) as valuable.
The realization that Im okay after hearing more about other patients lives ap-

HIV PREVENTION INTERVENTIONS 303

peared to help to break the isolation for some patients and may have resulted in a
normalizing affect.
And listening to some of the remarks [group members] made and some of that stuff was
the same thing I was thinking and feeling. So it let me know that I didnt have to feel
so much alone. It made me feel like, you know what, you aint the only one thinking
like this. And it really made me open up a lot too. Because I was able to tell some stuff
about me that I wasnt able to say before. (Scott)

Patients described the intervention discussions as affirming, uplifting, and in their

best interest. Many of the topics had not been addressed during previous clinic visits
even if a sexual risk assessment was conducted, particularly among interventions
that covered such topics as getting the relationships you want, negotiating condom use, and disclosing HIV status. Several patients mentioned the topic of emotional triggersexamining situations that may lead to having risky sexas being
unusually helpful. Ted, a 55-year-old gay man in a long-term relationship, participated in the study for altruistic reasons and did not anticipate personally benefiting
from the intervention. However, he ended up benefiting tremendously from his
sessions with the specialist. They dialogued about emotional issues that periodically
triggered his pursuit of unprotected sexual encounters with anonymous partners.
I was very happy with that session in which we talked about triggers, because it allowed
me to examine myself and alter my behavior in a way that I really wanted for a long
time but I had no means of altering it beforefor that Im very grateful to the project
and to [the specialist]. (Ted)

PWP INTERVENTIONS MAY FOSTER HONEST AND MEANINGFUL DISCUSSIONS ABOUT SEX
The central goal of the HRSA PwP initiative was to decrease the number of
potential new infections among partners of HIV-infected patients receiving the interventions. The interventions achieved this goal with many patients (Myers et al.,
2010). Patients having unprotected anal or vaginal sex with uninfected partners
discussed how they actively modified their sexual practices to reduce the potential
to transmit HIV. For example, some began using condoms with negative and positive partners (see Margarets vignette below); others stopped having or had fewer
anonymous sex encounters.
My ex-husband infected me and well, he took away a lot of my rights. Because he didnt
tell meand I feel, because of that and because of what I went through, that I have a
responsibility to let other people know and to be responsible for my own actions. If it
hadnt been for [the intervention specialist], I never would have even thought about it,
went on doing my own thing and said, you know, Pffsst, so what, I dont care. You
know, He dont care, I dont care. Whats the point? And if she hadnt sat down and
talked with me, I never would have changed my mind [started using condoms]. I promise
you that. (Margaret)

Some patients, particularly those who engaged in behaviors that put their uninfected
partners at risk for HIV, benefited from having the opportunity to explain and reflect
on their particular stance on engaging in unprotected sex. And yet, some of these
patients in our qualitative sample were unable or unwilling to change sexual behaviors despite the PwP interventions. Through their stories, we gain insights into what

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may have prompted them to engage in unprotected sex. For example, because she
did not want her HIV negative boyfriend, who was aware of her HIV serostatus, to
seek sex outside of their relationship, Maria willingly engaged in unprotected sex
with him. Initially, she attempted to avoid sex with him, since he was unwilling to
use a condom. However, after some time and in order to preserve the relationship,
periodically she would have unprotected sex with him. Its like, I dont want him to
go somewhere else. Her boyfriend assured her he was not going to become infected
and he would not care if he did become infected. We noted that among the few
patients who were unable to convince their HIV-negative partners to use condoms,
the uninfected partners routinely perceived themselves as immune to HIV and/or
expressed a lack of concern about becoming infected.
The opportunity to examine and offer an explanation for choices made around
unprotected sexual encounters appeared to facilitate some patients making substantial changes to their typical sexual script. In other cases, such as Marias, she was
able to discuss her rationale for why she engaged in one type of sex act over another.
In both situations, having to account for and examine sexual practices prompted
self-reflection that sometimes led to actual behavior change.

