EPIDEMIOLOGY AND SOCIAL SCIENCE Missed Opportunities: Prevention With HIV-Infected Patients in Clinical Care Settings Stephen F. Morin, PhD, Kimberly A. Koester, MA, Wayne T. Steward, PhD, MPH, Andre Maiorana, MPH, Marisa McLaughlin, BA, Janet J. Myers, PhD, MPH, Karen Vernon, BA, and Margaret A. Chesney, PhD Objective: To assess current practices related to prevention with HIV-positive patients in Ryan White–funded primary care settings and the barriers to providing such services. Method: Exit surveys about HIV prevention services were con- ducted with 618 HIV-infected patients at 16 primary HIV care clinics receiving Ryan White CARE Act funding. To place the exit survey findings in context, qualitative in-depth interviews were conducted with 16 clinic administrators, 32 primary care providers, 32 support service providers, and 64 patients. Results: One quarter of patients reported having had a general dis- cussion of “safer sex and ways to prevent transmission to others” dur- ing that day’s primary care visit. However, only 6% reported discuss- ing specific sexual activities. HIV prevention counseling was less common than counseling for adherence to antiretroviral therapy, emotional issues, and diet and nutrition (P < 0.001). Patients in clinics with established procedures for HIV prevention counseling were sig- nificantly more likely to report receiving such services (odds ratio = 2.17). Qualitative interviews identified barriers to providing preven- tion services as lack of time, training, funding for staffing, and pro- viders’ understanding of their roles and responsibility. Conclusions: HIV prevention counseling is not routine in most clin- ics, and the low frequency of such services represents missed oppor- tunities for HIV prevention. Key Words: prevention with positives, prevention in primary care settings (J Acquir Immune Defic Syndr 2004;36:960–966) U ntil recently, prevention planning has shied away from interventions directed toward people living with HIV be- cause of a justifiable concern about further stigmatizing them. 1 However, considering that every new infection starts with someone who is already infected, failing to include HIV- infected people in prevention efforts is a missed opportunity to avert new infections. A report from the Institute of Medicine recommended that HIV prevention interventions (prevention with positives) become a standard of care in clinical care settings that serve HIV-infected patients. 2 The US National HIV Prevention Plan, developed by the Centers for Disease Control and Pre- vention (CDC), lists prevention with HIV-infected individuals as the top priority, 3 and the agency has developed HIV preven- tion case management guidelines to accomplish this goal. 4 Most recently, the CDC announced a new initiative that fo- cuses on prevention with positives. 5 Among its recommenda- tions is the implementation of biannual risk screening and pre- vention counseling with HIV-infected patients in clinical care settings. 6 In part, this new emphasis is needed because people with HIV are living longer and more sexually active lives. In addition, unprotected sex among some populations is increas- ing, 7–17 and high-risk sexual behavior is common among HIV- infected people followed in primary medical care. 18 An estimated 350,000–528,000 individuals with HIV re- ceive regular primary care. 19 Thus clinical care settings are in a strategic position to improve ties between prevention and medical care. 20 A recent study in six California clinics found that 29% of HIV-infected patients reported that no clinic pro- vider had ever talked with them about safer sex. 21 Qualitative research with primary care providers reported that some con- duct risk assessment and counseling only during initial visits, when concerns about HIV risk are cued by changing circum- stances in a patient’s life (eg, new relationship) or by a medical condition (eg, sexually transmitted disease), or in response to a patient’s question. 22 Other providers conduct prevention as- sessment and counseling regularly and view themselves as ac- tively helping patients to reduce their risk of transmission. Re- search with HIV-infected patients indicates that a collabora- Received for publication August 22, 2003; accepted November 26, 2003. From the University of California, San Francisco. This project was funded as a Special Project of National Significance (6H4AHA00016-03-05) by the Health Resources and Services Adminis- tration (HRSA). The conclusions reached in this paper are those of the authors, not necessarily those of the funding agency. Wayne T. Steward was supported by a training grant from the National Institute of Mental Health (5T32MH019105). Reprints: Stephen F. Morin, AIDS Policy Research Center, University of Cali- fornia, San Francisco, 74 New Montgomery St, Suite 600, San Francisco, CA 94105 (e-mail: smorin@psg.ucsf.edu). Copyright © 2004 by Lippincott Williams & Wilkins 960 J Acquir Immune Defic Syndr • Volume 36, Number 4, August 1 2004