Many HIV-positive people not receiving recommended prevention counselling as part of their routine care

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Approximately half of HIV-positive people in the United States are not receiving prevention counselling as part of their routine care, results of a study published in the online edition of AIDS show.

“We found that less than half our clinic-based sample reported receiving individual-level HIV/STD prevention counseling from healthcare providers,” comment the authors. “Exposure to individual-level prevention counseling from prevention program workers and to small group interventions was even lower.” The investigators believe their findings highlight “missed prevention opportunities”.

More than 1.1 million people are living with HIV in the US. Guidelines recommend that HIV/sexual health risk reduction counselling should be incorporated into routine HIV care. However, little is known about the proportion of patients in care who receive such counselling.



Studies aim to give information that will be applicable to a large group of people (e.g. adults with diagnosed HIV in the UK). Because it is impractical to conduct a study with such a large group, only a sub-group (a sample) takes part in a study. This isn’t a problem as long as the characteristics of the sample are similar to those of the wider group (e.g. in terms of age, gender, CD4 count and years since diagnosis).

risky behaviour

In HIV, refers to any behaviour or action that increases an individual’s probability of acquiring or transmitting HIV, such as having unprotected sex, having multiple partners or sharing drug injection equipment.

sexually transmitted diseases (STDs)

Although HIV can be sexually transmitted, the term is most often used to refer to chlamydia, gonorrhoea, syphilis, herpes, scabies, trichomonas vaginalis, etc.

Researchers from the Medical Monitoring Project therefore used face-to-face interviews and medical records to establish the percentage of people receiving care who received three types of HIV/sexual health prevention intervention in 2009. The interventions were: counselling provided by healthcare workers; individual-level counselling provided by HIV prevention workers; participation in a small group HIV/sexual health risk-reduction intervention. The investigators also explored the factors associated with participation in such interventions.

A total of 4217 people from across the US participated in the study. Two-thirds were aged between 35 and 54 years, 71% were men and 65% belonged to racial and ethnic minorities. The majority – 65% – were subsisting on an annual income below $20,000. Thirteen per cent reported unprotected sex with a partner who was HIV negative or of unknown HIV status. A similar proportion reported diagnosis with a sexually transmitted infection (STI) in the previous twelve months. Use of stimulant drugs was reported by 11% of participants.

A one-to-one conversation in the past year with a healthcare worker about HIV/STI prevention was reported by 44% of participants. Just under a third of participants (30%) reported a conversation with a prevention programme worker and 16% told the investigators they had participated in a small group intervention within the previous twelve months.

Overall, 52% of participants reported participating in any one of the three interventions.

Among participants who reported unprotected sex in the past year that potentially involved a risk of HIV transmission, only 61% received a risk-reduction intervention. A similar percentage (63%) of participants diagnosed with a STI had one-to-one or group counselling.

Time pressures, lack of skill and embarrassment are offered by the investigators as possible explanations for failure to provide the risk-reduction counselling recommended in guidelines.

Low income, minority ethnic/racial origin and reporting risky sex were all consistently associated with receiving risk-reduction counselling.

In the investigators’ initial analysis, men who have sex with men (MSM) were shown to be significantly less likely than other groups to have received a HIV/sexual health risk-reduction intervention. However, this was no longer the case when the authors controlled for income and race. “It is possible that white and wealthier MSM may not be identified by program workers as being in need of prevention counseling,” suggest the investigators. “They may also be more likely than other MSM to receive care at facilities where those interventions may not be readily available (e.g., private practice).”

The authors conclude: “Levels of intervention exposure, particularly for individual-level prevention-level counseling delivered by healthcare providers, are low, given the fact that all of the participants in the sample are clinic patients, and, thus, presumably should have an opportunity to receive provider counseling.” They recommend that patients with high-risk behaviour should be “prioritized for receipt of interventions with a goal to reach as close to 100% as possible”.


Mizuno Y et al. Receipt of HIV/sexually transmitted disease prevention counseling by HIV-infected adults receiving medical care in the United States, Medical Monitoring Project, 2009. AIDS, 27, online edition, doi: 10.1097/QAD.000000000000057, 2013.