Author(s): Patrizia Meringolo, & Moira Chiodini

Abstract:

PRIMARY AND SECONDARY HIV PREVENTION: THE ROLE OF HEALTH PROFESSIONALS IN COMMUNITY BASED PROGRAMS.
Patrizia Meringolo, Moira Chiodini
Faculty of Psychology, University of Florence, Italy

The research is part of a project promoted by the Municipality of Florence in order to planning a program of HIV prevention and promoting the access to free HIV test. Theoretical approaches come from studies about health attitudes, healthy behavior and perceived control on wellbeing (Albarracin, Kumkale, &Johnson,2004; Davis, Hughes, Sloan, Tang, & McMaster, 2009; Fishbein,2008), different interventions in health promotion (Boone & Lefkowitz, 2004; Fortenberry, Tu, Harezlak, Katz & Orr, 2002; Harper, Bangi, Contreras, Pedraza Tolliver & Vess, 2004), importance of professionals (Durantini, Albarracin, Mitchell, Earl, & Gillette, 2006; Fisher, Bryan, & Misovich, 2002), particularly general practitioners (Schreibman & Friedland, 2003). The purpose of the research is to identify useful indications for community based interventions addressed to adult people. Our aim is collecting information about professionals’ perception of citizens’ attitude and behavior in order to find strengths and weakness in health promotion activities carried out by public services. The qualitative study was aimed to investigate attitudes towards the primary and secondary prevention, and willingness and motivation to taking HIV test. Participants were physicians, psychologists and volunteers, involved in health services addressed both to the whole of population (e.g. professionals working in surgeries and in consulting rooms) and to HIV positive people. Instrument was a semi-structured interview for exploring professionals’ perception of patients’ attitudes towards this disease, risky behaviors, preventive behaviors and evaluation about health services practices. Findings show a positive evaluation of available health services and their cooperation in facing the problem, despite difficulties in involving all the professionals. Prevention follows well-established paths but is not able to reach all citizens. There is a need of a wider information, and prevention involving people as individuals and groups. General practitioners may have a critical and important role, because of their trust relationship with their patients, and can be able to disseminate preventive practices.

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Article:

Introduction
Actually there isn't a comprehensive, effective, and efficient strategy for preventing the spread of the human immunodeficiency virus (HIV). The advances in treating AIDS have showed the necessity to improve the prevention system both primary and secondary.
Improved treatment is critically important, and efforts should be continued to extend such advances. With better treatment, more people are living with HIV/AIDS than ever before. However, this creates more opportunities for transmitting the virus and thus a greater need for prevention.

Despite the successes in HIV prevention over the past decade, there are additional prevention challenges. The populations that need to be reached by prevention interventions have changed considerably. An increasing proportion of new AIDS cases are now being linked to heterosexual exposure. These new at-risk populations (adult or young-adult, heterosexual) are not being reached for prevention as effectively, or on as large a scale, as at-risk populations have been in the past, and prevention programs tailored to specific social contexts of an earlier period in the epidemic are not proving as effective during the current period.

The majority of HIV-infected persons who know their status are in the treatment system and may receive a treatment and information about prevention. However, it is estimated that up to one-third of infected persons do not know their HIV status. Efforts should be made to increase the number of infected individuals who are aware of their status. In addition, individuals at risk for HIV infection often come in contact with the health care system for services at a variety of different entry points, and each of these clinical settings could provides opportunities for delivering HIV prevention services. (Del Rio, 2003)
The majority of HIV prevention efforts have focused primarily on preventing HIV acquisition by uninfected persons. However, given that every new infection begins with someone who already is infected, omitting persons with HIV from prevention efforts represents an important missed opportunity for averting new infections. This failure is made even more glaring by the fact that advances in antiretroviral therapy have considerably increased the number of people living with and receiving care for HIV/AIDS.

Several theoretical models highlight that adopting protective behaviors depends on information, social norms, attitudes about health / disease and the perception of control over their well-being. This relationship is influenced by other social variables such age, sex, ethnicity. (Albarracin, Kum Kale, & Johnson, 2004). Instead other studies have highlighted the low relationship between the level of information, awareness about risk, and adoption of preventive behaviors. (Davis, Hughes, Sloan, Tang , & McMaster, 2009).

