Assessing fidelity and exposure to physician-driven HIV prevention interventions: Lessons learned in an East Los Angeles HIV clinic

ISSUES: Provider HIV prevention models targeting seropositive patients are attracting increasing interest and funding. Assessing fidelity and exposure to HIV interventions with physicians as interventionists presents unique challenges. Physician-patient communication occurs in private, constraining objective assessment of whether and how they deliver the intervention. Uncertainty about how or if an intervention is delivered can compromise outcome interpretation.

DESCRIPTION: This presentation highlights challenges assessing exposure/ fidelity to Partnership for Health (PfH), a CDC evidence-based HIV prevention model (DEBI) delivered by physicians with seropositive patients during routine clinic visits. We focus on experiences implementing PfH in a Los Angeles HIV clinic.

LESSONS LEARNED: We present challenges of collecting valid fidelity/exposure data using "prevention prescription” scripts, chart abstraction, exit interviews and provider qualitative interviews. In spite of the model's promise, our experience underscores potential barriers to fidelity in the context of busy clinical practices. Understaffing, high patient volume, competing patient issues and the need to re-define providers' role can strain implementation. Chart data revealed 30% of monthly patient visits included prevention discussions. An unanticipated finding revealed prevention messages increased 250% following the launch of an electronic medical record (EMR) system prompting providers to discuss prevention.

RECOMMENDATIONS: An EMR proved to be effective for provider reinforcement. Additionally, fidelity/exposure may have improved if, the evaluation team had a daily presence to support intervention delivery; the implementation protocol included strategies for quality assurance and monitoring; and planning the intervention included clinic staff and provider input to ensure strategies were integrated into existing clinic routines and culture.