Transcript HIV Intervention Program for Providers

Prevention with HIV Positive
Individuals in the Clinic Setting
Janet Myers, PhD, MPH
Carol Dawson Rose, PhD, RN
Goals of Session
• Present findings from research at CAPS on the
prevention needs of positive individuals
• Discuss findings of key informant interviews with
HIV Care Providers about integrating prevention
into HIV clinic setting
• Present intervention/program models that are
part of HRSA SPNS demonstration
• Discussion about how to integrate prevention into
clinic setting. Implementation issues
CAPS Formative Research with
HIV Positive Individuals
• Heterosexual Serodiscordant Couples
• Gay and Bisexual Men
• Heterosexual Injection Drug Users
Heterosexual Serodiscordant Couples
• The California Partners Study, II: A Risk Reduction Intervention for
HIV Serodiscordant Opposite Sex Partners (1996-97) CDC; PI:
Nancy Padian, PhD; Co-PI: Cynthia Gómez, PhD
Prevention Needs
Serodiscordant dynamics
Negotiated safety and preservation of intimacy
Commodification
Calculated risk
Gay and Bisexual HIV+ Men
• Seropositive Urban Men’s Study (SUMS): Formative Behavioral
Research on the Prevention of Sexual Transmission of HIV by
Seropositive Men Who Have Sex With Men (1997-8) : CDC; PI:
Cynthia Gómez, PhD
Prevention Needs
Relationship between drugs and unsafe sex
Grey areas (oral sex, withdrawal, insertive/receptive)
Relationship between HIV treatment, viral load, and
infectivity
Serostatus assumptions
Power dynamics
Need for communication and disclosure skills
Mental health impact sexual behavior and health care
Need to focus on STD’s
Heterosexual Injection Drug Users
• Seropositive Urban Drug Injectors Study (SUDIS): Formative
Behavioral Research on the Prevention of Transmission of HIV by
Seropositive Drug Injectors (1997-99),CDC; PI: Cynthia Gómez, PhD
Prevention Needs
Negotiated safety
Context and partner type affect prevention decision-making
Dynamics of drug-sex economy
Gender and power dynamics
Commodification of HIV
Criminal justice system
Need for skills building
Drug use management
Overall Findings
• The responsibility for prevention HIV
transmission is a key area of concern for HIV+
individuals
• HIV+ individuals would like to have
prevention discussions with their medical
providers
CAPS Formative work with HIV
Medical Providers
• HIV Intervention for Providers (HIP): Behavioral Intervention Trial
with HIV Primary Care Medical Providers (2000 - ongoing): CDC; PI:
Carol Dawson Rose, PhD, RN; Grant Colfax, MD.
Key Informant Interviews
• Interviewed HIV primary care medical providers
• MD, Infectious Disease (2); MD, Internal Medicine; MD,
Family Practice; MD, HIV Specialist GP (2); RN, Education
and Support, HIV Health
Patients
• 2045 HIV+ patients
• MSM, MSM/IDU, heterosexual men and women, injection
drug users
CAPS Study of RWCA Clinics
 Aim: To assess the current practices of
providers regarding prevention for HIVinfected patients in Ryan White funded
clinics
 Method: Interviews (N=618) with patients
exiting regular HIV primary care visits
 Sample: 16 Ryan White funded clinics in
9 states -- mix of high, medium & low
volume providers
Research Sites
Barriers
• Barriers identified by providers were often
practical
– Time Constraints
– Lack of training in counseling
– Lack of dedicated funding
• Participants were significantly more likely
to report prevention counseling if the office
visit lasted more than half an hour
(OR=1.55; p<.05)
Provider Role Conflicts
• Concept of “prevention with positives”
is not well understood
• Many providers see role as “patient
advocate.”
• This role seen as potentially conflicting
with “public health” role.
• Not clear who at clinic would be
responsible for providing prevention
services.
Prevention Messages
• No consistent message
• Viewed current messages as
“ineffective”
• “Use Condoms” -- to protect others
• “Protect Yourself” -- reinfection,
STDs
• Moral -- being good v. being bad
• Medical advice v. motivational
counseling
Fatalism
• Providers at 14 of 16 clinics expressed frustration
about inability to counsel HIV-infected patients
about preventing transmission.
• Providers in these clinics expressed fatalism; e.g.
“How much of this can we change if it hasn’t
changed already.”
• Patients in high fatalism clinics were significantly
more likely to be gay men than heterosexual men
(OR=11.96; p<.05) or women (OR=2.14; p,.05).
Patient Needs & Wants
(Patients want …)
•
•
•
•
•
To “Not transmit HIV to others”
More understanding of complexity
Information (re-infection)
Support (learn how others cope)
Leadership role -- prevention &
reducing stigma (speaking to youth)
SPNS Clinic-based PwP
Demonstration Project
• 15 Sites, four year funding
• Evaluation Center (UCSF) funded one year
earlier
• Multiple Interventions
• Local and Cross-site Evaluation
Components
SPNS Sites
UNC, Chapel
Hill
Drexel U,
Philadelphia
UA Birmingham
Johns Hopkins
Dekalb County,
Decatur
St. Luke’s, New
York
UC San Diego
U of Miami
Whitman-Walker,
Washington, D.C.
Mt. Sinai Hospital,
Chicago
El Rio CHC,
Tucson, AZ
Dept. of Health
Services, Los
Angeles
Fenway CHC,
Boston
University of
Washington,
Seattle
UC Davis
Intervention Types
• Primary Care Provider delivered
• Intervention delivered by Prevention
Specialist
• Intervention delivered by HIV+ Peers
Intervention Types
Site
Peer
ILI
Chicago