The Theory of Reasoned Action  (Ajzen & Fishbein, 2005; Conner & Sparks, 2005; Sutton, 2006) is particularly useful in designing interventions for secondary prevention (Boone & Lefkowitz, 2004; Fortenberry, Tu, Harezlak, Katz, & Orr, 2002; Harper, Bangi, Contreras, Pedraza Tolliver & Vess, 2004).

Other studies underline the role of  positive attitudes and expectations, perceptions of control and correct information in implementing protective behaviors (Albarracin, McNatt, Klein, I, Mitchell, & Kum Kale, 2003).

Referring to the prevention programs, several studies emphasize the role of physicians in implementing HIV prevention actions, because they are the most trusted source of health information (Schreibman & Friedland, 2003).

Method
The data to which we refer coming from a research carried out within a Project founded by the Municipality of Florence, aimed to plan a system of prevention both primary and secondary in order to reach the new population at risk: adult and young adult heterosexual not reached by the traditional prevention campaigns.

Qualitative research, based on interviews,  was carried out in order to gather information  about professionals’ perception of citizens’ attitude and behavior in order to find strengths and weakness in health promotion activities carried out by public services.

Participants:
The participants interviewed as key informants were: physicians, psychologists and volunteers, involved in health services addressed both to the whole of population (i.e. working in surgeries and in consulting rooms) and to HIV positive people.

Instruments:
Schedules of the semi-structured interviews

Data analysis:
The interviews were recorded, transcribed and then underwent a computer-assisted content analysis (ATLAS.TI software).

Results of the qualitative research
The content analysis of the interviews show that patients present difficulties in talking about sensitive issues like risk behaviors particularly when these behaviors concern sexual intercourses or drug use.

Professionals refer how pepole seem have difficulty in protect themselves, and this perception is particularly high in young people and heterosexuals.

“I think that young people are now fascinated by latest advertising, also for health."
“Heterosexuals don't think of it...they have difficulties in perceiving the risk of HIV, they are hardly able to perceive themselves at risk of AIDS”.

Regarding the relationship between information and behavior professionals seem confirm the low relation between the two characteristics, referring an inconsistency between information and undertaken behaviors “After all, between knowledge and behavior there is a great difference”.

“It is impossible that someone doesn't know, e.g. the risk related to drive while intoxicated... So the question is: why there isn't risk perception?"

Professionals seem to have a clear idea about weakness of prevention and about what have to be done to increase the prevention efficacy.

The weakness of the primary prevention programs are:

1. Lack of information
2. Low attention in mass media
3. Lack of suitable prevention campaign both in educational Institutions and health services

In schools “We talk about migration, we talk about violence against women, we talk about substances, but information about STD or HIV is only a part, added to substance abuse”.

In health services “We should give some information... but we are unable… It is impossible with a lot of patients asking for medical examinations... we should give them... The family doctor, the general practitioner would be important. But I think that nobody do it.”

Regarding the attitudes towards secondary prevention the actions that can be implemented are the following:

1. Taking the test on medical advice “Sometimes they complaint when the doctor advises the test, anyway they take it”
2. "... We have to spend a short time for explaining that it’s a good thing to do...” Willingness to take the test for being reassured

“Patients take the test when they are sure they have done something wrong”
“… for being reassured. The fear of disease will come later... above all anxiety for being  infected…”

However some difficulties in implementing actions can be point out:

1. 1. Refusal as a defense against the fear of infection
   "... someone may suspect to be infected, knowing the situation of his/her partner... but  anyway doesn’t take the test...”
   “... They are afraid of discovering it, because it’s difficult to say it to their partner, it’s  a great obstacle... fear to be left…"
2. Low motivation
   “... they think there is no need, they think „I do so, I always did so, I am well and so I  don’t need the test...”

One of the most important risk, according to literature, is the perceived low threat by heterosexual individuals.

They have a less perceived harm and more familiar relationships with HIV positive individuals.

“We know that survival of HIV positive individuals is now extended... and so they may have, perhaps, a HIV positive friend from 15-20 years... I don’t mean that they have no fear or attach no importance to it, but surely their attention towards risk –unconsciously –is decreasing.”

Also new therapies are slowing down the disease course and is related to unsafe sexual behavior.

