HIV Prevention through Case Management for HIV-Infected Persons -- Selected Sites, United States, 1989-1992

Transmission of human immunodeficiency virus (HIV) infection can be prevented through HIV-prevention case management -- a one-on-one client service specifically designed to assist HIV-infected persons in receiving services that will prevent or reduce behaviors that result in further spread of the virus, delay the onset of symptomatic HIV disease, and improve the client's health status (1). This approach enables HIV-infected persons to enter a stable, ongoing medical-care system and supports prevention goals by providing multiple opportunities to provide risk-reduction information and to reinforce safer behaviors. This report summarizes an assessment of HIV-prevention case-management systems in three community health centers (CHCs) during 1989-1992 and provides information regarding self-reported changes in sexual risk behaviors of HIV-seropositive clients.

From October 1, 1989, through September 30, 1992, CDC and the Health Resources and Services Administration funded three CHCs to provide integrated HIV-prevention and early intervention services within existing primary health-care programs. Sites were selected in Miami; New York City; and Newark, New Jersey, because those cities had high annual acquired immunodeficiency syndrome (AIDS) incidence rates per 100,000 population from August 1988 through July 1989 (45.0, 63.0, and 52.3, respectively) (2) and because CHCs in those sites were providing health services to large numbers of racial/ethnic minorities, a population disproportionately affected by the HIV epidemic (3).

The risk-reduction programs of each of the three CHCs comprised the same standard components: HIV counseling and testing routinely offered to all persons and case-management services offered to HIV-seropositive persons. A follow-up visit (time 1) was scheduled for persons after they received HIV-test results and posttest counseling. During this visit, the case manager administered a standardized questionnaire about drug and alcohol use and sexual behaviors, provided additional risk-reduction counseling, and developed a care plan for necessary medical and psychosocial services. Four to 6 months after the first follow-up visit, clients were scheduled to meet with the case manager (time 2), and the behavioral questionnaire was administered again.

Five questions asked of clients at times 1 and 2 were analyzed: 1) "Have you had sex with anyone in the past 30 days?"; 2) "How many persons have you had sex with in the last 30 days?"; 3) "How many of these were new sexual partners (i.e., persons you have not had sex with before)?"; 4) "Did you have a regular (steady) partner during the past 30 days?"; and 5) "During the past 30 days, did you use condoms with your regular (steady) partner?"

From October 1989 through June 1992, 755 HIV-seropositive clients received HIV-prevention case-management services in the three CHCs. However, because of difficulties in implementing a uniform data collection protocol, standardized data for study evaluation purposes are available only for the latter part of the project: December 1991-September 1992. Sixty-one clients completed the same questionnaire at both time 1 and time 2 (29 clients at the CHC in Miami; 20, in New York City; 12, in Newark). The median age of study group clients was 35 years. Study group clients were similar to other HIV-seropositive clients in age and sex, although a greater proportion of the study group clients were non-Hispanic blacks.

The median interval between posttest counseling and time 1 was 2.4 months (interquartile range: 0.3-7.6 months), reflecting the need for case managers to delay administration of the questionnaire because of personal or psychological circumstances for some clients. The median interval from time 1 to time 2 was 6.3 months (interquartile range: 5.5-7.1 months).

Of the 55 persons who responded to the question about whether they had had sex during the previous 30 days, 19 (35%) at time 1 stated that they had not, compared with 29 (53%) at time 2 (p<0.05, McNemar test matching client's responses at time 1 and time 2) (Figure 1). Of the 61 persons who answered the question regarding number of sex partners, 24 (39%) reported at time 1 that they had had no sex partners during the previous 30 days, compared with 35 (57%) respondents at time 2 (p<0.05, McNemar test matching client's responses at time 1 and time 2). From time 1 to time 2, client responses to questions about new sex partners, regular partners, and condom use with regular partners were not significantly different (Figure 1, page 455).

Reported by: Economic Opportunity Health Center, Miami. Morris Heights Health Center, Bronx, New York. Newark Community Health Center, New Jersey. Div of Special Populations, Bur of Primary Health Care, Health Resources and Svcs Administration. Office of the Deputy Director (HIV), National Center for Prevention Svcs, CDC.

Editorial Note

Editorial Note: The findings in this report indicate that a sample of HIV-infected persons who received ongoing HIV-prevention case management adopted and sustained selected safer sexual practices during the 6-month follow-up period. Even though this study did not employ a comparison group of HIV-infected persons who had not received HIV-prevention case management, changes to safer sexual behaviors have been observed in previous studies, including those of cohorts of HIV-seropositive men who have sex with men (4), injecting-drug users (5), and persons with hemophilia (6), suggesting that ongoing receipt of client services may be associated with reductions in sexual risk behaviors.

The findings in this report are subject to at least three limitations. First, because the sample size in this study was small, the power to detect statistically significant changes in behavior was limited. Second, because degree of illness (e.g., symptoms or CD4+ T-cell levels) was not controlled for in the study, reports of decreased sexual activity may have been related to the progression of HIV disease or associated illnesses, or to psychosocial effects. Third, no behavioral data were collected during the interval from receipt of HIV test results with posttest counseling until time 1, when changes in risky behaviors may have occurred; because most studies of persons before and after learning HIV-positive results indicate a decline in high-risk behavior, the findings in this report likely underestimate the behavior changes.

Transmission of HIV can be interrupted by assisting persons with HIV infection in reducing their unsafe sexual and drug-use behaviors. HIV-prevention case management is an early intervention strategy to provide this assistance through counseling, education, psychosocial referrals, and behavioral skills training (7). Since 1992, HIV-prevention case management has been identified as a specific program priority for state and local health departments and community-based organizations (CBOs) receiving HIV-prevention funding from CDC (1). CDC directly funds 19 CBOs to provide HIV-prevention case management, and many health departments have implemented this HIV-prevention service.

References

1. CDC. Cooperative agreements for human immunodeficiency virus (HIV); prevention projects program announcement and availability of funds for fiscal year 1993. Federal Register 1992;57:40675-83.

2. CDC. HIV/AIDS surveillance report. Atlanta: US Department of Health and Human Services, Public Health Service, August 1989:6-7.

3. Selik RM, Castro KG, Pappaioanou M. Distribution of AIDS cases, by racial/ethnic group and exposure category -- United States, June 1, 1981-July 4, 1988. MMWR 1988;37(no. SS-3):1-10.

4. McCusker J, Stoddard AM, Mayer KH, Zapka J, Morrison C, Saltzman SP. Effects of HIV antibody test knowledge on subsequent sexual behaviors in a cohort of homosexually active men. Am J Public Health 1988;78:462-7.

5. Van den Hoek A, van Haastrecht HJ, Coutinho RA. Heterosexual behaviour of intravenous drug users in Amsterdam: implications for the AIDS epidemic. AIDS 1990;4:449-53.

6. Dublin S, Rosenberg PS, Goedert JJ. Patterns and predictors of high-risk sexual behavior in female partners of HIV-infected men with hemophilia. AIDS 1992;6:475-82.

7. Francis DP, Anderson RE, Gorman ME, et al. Targeting AIDS prevention and treatment toward HIV-1-infected persons: the concept of early intervention. JAMA 1989;262:2572-6.

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