Selected to address the challenge is the Center for Infectious Diseases at the University of North Carolina at Chapel Hill School of Medicine.
The center has received a $1.8 million grant from the federal Centers for Disease Control and Prevention and the Health Resources and Services Administration, a component of the U.S. Department of Health and Human Services (DHHS), and recently has established a demonstration project in UNC Hospitals' Infectious Diseases Outpatient Clinic.
The clinic treats about 1,500 HIV-infected North Carolinians annually. If successful, the project may help shape the approach to HIV outpatient therapy nationally, researchers said.
"Over the last decade or so, and despite extensive preventive efforts targeted at people not infected with HIV, 40,000 new HIV cases are identified in the U.S. annually, a number that has remained somewhat consistent," said Dr. Evelyn Byrd Quinlivan, assistant professor of medicine at UNC and medical director of the infectious diseases clinic.
"This number seems to represent a threshold beyond which no one has been able to move."
In 1999, the CDC requested that the Institute of Medicine, a component of the National Academy of Sciences, form the Committee on HIV Prevention Strategies in the United States.
Among committee members was Dr. Myron S. Cohen, professor of medicine, chief of infectious diseases and director of the Center for Infectious Diseases at UNC. In 2001, Cohen and his colleagues published their recommendations in a book, "No Time to Lose: Getting More from HIV Prevention."
The book's underlying premise is that "each new infection begins with someone who is already infected." Thus, prevention can be enhanced by also targeting the infected individual.
"This is a total paradigm shift in thinking about prevention," Quinlivan said. "It recognizes that transmission occurs between two people, that current prevention efforts have addressed only half of that interaction and that we ought to think of new ways to resolve this problem."
In its report, the committee recommended that prevention services for HIV-infected people become a standard of care in all clinical settings, such as primary care centers, sexually transmitted diseases clinics, drug treatment facilities and mental health centers. The report called for research proposals to develop effective "secondary prevention" programs that would integrate prevention activities into treatment of HIV-infected individuals. UNC's proposals were accepted for funding.
Counseling and education efforts are at the heart of these prevention activities. Caregivers in the UNC clinic, including physicians and nurse-practitioners, will receive training aimed at enhancing their counseling and behavioral intervention skills.
"We will all undergo a refresher course on how to persuade, coax, cajole - whatever it takes - to help a patient make a behavior change," Quinlivan said.
For more complex situations - individuals who don't understand how to use condoms or who are in relationships where they don't feel safe about disclosing their HIV status - a counselor in the clinic will be available to intervene, she added.
These efforts will be combined with medical therapy aimed at reducing HIV levels in the blood, thus lowering the amount of virus that is shed. Experts predict that medical therapy aimed at reducing HIV levels, combined with counseling and education, will be more effective than either effort alone.
In terms of outcome specifics, the program will assess the degree to which self-reports of HIV risk behaviors, sexually transmitted infections and HIV status disclosure outcomes are improved by integrating prevention counseling services into primary care.
Three factors make for good timing to begin this program, Quinlivan said. Now in a larger space with more examination rooms, the clinic has three rooms dedicated for interviewing or counseling. In addition, via a program funded by the U.S. DHHS's Substance Abuse and Mental Health Services Administration, a study is under way to determine if on-site addiction counseling and treatment have an impact on HIV interventions.
"Treating and getting people to make behavior change is difficult if you're cross-refer," Quinlivan said.
Finally, the clinic director believes the new program will improve coordination with the state's partner notification activities. "We really believe we're in a unique position to get a program like this going," she said.
By Leslie H. Lang
UNC School of Medicine
Note: Contact Quinlivan at ebq@med.unc.edu or 919-966-2536.
School of Medicine contact: Les Lang, 919-843-9687 or llang@med.unc.edu