welcome to i-tech hiv/aids clinical seminar series october 9, 2008 hiv prevention with positives in...
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Welcome to I-TECH HIV/AIDS Clinical Seminar Series
October 9, 2008HIV Prevention with Positives in Clinical Settings: A Powerful Tool
Janet Myers, PhD
OverviewOverview Describe a 20-site clinical site Describe a 20-site clinical site
demonstration project that evaluated the demonstration project that evaluated the effectiveness of behavioral prevention effectiveness of behavioral prevention intervention programs for HIV-infected intervention programs for HIV-infected patients seen in clinical settings in the US.patients seen in clinical settings in the US.
State the features of successful behavioral State the features of successful behavioral interventions that were shown to reduce interventions that were shown to reduce HIV transmission risks.HIV transmission risks.
Identify two examples of tools to help Identify two examples of tools to help clinics integrate behavioral prevention clinics integrate behavioral prevention activities into clinical services.activities into clinical services.
Discuss ways to apply lessons from this Discuss ways to apply lessons from this project to international settings.project to international settings.
Ryan White HIV/AIDS ProgramRyan White HIV/AIDS ProgramEvolution of HAB Prevention Evolution of HAB Prevention
ActivitiesActivities The Ryan White CARE Act Prevention The Ryan White CARE Act Prevention
Project (2000-2002)Project (2000-2002) Incorporating HIV Prevention into the Incorporating HIV Prevention into the
Medical Care of Persons living with HIV: Medical Care of Persons living with HIV: Recommendations of CDC, HRSA, NIH, and Recommendations of CDC, HRSA, NIH, and HIVMA (2003)HIVMA (2003)
SPNS Initiative: Prevention with HIV-SPNS Initiative: Prevention with HIV-Infected Persons seen in Clinical Settings Infected Persons seen in Clinical Settings (Prevention with Positives Initiative, 2002 – (Prevention with Positives Initiative, 2002 – 2008)2008)
OPTIONS Project (2005-2007)OPTIONS Project (2005-2007)
Findings:Findings:The Ryan White CARE Act The Ryan White CARE Act
Prevention ProjectPrevention Project** HIV prevention counseling was not routine in most
clinics; patients reported receiving prevention counseling significantly less frequently than counseling related to diet, nutrition and adherence to ARVs.
Lack of time, lack of specialized training and funding dedicated to the provision of prevention counseling were cited as barriers providing HIV prevention in the clinical setting.
Some clinical providers did not understand their role in “prevention with positives”.
The low frequency of HIV prevention services in these clinical settings represented “missed opportunities” for reducing HIV transmission.
*Morin et al. (2004) Missed Opportunities: Prevention with HIV-infected Patients in Clinical Care Settings. JAIDS, 36(4):960-966.
Incorporating HIV Prevention into the Incorporating HIV Prevention into the Medical Care of Persons living with Medical Care of Persons living with
HIV: Recommendations of CDC, HRSA, HIV: Recommendations of CDC, HRSA, NIH, and HIVMA/IDSA*NIH, and HIVMA/IDSA*
Guidelines support the provision of Guidelines support the provision of HIV prevention in clinical settingsHIV prevention in clinical settings
Provide clinicians with the tools Provide clinicians with the tools needed to conduct a behavioral needed to conduct a behavioral assessment, screen for sexually assessment, screen for sexually transmitted diseases, and provide transmitted diseases, and provide appropriate prevention messagesappropriate prevention messages
*CDC. (2003) Incorporating HIV Prevention into the Medical Care of Persons Living with HIV. Recommendations of CDC, the Health Resources & Services Administration, the National Institutes of Health, and the HIV Medicine Association of the Infectious Diseases Society of America. MMWR Recommendations and Reports, 52 (RR-12), 1-24.
SPNS Initiative: Prevention with HIV-SPNS Initiative: Prevention with HIV-Infected Persons seen in Clinical Infected Persons seen in Clinical
Settings Settings (Prevention with Positives Initiative)(Prevention with Positives Initiative)
Goal:Goal: To evaluate the effectiveness of To evaluate the effectiveness of behavioral prevention intervention programs behavioral prevention intervention programs for HIV-positive clients seen in clinical care for HIV-positive clients seen in clinical care settings by examining the following questions:settings by examining the following questions:
Can behavioral interventions in primary care Can behavioral interventions in primary care clinical settings help HIV+ clients reduce the risk of clinical settings help HIV+ clients reduce the risk of transmitting HIV to others? transmitting HIV to others?
What models are most appropriate with different What models are most appropriate with different populations (e.g., MSM of color, heterosexual populations (e.g., MSM of color, heterosexual women, rural drug users)? women, rural drug users)?
