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HIV and Healthcare: The Positive Choice Project

Dental Healthcare:

HIV and Healthcare: The Positive Choice Project

We are pleased to report that “Positive Choice: Interactive Video Doctor” has been selected to be part of the Centers for Disease Control and Prevention’s (CDC) 2008 Compendium of Evidence-based HIV Prevention Interventions.

The 2008 Compendium is central to HIV prevention practice because it is a single source of interventions representing the strongest behavioral HIV interventions in the literature to date that have been rigorously evaluated and have demonstrated efficacy in reducing HIV or STD incidence or HIV-related risk behaviors or promoting safer behaviors.

study participant at video doctor
The video doctor program is installed on a laptop computer. Participants watch video clips, respond using a color-coded keyboard, and wear headphones for privacy.
Photo: Kristin Gerbert

The Positive Choice study is an innovative effort to address ongoing behavioral risks among HIV-positive patients in medical care without creating additional burdens for health care providers. Using our established Video Doctor model and a framework that emphasizes concern for the patient’s own health rather than transmission of HIV (see Reframing “Prevention with Positives”), we developed Positive Choice, a multimedia computer program, to support and simplify providers’ risk-reduction efforts with their HIV-infected patients. We conducted a randomized, controlled trial of Positive Choice in clinical settings to test its efficacy at reducing risky behaviors among patients reporting illicit drug use, risky alcohol drinking, or unprotected sex. We hypothesized that the intervention group would show greater reductions of these risky behaviors than the usual care group.

Between December 2003 and September 2006 Positive Choice was integrated into the routine operations of 5 outpatient HIV clinics in the San Francisco Bay Area, including 2 public hospitals, a community-based organization, a private hospital, and an HMO. All patients at the study sites were eligible to participate provided they were age 18 or older, were HIV-positive 3 months or longer, and spoke English. In addition to the initial session, participants returned for two follow-up visits at 3 and 6 months post-baseline.

Participants used a laptop computer to complete the Positive Choice risk assessment immediately prior to a regularly scheduled medical appointment. Privacy was assured by use of a private examination room and headphones. Upon completion of the risk assessment and prior to the medical appointment, the Positive Choice program seamlessly transitioned to the Video Doctor for those participants randomized to the intervention group. An actor-portrayed Video Doctor delivered interactive risk-reduction messages, designed to simulate an ideal discussion with a health care provider. Using a library of digital video clips, extensive branching logic, and participant input, the program tailored messages to the participant’s gender, risk profile, and readiness to change.

In the example below, the Video Doctor begins a frank discussion of a patient’s drug use. She is respectful yet concerned, and frames drug use as an important issue affecting the patient’s own health.


The Video Doctor clips are interactive, and subsequent branching is directed by patient input. In the example below, she asks about a patient’s readiness to stop using drugs.


In the example below, the Video Doctor acknowledges a patient’s ambivalence about quitting drugs, offers support, and suggests some questions for self-reflection.


At the conclusion of each intervention session, the program automatically printed 2 documents: 1) an “Educational Worksheet” for participants with questions for self-reflection, harm reduction tips, and local resources; and 2) a “Cueing Sheet” for providers, which offered a summary of the patient’s risk profile and readiness to change, and suggested risk-reduction counseling statements. The Cueing Sheet was placed in the patient’s medical record for the provider’s use during the medical appointment. (To view a sample Worksheet, click here. For a sample Cueing Sheet, click here.)

Intervention participants received an additional 10–15 minutes of “booster” Video Doctor counseling at the 3 month follow-up. Participants assigned to the control group received the clinic’s usual care.

Reframing “Prevention with Positives”

The development of Positive Choice occurred at a time when advances in the treatment of HIV have dramatically increased the duration and quality of life for those infected. Because HIV-positive individuals are living longer, and to more efficiently target potential transmission, prevention strategies have shifted their focus from HIV-negative to HIV-positive persons. This new emphasis is often described as “Prevention with Positives.” Because behaviors risky to the patient’s health often overlap with behaviors risky to transmitting HIV, we have proposed that HIV care providers reframe Prevention with Positives as concern for the patient’s own health rather than solely to prevent transmission to others. This avoids conceptualizing the HIV-infected person as a vector of disease, and may reduce stigma associated with risk-reduction messages in the health care setting, and thereby strengthen the patient-provider relationship.

Previous Work

Positive Choice in the most recent of a variety of studies that CHIPS has conducted in response to the HIV/AIDS epidemic. These studies include seminal work in the 1980s about dentists’ willingness to treat HIV-positive patients and dentists’ use of infection control.

Additional aspects of our HIV-related research have included:

  • Public perception about HIV transmission in health care settings
  • Physician and patient barriers to taking sexual risk histories
  • Physician styles of assessing and counseling HIV transmission prevention
  • Physician behaviors that promote patient involvement with HIV treatment
  • Physician and patient perceptions regarding the risk of HIV transmission by oral sex

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Page last updated September 18, 2009