News & Events

Provider Fatalism Reduces Prevention Counseling in HIV-Positive Patients
Posted to the Web: Friday, December 07 , 2007
December 7, 2007 (Atlanta) — Fatalism about HIV infection is associated with less frequent delivery of counseling to HIV-positive patients among providers in publicly funded clinics, according to a presentation here at the 2007 National HIV Prevention Conference.

Wayne Steward, PhD, MPH, from the University of California, San Francisco (UCSF), said the study had grown out of an earlier observation in program evaluation conducted by the UCSF Center for AIDS Prevention Research that some HIV care providers "expressed a really pronounced sense of fatalism; the idea that there was nothing they could actually do to change their clients' behaviors."

He later went on to demonstrate that patients were significantly less likely to report that HIV prevention services and messages had been provided at certain clinics, correlating with a higher degree of prevention fatalism among the staff at those sites.

In this study, part of a special project of prevention with HIV-positive patients, Dr. Steward's goal was to dig deeper — to create a context for that observed fatalism and examine how it interacted with other beliefs and functions. He presented the baseline assessment of both patients and providers from an intervention study that is just concluding.

Clinical providers (N = 316) whose duties included the provision of prevention counseling were given a standardized survey that measured fatalism, comfort, training and knowledge, and the adequacy of time to accomplish tasks.

That the researchers found that new HIV-positive clients were more likely to receive counseling on risk reduction than were returning clients (67% vs 53%). The more fatalistic settings were 10% and 11% less likely to offer counseling to new and returning patients, respectively, than were the less fatalistic settings.

Dr. Steward looked to see whether any other beliefs might drive fatalism; "I have never seen so many zeros in all my life. Fatalism does not correlate with anything...rather, it seems to modify the expression of a lot of other beliefs, making them more pronounced."

For example, among providers who were uncomfortable talking about injection drug use, the less fatalistic group was 8% less likely to offer prevention counseling, but the more fatalistic group was 53% less likely to do so.

"The primary thing that distinguishes the fatalistic from the nonfatalistic is the demographic of the patient," Dr. Steward said, noting that one cannot directly ask questions on racism or homophobia because one is likely to get the socially acceptable response.

"You don't always know exactly which patients are seeing which providers and how frequently they see them, but you do know something about the median level of fatalism" at a particular site and can reach some conclusions at the site level.

"If the patient was [a man having sex with a man (MSM)], they were encountering providers with significantly higher fatalism than patients who were not MSM." When it came to race, Dr. Steward said, "Unlike almost everything else that I've ever seen, being African American actually protects when it comes to prevention counseling.... There is more fatalism among providers seeing gay, white men."

Dr. Steward continued, "If you are a white gay man, you have a lot of fatalism coming towards you and not a lot of counseling. If you are a black gay men, you don't get as much counseling as, say, a black heterosexual woman, but you get more counseling than if you were a white gay man."

Dr. Steward does not believe it is the result of homophobia — "it's more complicated than that." He speculated that it might be tied up with the rhetoric, "gay men should know better," but more study is needed, he said.

Session chair Carlos del Rio, MD, asked whether it was possible that fatalism was tied to the length of time that the provider had been in HIV care. Dr. Steward said it was all interrelated because of how the epidemic emerged and spread in the United States.

The researchers have disclosed no relevant financial relationships.

2007 National HIV Prevention Conference: Abstract F07-3. Presented December 3, 2007.