What models are most appropriate for different What models are most appropriate for different primary care settings (e.g., rural, urban, high primary care settings (e.g., rural, urban, high volume, community-based organization, large volume, community-based organization, large hospital)? hospital)?
Prevention with Positives Prevention with Positives Initiative OverviewInitiative Overview
15 sites (20 clinics) were funded to 15 sites (20 clinics) were funded to implement and evaluate HIV implement and evaluate HIV prevention interventions tailored to prevention interventions tailored to their individual clinicstheir individual clinics
A TA & Evaluation Center received A TA & Evaluation Center received funds to conduct a multi-site funds to conduct a multi-site evaluation and assist demonstration evaluation and assist demonstration sites in designing their interventions sites in designing their interventions and local evaluationsand local evaluations
SPNS Prevention with Positives SPNS Prevention with Positives Initiative Demonstration SitesInitiative Demonstration Sites
Intervention ModalityIntervention Modality SiteSite Intervention Modality Intervention Modality
Individual Individual LevelLevel
Group Level Group Level
Johns Hopkins University, BaltimoreJohns Hopkins University, Baltimore
University of Alabama, BirminghamUniversity of Alabama, Birmingham
County of Los AngelesCounty of Los Angeles
St. Luke’s Roosevelt Hospital, New St. Luke’s Roosevelt Hospital, New YorkYork
El Rio/Special Immunology Health El Rio/Special Immunology Health Ctr., TucsonCtr., Tucson
University of Washington, SeattleUniversity of Washington, Seattle
Mt. Sinai Hospital, ChicagoMt. Sinai Hospital, Chicago
Fenway Community Health CenterFenway Community Health Center
University of MiamiUniversity of Miami
Drexel University, PhiladelphiaDrexel University, Philadelphia
DeKalb County Board of Health, DeKalb County Board of Health, Decatur, GADecatur, GA
University of North Carolina, Chapel University of North Carolina, Chapel HillHill
Whitman Walker Clinic, Washington, Whitman Walker Clinic, Washington, DCDC
University of California, San DiegoUniversity of California, San Diego
University of California, DavisUniversity of California, Davis
Target PopulationsTarget Populations
All patients (3)All patients (3) Patients with sex or drug Patients with sex or drug
risk in last 6 months (2)risk in last 6 months (2) MSM with sexual activity MSM with sexual activity
in last 6 months (1)in last 6 months (1) All returning patients All returning patients
with sexual activity in with sexual activity in last 3 months (1)last 3 months (1)
All returning patients (1)All returning patients (1) All MSM (1)All MSM (1)
Patients reporting sexual Patients reporting sexual activity in last 3 months activity in last 3 months (1)(1)
Male patients (1)Male patients (1) Female patients (1) Female patients (1) Patients reporting risk in Patients reporting risk in
last 6 months (1)last 6 months (1) Patients diagnosed with Patients diagnosed with
HIV for at least 3 months HIV for at least 3 months (1)(1)
Patients age >45 reporting Patients age >45 reporting unprotected sex in last 12 unprotected sex in last 12 monthsmonths
Type of Professional Delivering Type of Professional Delivering InterventionIntervention
SiteSitePrimary
CareProvider
InterventionSpecialist Peer
Johns Hopkins University, BaltimoreJohns Hopkins University, Baltimore
University of Alabama, BirminghamUniversity of Alabama, Birmingham
County of Los AngelesCounty of Los Angeles
St. Luke’s Roosevelt Hospital, New St. Luke’s Roosevelt Hospital, New YorkYork
(Social Worker)(Social Worker)
El Rio/Special Immunology Health El Rio/Special Immunology Health Ctr., TucsonCtr., Tucson
(Health Educator)(Health Educator)
University of Washington, SeattleUniversity of Washington, Seattle (Social Worker)(Social Worker)
Mt. Sinai Hospital, ChicagoMt. Sinai Hospital, Chicago
Fenway Community Health CenterFenway Community Health Center
University of MiamiUniversity of Miami
Drexel University, PhiladelphiaDrexel University, Philadelphia (Health Educator) (Health Educator)
DeKalb County Board of Health, DeKalb County Board of Health, DecaturDecatur
(Specialist) (Specialist)
University of North Carolina, Chapel University of North Carolina, Chapel HillHill
(Specialist)(Specialist)
Whitman Walker Clinic, Washington, Whitman Walker Clinic, Washington, DCDC
(Health Educator)(Health Educator)
University of California, San DiegoUniversity of California, San Diego (Health Educator)(Health Educator)
University of California, DavisUniversity of California, Davis (Social Worker)(Social Worker)
Study Assignment Study Assignment by Intervention Typeby Intervention Type
SitesSites
(N=14(N=14))
NN
(N=3799)(N=3799)PercentPercent
%%
ProviderProvider 33 885885 23%23%
Health Educator Health Educator (HE) (HE)
66 976976 26%26%
Mixed (Provider Mixed (Provider + HE)+ HE)
55 759759 20%20%
Assessment onlyAssessment only 88 11791179 31%31%
Sample CharacteristicsSample CharacteristicsGender Gender
MaleMale
FemaleFemale71%71%
28%28%
Age Greater than 40Age Greater than 40 63%63%
Education: High School or Education: High School or lessless
51%51%
Sexual orientationSexual orientation
MSMMSM
MSWMSW
WomenWomen
51%51%
19%19%
28%28%