PATIENTS WITH NO OR LOW RISK OF

TRANSMITTING HIV MAY BENEFIT FROM PWP
When designing the interventions, intervention developers had to consider that
a number of patients were at either low or no risk for transmitting HIV. To include
these patients in the study meant a possible dilution in the overall likelihood of illustrating intervention effectiveness. For example, in the quantitative sample drawn
to assess intervention effectiveness, 33% of the participants reported no sex in the
last 6 months (Myers et al., 2010). Among our qualitative sample, 45 patients were
sexually active, 11 patients were abstinent, and it was unclear whether 4 patients
were sexually active or not. And the overwhelming majority of sexually active patients qualitatively interviewed described enacting long-held prevention practices
upon being diagnosed with HIV, I mean Ive been practicing safe sex continuously
since 1983.
The interventions appeared to be meaningful to participants intentionally engaging in low risk sex acts, such partnering only with other HIV+ partners or seroadaptation (Le Talec & Jablonski, 2008; McConnell, Bragg, Shiboski, & Grant,
2010) or mutual masturbation. Although the likelihood of making behavior changes
to avoid transmitting HIV was negligible and for the most part unnecessary, these
patients were willing and eager to discuss their carefully calculated sexual risk reduction strategies. They wanted additional information to incorporate into their decision-making processes (e.g., for those implementing seroadaptation, they wanted to
better understand the risk of superinfection).
For some patients, particularly those who chose to seroadapt, their sex lives
did not include condoms. These men (and a few women) reported feeling awkward
when faced with a provider inquiring about whether or not they were using condoms. This was an area of patient-provider communication that needed improvement. We learned from Phillipa patient who seroadapts when he has sex with
men outside of his primary relationship and does not have penetrative sex with his
primary romantic partner who is HIV-negativethat even with the tools to facilitate
a tailored discussion about HIV prevention, his physician remained uncomfortable
and made the assumption that Philip used condoms.

HIV PREVENTION INTERVENTIONS 305

So, I think a clinician hasI mean theyre being called to be comfortable, to become
comfortable with things that are very uncomfortable issues. And you know, I like my
physician a lot, or I would be going to somebody else. Andand yet I felt like he was
real uncomfortable with it. Weve had very little, if any [conversations about sex with
clinic staff]and I dont know if thats because they want to make an assumption that
I know betteror that theres certain things that I would never think of doing, so they
would make the assumption that I dont do certain things, when I might. (Philip)

DISCUSSION
Our implicit hypothesis was that patients would not necessarily perceive HIV prevention interventions conducted within the clinical encounter or in healthcare settings to be acceptable because of the individual-level and medicalized context of the
interaction. We based this hypothesis on (1) our training and orientation as anthropological researchers (first two authors), (2) on previous research on risk environments which established that many risk factors are exogenous to individuals (for
example, see Rhodes, 2002 or Sumartojo, 2000), and (3) on our previous research
indicating many PLWH did not perceive HIV prevention to be related to their medical care (Morin et al., 2004). Our most recent findings revealed that a few patients
experienced little, if any, benefit from participating. However, most overwhelmingly
expressed enthusiastic support of and/or gratitude for the PwP interventions.
Provider-delivered interventions appeared to create new opportunities for HIV
prevention-related discussions to occur between provider and patient. Patients
found the prevention message or dialogue to be salient because it was tailored to
their individual situations. Not all providers achieved this level of satisfaction with
patients. Some patients did not want to discuss prevention and others never had
the opportunity to engage in the conversation. However, when patients willingly
supplied honest information about risk taking and when providers had ample information about a patients risk-taking situation, they could have a conversation that
was mutually satisfying. In the absence of adequate patient information related to
HIV prevention, the provider could do little more than provide a generic prevention
message. Our findings indicate that some patients are willing to actively engage in
awkward conversations about sex and prevention, rather than passively receive
generic prevention messages.
Specialist-delivered interventions, specifically the group-level interventions,
provided opportunities to integrate participants into social networks, which in turn
provided social support and a reduction in social isolation. The individual-level
specialist-delivered interventions were flexible and exceedingly patient-centered.
With input and guidance from the specialist, participants explored HIV preventionrelated topics of their own choosing, thereby personalizing the intervention to meet
their needs in ways that neither the group-level modality nor the provider-delivered
intervention was able to achieve.
Our findings illustrate the importance of tracking the benefits and protective
features of the interventions from the perspective of the individuals enrolled in these
interventions. We want to emphasize this point particularly in light of the results of
the corresponding quantitative data set. Those results found the provider-delivered
interventions to be more robust than the specialist-delivered interventions on this
particular and important measure (Myers et al., 2010). Indeed, the qualitative findings support the idea that the providers were effective in opening up new areas of

