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Human immunodeficiency virus (HIV) is a retrovirus that attacks and destroys the immune systems helper T cells, placing a person at risk for further infection and disease. Spread by bodily fluids through sexual contact, coming in contact with infected blood, and with the use of infected drug needles or equipment, HIV is becoming more and more prevalent throughout the United States (US). According to the CDC, 1.1 million people in the US are living with HIV (Cotler, Yingling, & Broholm, 2018, p. 376). In the southern states alone, HIV diseases, illnesses, and death are higher when compared to any other region in the US (Rice et al., 2019, p. 2966).
Today, Atlanta, Georgia has a large population of lesbian, gay, bisexual, and transgender (LGBTQ). Men having sex with men (MSM), increased number of sexual partners without the use of condoms, and anal sex places these populations, as well as others, at high risk for HIV infections. The Georgia Department of Public Health noted, 2,698 persons in Georgia were diagnosed with HIV in 2017, for a rate of 31.2 per 100,000 people in ages 13 and older, ranking the city of Atlanta third on the list of metropolitan cities in the US with the highest prevalence of HIV (2017, p. 1). Understanding this, healthcare providers today need to be the front line for helping patients prevent HIV infections through education, STD testing, and using pre-exposure prophylaxis (PrEP) medications in order to stop the spread of HIV. Using PrEP medications, such as Truvada or Descovy, for patients at high risk for HIV can reduce infection risk by 92% (Cotler, Yingling, & Broholm, 2018, p. 376). Healthcare providers, including nurse practitioners, play an important role in helping protect patients at risk for HIV by integrating education on HIV infections and discussing different HIV prevention methods with high-risk populations into daily practice. The purpose of this paper is to discuss the health promotion project completed on high-risk HIV patients in Atlanta, Georgia needing education on HIV and HIV prevention methods.
Learning Needs Assessment
Primary care offices in Atlanta, Georgia often see large volumes of gay, lesbian, bisexual, and transgender patients. The Piedmont Physicians Clinic in Atlantic Station, sees on average five to ten patients each day coming in requesting HIV testing, consults for HIV PrEP medications, or medication checks and refills using HIV PrEP medications. The practice includes three physicians and one physicians assistant and sees roughly 300 adult and geriatric patients a week made up of various demographics and ages. Due to the geographic area in which the practice is located, patients are from all economic levels, including middle and upper-class adult and geriatric populations, from the Atlanta area. Roughly half of the patients have private health insurance, while the other half of patients are on state and/or federally funded public health insurance.
After speaking with the physicians assistant (PA), the main opportunity for improvement of the educational gap was to further educate patients on HIV infections, how HIV is contracted, and how to prevent HIV infections with the use of HIV PrEP medications in high-risk patient populations. Many patients come in repeatedly to the clinic requesting sexually transmitted infection (STI) testing after practicing risky sexual behaviors with the fear of contracting STIs and HIV. Interventions, such as handouts, could provide these patient populations with HIV prevention education in hopes of reducing these risky behaviors, thus reducing the chances of becoming infected with HIV. The Georgia Department of Public Health found, 1,715 HIV diagnoses (82%) were attributed to male to male (MSM) sexual contact; 94% of transgender cases were attributed to sexual contact, and 1,908 new diagnoses of HIV infections (71%) were among Blacks, and the rate of diagnosis was highest among Blacks (2017, p. 2). With the increase in HIV infections seen in MSM patients, LGBTQ populations, and in the Black or African American populations in Atlanta, the PA felt providing physical handouts at each patients visit on HIV education and helpful interventions, such as discussing PrEP medications, would better serve the patients in this Atlanta community.
Learning Objectives and Strategy
After the discussion with Piedmont Physicians PA regarding the learning needs of the high-risk patient population seen at the clinic, three learning objectives were formulated. The first objective, understanding of what an HIV infection is, discussed the virus itself and what the virus does to a persons body once infected. HIV is a virus that once contracted the person will have for life, as the virus cannot be cured. The Centers for Disease Control and Prevention writes that , HIV reduces the number of CD4 cells (T cells) in the body, making the person more likely to get other infections or infection-related cancers and can destroy so many of these cells that the body cant fight off infections and disease (2019). Though HIV cannot be cured, today there are medications known as antiretroviral therapy, that can minimize the viral load to make it undetectable if medications are taken diligently as prescribed. The second objective, knowledge of the transmission of HIV, discussed how the virus is transmitted and who is at risk. HIV is transmitted through blood, bodily fluids, sex (oral, anal, or vaginal), and needle or syringe usage. People participating in unprotected sex, coming into contact with semen, blood, pre seminal fluid, breastmilk, rectal or vaginal fluids can contract HIV. The CDC notes that, For the HIV-negative partner, receptive anal sex (bottoming) is the highest-risk sexual behavior and with drug use, HIV can live in a used needle up to 42 days (2019). The third objective, understanding of HIV prevention methods, included information on safe-sex practices and HIV PrEP medications. Prevention of HIV starts with safe sex practices, such as condom use, reducing the number of sexual partners, choosing less risky sexual activities such as oral sex, or abstinence. Cotler, Yingling, & Broholm (2018) write, Newer strategies, such as HIV treatment and viral load suppression to reduce transmission and using PrEP for those at high risk of HIV acquisition are found to be the most effective in preventing new HIV infections (p. 377). PrEP medications like Truvada or Descovy have overall good patient tolerance, minimal adverse effects, acquired no drug resistance, and reduced transmission rates by 67-75% (Feinberg, 2012, p. 521). Barriers to prescribing PrEP medications are minimal, including cost, patient non-adherence to treatment, and possible drug toxicity, yet can be managed using drug coupons for patients, medication re-check visits which include lab work to check for toxicity every three to six months.