Race Race
African AmericanAfrican American
WhiteWhite
LatinoLatino
OtherOther
46%46%
35%35%
15%15%
4%4%
Study OutcomeStudy Outcome
Transmission Risk BehaviorTransmission Risk Behavior ANY unprotected sex with HIV-uninfected or ANY unprotected sex with HIV-uninfected or
unknown status partnerunknown status partner
Sexual transmission risk Sexual transmission risk behavior behavior
by intervention typeby intervention type
0%
5%
10%
15%
20%
25%
30%
0 6 12
Months
% R
isky
Sex
Provider Health Educator Mixed Assessment
Summary and Summary and ConclusionsConclusions
Provider-led interventions led to significantly Provider-led interventions led to significantly greater reduction in sexual risk at 12 months greater reduction in sexual risk at 12 months compared to the assessment only group.compared to the assessment only group.
Brief risk assessment and provider-led Brief risk assessment and provider-led interventions appear to have the greatest interventions appear to have the greatest effect on reduction in sexual risk among effect on reduction in sexual risk among patients seen in clinical settings.patients seen in clinical settings.
More analysis is needed to explore whether More analysis is needed to explore whether and how professional and peer counselor-led and how professional and peer counselor-led interventions affect the lives of HIV-infected interventions affect the lives of HIV-infected individuals in clinical settings.individuals in clinical settings.
Qualitative FindingsQualitative Findings
Risk assessment facilitated openness Risk assessment facilitated openness among some patients among some patients
Interventions facilitated increased Interventions facilitated increased comfort in talking to providers about comfort in talking to providers about sex sex
Interventions improved communication Interventions improved communication between patient and providerbetween patient and provider
Interventions facilitated self- reflectionInterventions facilitated self- reflection
Provider-Delivered Provider-Delivered InterventionsInterventions
““The doctor in this program has really The doctor in this program has really caused me to think more so than I used to caused me to think more so than I used to about how I handle myself, especially about how I handle myself, especially when it comes to infecting other people.”when it comes to infecting other people.”
Willingness + Risk Assessment = Willingness + Risk Assessment = Dynamic Exchange OpportunitiesDynamic Exchange Opportunities
Interventions facilitated Interventions facilitated teaching/learning exchangesteaching/learning exchanges Providers counseled on re-infection, Providers counseled on re-infection,
safer sex – condoms, disclosure safer sex – condoms, disclosure Patients discussed “lifestyle” and/or Patients discussed “lifestyle” and/or
sexual behaviors, preferences sexual behaviors, preferences Patients appreciated doctor’s point of Patients appreciated doctor’s point of
view view
Provider-Delivered Intervention Provider-Delivered Intervention FitFit
May work well:May work well: Privacy-sensitive Privacy-sensitive
patientspatients ““Doctor knows best” Doctor knows best”
patientspatients Low health literacy Low health literacy Willingness/openness Willingness/openness
to reveal sex to reveal sex practices/preferencespractices/preferences
May not work well:May not work well: High health High health
literacyliteracy Sex positive Sex positive
patientspatients Pre-existing Pre-existing
discussions about discussions about sex practicessex practices
Women ?Women ?
Provider PerspectivesProvider Perspectives
Feasible to deliver prevention during Feasible to deliver prevention during medical visitmedical visit
Increased comfort level to talk about Increased comfort level to talk about preventionprevention
Risk assessment served as a Risk assessment served as a reminder and vehicle to learn new reminder and vehicle to learn new information about patientsinformation about patients
Provider PerspectivesProvider Perspectives
““I thought the report of the risk factors was I thought the report of the risk factors was very helpful to me, particularly in pointing out very helpful to me, particularly in pointing out
things that I hadn't picked up with my interview things that I hadn't picked up with my interview with the patients….It was very helpful, as I with the patients….It was very helpful, as I
would have these focused conversations …It led would have these focused conversations …It led to a lot of discussions with the patients….it to a lot of discussions with the patients….it
opened up this other area that we hadn't really opened up this other area that we hadn't really talked about. It helped me get comfortable talked about. It helped me get comfortable too…. So I think you have to get a level of too…. So I think you have to get a level of
comfort about that as a provider, and I think comfort about that as a provider, and I think the -- having it in the folder there and having the -- having it in the folder there and having
the patient already thinking about it …and the patient already thinking about it …and saying "let's see what the [risk assessment] saying "let's see what the [risk assessment]
came up with for you today."came up with for you today."