“In heterosexuals individuals, those with promiscuous sexual behaviors… there is a kind of illusion about possibility of „seeing‟ if someone is infected... ”

Adult people tend to think about “normal” relationships
“They don’t think that it is possible to be infected also by those who –hypothetically –never would be thought as HIV positive”

This opinion is based on social construction founded on the first kind of contagion
“For a long time HIV was a disease labeled as belonging to drug addicts and homosexuals”

Referring to the issues that must be improved in health services, professionals and volunteers highlights three different actions:

1. Protection of anonymity and privacy for those who make the test HIV
   “Those coming from a town go to another town, and so there ... Perhaps there is no hospital there? They all come here... And then, they have to go in their service, for a lot of thing to do... However they have reason, because if they are seen in a ward for infectious disease... someone could think that....”
2. Increasing local resources
   “It would be better a widespread intervention, offering counseling, without –I think –psychological terrorism ... in any case the general practitioner is the person asked for an advice for every think…”
3. Integration and coordination among services working on HIV

Discussion
Findings show a positive evaluation of health services and collaboration among them, despite difficulties in a full involvement of professionals. There are well-established paths for prevention, although unable to reach the whole of citizens. It would be important a wider dissemination of accurate information, both by mass media and targeted campaigns, and more interventions addressed to individuals and groups. General practitioners may have a basic role, because of their trust relationship with patients, so to spread good preventive practices.

HIV testing offers another option for the integration of prevention into the clinical care context. Testing plays multiple roles, including identifying people with HIV and those at risk of infection who can receive prevention services, identifying HIV-infected persons so they can receive more intensive clinical care services.

References
Albarracin D., KumkaleG.T., & Johnson B.T. (2004). Influences of social power and normative support on condom use decisions: a research synthesis. AIDS Care,16, 6: 700-723.

Boone T. L., & Lefkowitz E.S. (2004). Safer Sex and the Health Belief Model: Considering the Contributions of Peer Norms and Socialization Factors. Journal of Psychology and Human Sexuality, 16, 1: 51-68.

Davis C., Hughes L., Sloan M., Tang C., & McMaster S. (2009). HIV/AIDS Knowledge, Sexual Activity, and Safer Sex Practices Among Female Students in Hong Kong, Australia, and the United States. Journal of HIV/AIDS and Social Services, 8, 4: 414-429.

Del Rio C. (2003). New Challenges in HIV Care: Prevention Among HIV-Infected Patients. Topics in HIV Medicine, Vol. 11 Issue 4 July/August 2003: 140-145.

Durantini M.R., Albarracin D., Mitchell A.L., Earl A.N., & Gillette J.C. (2006). Conceptualizing the Influence of Social Agents of Behavior Change: A Meta-Analysis of the Effectiveness of HIV-Prevention Interventionists for Different Groups. Psychological Bulletin, 132, 2: 212–248.

Fishbein, M. (2008). A Reasoned Action Approach to Health promotion. Medical Decision Making, 28, 834-844.

Fisher J.D., Fisher W.A., Bryan A.D., & MisovichS.J. (2002). Information-Motivation-Behavioral Skills Model–Based HIV Risk Behavior Change Intervention for Inner-City High School Youth. Health Psychology, 21, 2: 177-186.

Fortenberry J., Tu W., HarezlakJ ., Katz B.P., & Orr D.P. (2002). Condom use as a function of time in new and established adolescent sexual relationship. American Journal of Public Health, 92: 211-213.

Harper G. W., Bangi A.K., Contreras R., Pedraza A., Tolliver, M., & Vess, L. (2004). Diverse phases of collaboration: Working together to improve community-based HIV interventions for adolescents. American Journal of Community Psychology,33, 3-4: 193-204.

Schreibman T. & Friedland G. (2003). Human Immunodeficiency Virus Infection Prevention: Strategies for Clinicians. Clinical Infectious Diseases, 36: 1171-6.
 

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Author(s)

Patrizia Meringolo, & Moira Chiodini

Patrizia Meringolo is full professor in Community Psychology at Faculty of Psychology University of Florence - Italy

Moira Chiodini is lecture in Psychology of social empowerment at Faculty of Psychology University of Florence - Italy

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