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prevention discussions with patients in a meaningful way; yet, this appeared to most
frequently occur when providers had access to a tool to facilitate these discussions.
On the other hand, for patients enrolled in the specialist-delivered interventions, we documented the powerful stories of transformation and overall improved
well-being. These types of transformations may have been possible because of the
duration associated with these interventions. Specialists spent more time with patients to build rapport and to engage in lengthier, more in-depth discussions about
HIV prevention and all the types of topics that may intersect with prevention. Medical providers simply cannot afford to spend the time engaged in these kinds of
discussions. Medical providers may have only 23 minutes to devote to discussing
HIV prevention, and within in those few precious minutes, they are also carefully
managing their relationship with the patient to ensure that they do not risk potentially offending him or her or enter into a conversation that might derail their tightly
prescribed clinic schedule.
We also discovered numerous benefits for patients who identified as at low or
no risk of HIV transmission, addressing an important underlying issue about PwP
services: whether services should be targeted only to those patients deemed at risk at
the time of the assessment. An important finding related to this subset of low or no
risk patients was their receptivity to HIV prevention interventions. Because risk is
not static and changes over time and place, and because it is dependent on the nature
of the sexual or drug-using partnership and the setting of the sexual and/or drug
use, we argue that it makes sense to offer PwP to all patients, in order to encourage
continuation of no or low risk and to forestall any future risk. Further, we noted
psychological benefits associated with the intervention that may lead to a patients
improved self-efficacy or belief in his/her ability to achieve goals, including the possibility of dating, being sexual, and disclosure of HIV statusand, in general, working through the latent emotions associated with living with a disease that while now
considered chronic remains associated with shame and stigma. For the low/no risk
patients, increased self-efficacy is a powerful intervention outcome, since we know
this reduces vulnerability and strengthens resiliency (Bandura, 2001).
In our study, we found that HIV prevention counseling benefits patients regardless of risk status. Patients reported feeling fulfilled by communicating with a
provider who was objective, yet empathic and non-judgmental about sex. Future
integration of PwP requires support from management to attend trainings and, in
the case of provider-delivered interventions, tools to effectively address PwP during
routine clinical encounters. In the absence of tools, providers currently working with
PLWH can benefit from knowing that patients are willing to talk about sensitive topics if the topics are introduced with care and handled in a supportive fashion.
There were several limitations to our study. We did not interview individuals
either enrolled in the standard condition or those not enrolled at all in the interventions. It is possible that HIV prevention counseling is not acceptable to these patients
and that our data therefore overestimate the meaning of conducting PwP in clinical settings. Further, because of budget limitations, we designed our sample size in
order to conduct across-site, rather than within-site analyses. In future studies on
this topic, a stronger research design would include a sample size that could achieve
saturation within a particular clinical setting as well as inclusion of participant observation of prevention discussions.

HIV PREVENTION INTERVENTIONS 307

CONCLUSION
We studied whether patients valued clinic-based PwP interventions. Clinical environments condition patients and providers to focus on biology and that which can be
measuredfor example, viral load, CD4and implicitly discourage patients from
talking about their illness experience, which is expansive and dramatic particularly
when it comes to HIV disease. While patients overwhelmingly characterized their
relationships to their healthcare providers as fulfilling and warm (patients clearly
felt respected and well cared for), clinical encounters more typically focus on disease. The added value of these interventions elicited discussions that were inherently
meaningful to patients since they validated their day-to-day struggles and focused
on the contextual aspects of their lives, particularly the specialist-delivered interventions. Our participant James summed it well: Im glad that the people thats doing
this study are so interested in the person. In an era of HIV as a chronic disease or
illness, it may be a particularly poignant and appropriate time to integrate prevention programs that address the biological alongside the social and emotional consequences of living with HIV.

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