In order for patients to become educated on the three objectives, three handouts (see appendix A, B and C) created by the CDC were given to each patient upon check-in at the beginning of the visit. Due to the fast-paced nature of the clinic, the handouts presented the most amount of education to the patient, providing education on HIV prior to meeting with the provider. These handouts allowed the patients to take home the information, allowed the ability to be referenced at any time or even to be passed along to others. When used in practice, these handouts prompted multiple HIV prevention discussion topics about PrEP medications during the visit. At the end of the appointment, the patients were provided with a survey to assess the benefit of using handouts for HIV education.
Project Design, Development, and Implementation
This project took place at Piedmont Physicians clinic, located in Atlanta, GA on November 7-8, 2019. Piedmont Physicians in Atlantic Station is owned and operated by Piedmont Hospital in Atlanta, Georgia. Each of the four providers were important to the projects success through the two-way communication, recruitment of the patients, and always willing to help implement the project in any way possible. All providers expressed enthusiasm for the project and agreed there was a need for change in order to help improve HIV education and prevention.
The health promotion project was designed and developed with the help of the PA at Piedmont Physicians. Designed for patients to receive educational handouts, the project was aimed to be successful in furthering the knowledge of HIV infections, transmission, and prevention. Each of the handouts and the survey were used based on the clinics fast-paced environment as the handouts are given to the patients prior to each appointment and survey takes less than five minutes to complete. The project implementor will be able to assess the knowledge the patients have on HIV by using the survey questions and providing the patients with more education. This helps to further protect the patients by providing specific education with the hopes of helping prevent new HIV infections seen in the clinic.
Learning Theorist used in Project Design
Dorthea Orem, a nursing theorist, created the Self-Care theory of nursing. This theory, focuses on assisting patients who require the help of a provider with guidance, support, with an environment that promotes personal development, and teaches patients how to cope with obstacles they may potentially face in the future (Norwich University, 2017). Patients at high-risk for developing HIV often require extensive education in order to prevent new infections. This self-care theory helps patients initiate better and safer health strategies, provides guidance on various lifestyles, and teaches patients to care for the well-being in order to prevent HIV infections, increased health care appointments, and hospitalizations. Orem created a theory that helped providers give the patients the utmost care, while also teaching patients about self-care. This health promotion project aims at educating patients on HIV prevention, which focuses on not only provider prevention, such as PrEP medications, but also on patient prevention, such as safe sex practice.
Delivery
The Piedmont Physicians Atlantic Station clinic sees roughly 300 adult and geriatric patients a week, including roughly 50 of those 300 patients coming in for STI or HIV related appointments. The participants for this project were adult patients, male and female, ages 18 to 40 who are patients at Piedmont Physicians Atlantic Station coming in for STI or HIV related appointments. The inclusion criteria included being adult patients at high-risk for becoming infected with HIV through unsafe sex or having same sex intercourse and patients wanting information and counseling on starting PrEP medications. Exclusion criteria would include geriatric patients, patients not eligible to be prescribed HIV PrEP medications, and adults with allergies to the PrEP medications used. Of the 10 adults who participated, eight were male, and two were female, with the mean age being 32 years old. Five of the patients were Black or African American and five were Caucasian.
Patients were given a brief history and description of the promotion project and asked to sign a consent form for participation. After signing consent, three CDC handouts (see appendix A, B, and C) on HIV basics, transmission, and prevention were provided to the patients upon check in at the front desk for an STI or HIV related appointment. The wait time after check-in is roughly 5-10 minutes, giving the patients time to read through each of the three handouts. Patients then completed each appointment with the scheduled provider per usual protocol. Prior to leaving the appointment, the patient finished with a survey to assess the benefit of the educational handouts.
Data was collected through 10 patient surveys on how well the patient felt educated on the knowledge of HIV, transmission of HIV, and prevention of HIV. Each of the surveys included six questions using the Likert scale and provided ordinal data to analyze the benefit of using the handouts to provide HIV education to high-risk patients.
Evaluation
The results of the survey concluded the HIV educational handouts were helpful in teaching high-risk patients about HIV, transmission, and prevention methods. On question 1, the participants concluded that 40% of patients felt educated on the understanding of HIV infections, while 60% felt uneducated on the topic. Question 2 found that participants found themselves 70% educated on how HIV is transmitted, while 30% neither felt educated or uneducated on the topic. Question 3 found that the participants found themselves 40% educated on the prevention of HIV, while 20% felt neither educated nor uneducated, 20% felt uneducated, and 20% felt very uneducated on the topic.
After receiving the handouts, patients overall concluded each person learned something new with each specific handout. Question 4 concluded participants felt 70% educated and 30% felt neither educated nor uneducated on HIV infections. Question 5 found participants were 80% were educated on HIV transmission while 20% of participants felt neither educated or uneducated on the topic. Question 6 concluded patients felt 90% educated on HIV prevention methods and 10% felt very educated on the topic. The increase in education with the handouts proved the rise in HIV awareness, transmission, and prevention methods with 10 participants was successful and necessary to preventing new HIV infections. Through this health promotion project, health care providers can use easy interventions, such as these handouts, to help promote healthier, safer lifestyles in patients who are at high-risk for HIV infections.
Conclusion
As it is evident the need for HIV prevention and education is expanding, the recognition of the aforementioned points is paramount; namely, prevention of HIV through the use of safe sex practices, as well as the new methods of using PrEP medications in high-risk patients. The use of PrEP medications is a fairly new prevention strategy since the FDA approved Truvada in July 2012 and now there are different options are available for HIV prevention as well as education throughout the healthcare system. Additionally, the use of HIV handouts can provide further education for patients and lead to more patient/provider discussions on prevention methods, ultimately decreasing the amount of newly diagnosed HIV infections.
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