Miami

Philadelphia
PCP

Specialist

Tucson
 (Health Educator)
Seattle
 (CSW)
New York
 (Social Worker)

 (Staff Specialist)









Boston
GLI

Chapel Hill


Baltimore


Los Angeles


Birmingham


San Diego

 (Health Educator)

D.C.

 (Health Educator)

De Kalb

 (Specialist)

Davis

 (Nurses & Social
Workers)


PCP Delivered Intervention
Partnership for Health
Test of Brief Safer Sex and Adherence
Interventions
at HIV Clinics
Partnership for Health
The Action of One, The Partnership of Two, The Power of Many
Funded by the NIMH
With additional support from the UARP and the CDC
1
Characteristics of the Program
• Integrates prevention into routine primary
care
• Emphasize Self Protection, Partner
Protection and Disclosure
• Every patient counseled at every visit
• Also can produce change in clinic norms
Study Intervention
•
Emphasizes the patient/provider partnership
•
Primary care provider component
- Introduce/discuss partnership
- Ask about sexual behavior
- Verbalize prevention messages to patient
- Brief risk-reduction counseling
•
Provider initiates a 3 - 5 minute interaction focused on:
– Patient Self Protection
– Partner Protection
– Disclosure of status to sex partners
•
Messages reinforced at every visit
7
Materials Specific To Intervention Arm
All materials printed in English and Spanish
• PFH posters (waiting room, exam rooms)
• Brochures (Gain, Loss, Adherence)
- Describes partnership
- Gives G/L prevention messages
- States ways to reduce risk/stay adherent (used for setting
behavior goals)
- Eight Informational inserts (framed for intervention arm)
• Provider pocket guide
• Checklist sticker for medical chart
- Reflects risk-reduction goals for the patient
10
Study Intervention Flow Chart
•Patient enters clinic & receives brochure
•Sees PfH posters on walls
•Reads brochure and takes it to exam room
•Communicates importance of partnership
•Reviews brochure with patient
•Provider states safer sex & disclosure G/L messages
•Discuss safer sex goals and risk reduction
•Fills our goals sticker and places in patient’s chart
•Patient returns for another visit
•New information insert
•Provider addresses barriers and reinforces message.
13
Peer Delivered Intervention
Howard Brown’s
Treatment Advocacy Program
The University of Illinois at Chicago
Howard Brown Health Center
Treatment Advocacy Program
HIV medication skills 2:
Men beginning HIV medications
4 / 24 / 03
Medication skills 2: Goals
Welcome back to TAP
This visit we will:
 Cover “difficult doses” & adherence
 Talk about different coping areas
 …use your answers to develop a coping profile
of your strengths and where we should focus
more…
 Develop a treatment coping plan
HIV Coping Check-in…
What questions do you have about HIV
treatment?
HIV Information
How are things going with..
 Medications & treatment?
 Sexuality & intimacy?
Areas where things are going..
 Particularly well?
 Difficult?
Advocate’s notes &
checklist
• Advocate: Visit Checklist




Coping interview form
Coping planning worksheet
Referral sheet (if used)
Next appointment hand card distributed
Complete Counseling Notes Form and Visit Log for file.
Prevention Specialist
Delivered Intervention
University of Washington,
Department of Psychiatry
Characteristics of the Program
• Individual Sessions delivered by Licensed
Social Worker
• 4 – 50 minute individual sessions
• 6 – Group level sessions co-facilitated by
– Peer and Social Worker (specialist)
Individual Sessions
• Counseling Model
• Assessment of Individuals Stage of Change
• Risk Assessment
• Motivational Interviewing approach
– Client centered
Individual Sessions
• Documentation
–
–
–
–
Research Chart
Stage of Change Assessment
Progress notes
Specific issues addressed during session
Group Sessions
• Topics
–
–
–
–
–
Community Norms
Negative Self Talk
HIV Disclosure
Defining Safe Behavior
Negotiating Relationships
HIV Provider Needs for Integrating
Prevention into the Clinic Setting
• External pressure to incorporate prevention into care
• Barriers (time, role, research)
• Support/Training for behavior change
• Public Health Vs. Individual’s Health
Questions
Prevention Message
• Provider delivered prevention message
• Harm Reduction Approach
• Provider / Patient Response Type
Implementation
• Clinic Policy
• Documentation of Risk
• Legal Issues
• Provider Fatigue
Contact Information
• Carol Dawson Rose
• [email protected]
• 415 597 9338
• Janet Myers
• [email protected]
• 415 597-8168