Conclusions Conclusions
Interventions targeted behavior Interventions targeted behavior change among patients change among patients andand providers providers
Interventions directed providers to be Interventions directed providers to be more attentive to HIV preventionmore attentive to HIV prevention
Some patients enjoyed new Some patients enjoyed new opportunities to talk about HIV opportunities to talk about HIV prevention and sexual practices with prevention and sexual practices with their provider and vice versatheir provider and vice versa
Regularly assessing risk facilitated Regularly assessing risk facilitated patient reflection on sex practices patient reflection on sex practices
Interventions were not universally Interventions were not universally accepted among patients or providersaccepted among patients or providers
Methods and Tools:Provider-delivered
Interventions
Computerized Risk Computerized Risk Assessment to Assessment to Support Risk Support Risk
Reduction CounselingReduction CounselingEmily J. Erbelding, MD, MPHEmily J. Erbelding, MD, MPH
Johns Hopkins University School Johns Hopkins University School of Medicineof Medicine
Computer Assisted Risk Computer Assisted Risk Assessment (CARA)Assessment (CARA)
Trained medical providers deliver Trained medical providers deliver counseling based upon Stage-of-counseling based upon Stage-of-Change theoryChange theory
Critical behaviors targeted: Critical behaviors targeted: Condom useCondom use Disclosure of HIV status to partnersDisclosure of HIV status to partners Drug useDrug use Needle sharingNeedle sharing
CARA printout content: CARA printout content: exampleexample
[Patient initials][Patient initials] 9/18/20059/18/2005Completed the CARA today and identified:Completed the CARA today and identified:
Stage for condom useStage for condom useMain partner Main partner C C My main partner doesn’t want My main partner doesn’t want totoCasual partner Casual partner Patient states no casual partnersPatient states no casual partners
Stage for disclosure of HIV statusStage for disclosure of HIV statusMain partner Main partner MMCasual partner Casual partner Patient states no casual Patient states no casual partnerspartners
Stage for drug useStage for drug useStop SharingStop Sharing
Stop usingStop using Patient states no drug use past 3 Patient states no drug use past 3 monthsmonths
Enter Drug treatmentEnter Drug treatment
PASHINPASHIN
Peers Advocating for Peers Advocating for Sexual Health InitiativeSexual Health Initiative
Laura Bachmann, MD, Laura Bachmann, MD, MPHMPH
Associate Professor of Medicine Associate Professor of Medicine and Epidemiologyand Epidemiology
UAB Schools of Medicine and UAB Schools of Medicine and Public HealthPublic Health
Birmingham VA Medical CenterBirmingham VA Medical Center
Diane M. Grimley, PhDDiane M. Grimley, PhDProfessor of Public Health and Professor of Public Health and
MedicineMedicineChair, Department of Health Chair, Department of Health
BehaviorBehaviorUAB School of Public Health and UAB School of Public Health and
MedicineMedicine
InterventionIntervention Assessment based on stages of Assessment based on stages of
change construct for three target change construct for three target behaviors.behaviors.
Intervention messages are stage Intervention messages are stage specific and were developed specific and were developed based on the decisional balance, based on the decisional balance, self-efficacy, and process of self-efficacy, and process of change constructs.change constructs.
AcknowledgementsAcknowledgements
Andre Maiorana Andre Maiorana Faye MalitzFaye MalitzKaren Vernon Karen Vernon Sandi Duggan Sandi Duggan Jennifer BieJennifer Bie Pam BeltonPam BeltonCarol Dawson RoseCarol Dawson Rose Katherine Katherine
McElroyMcElroySteve MorinSteve Morin Michelle TetiMichelle Teti
Starley ShadeStarley Shade Celina KapoorCelina Kapoor
Participating patients, providers & Participating patients, providers & research collaborators across 15 sitesresearch collaborators across 15 sites
For more information:
AIDS and Behavior Volume 11, Supplement 1
September, 2007
Contact Information
Janet Myers, PhD, MPHNational Evaluation Center
AIDS Education and Training Centers University of California, San Francisco
(415) [email protected]
