Notes

Outline

"Prevention with Positives Institute" Prevention with Positives Institute Ryan White Conference Workshop     24 August 2004

Can Results from Computerized Risk Assessment Help Providers Deliver More Effective Risk Reduction Counseling? Mollie W. Jenckes, MHSc, BSN, Emily Erbelding, MD, MPH

Problem Effectively addressing transmission behaviors among patients receiving HIV services is critical This is an essential element of the national strategic plan for HIV prevention Time constraints among providers and inconsistent behavioral counseling skills and are major barriers

Our initiative To train HIV primary care providers to a standardized curriculum for stage-based counseling To conduct a randomized clinical trial Use the audio-CASI technology Obtain patient input on specific risk factors Provide providers for the intervention group with the output from the patient assessment prior to the clinical visit

Target population All patients at designated HIV primary care adult clinics are eligible HIV clinics are selected in the greater Baltimore area from the Johns Hopkins AIDS service to provide a variety of settings (Carroll County, Harford County, Howard County,  Green Spring Station)

Pre-Intervention/Capacity Building Provider intervention includes Training of client intervention team (n=6) on assessing behavioral interventions and on provider training techniques Initial expert training for providers Follow up individual and group exercises by client intervention team to maintain consistent standard among providers

Theoretical basis Stage of change/transtheoretical model (SOC/TTM) Adapted to develop a behavioral counseling intervention for HIV/STD prevention SOC defines a patient’s readiness for change TTM used to identify counseling strategies

Steps in stage-based behavioral counseling Identify a target behavior and assess patient’s readiness to adopt this behavior Select a counseling strategy that matches the client’s readiness Document the stage, counseling strategy, and client Provide continuity of care; evaluate effectiveness

Identify a target behavior Sexual target behaviors Delay or avoid intercourse Use condoms consistently Disclose HIV status to all partners Harm reduction target behaviors Get regular STD/HIV testing Reduce number of partners Use condoms with all partners, not just main partner Any “first step” patient agrees to

Target behaviors, cont’d Substance abuse target behaviors Stop using Enter a treatment program Avoid sharing needles/works Health care seeking target behaviors Receive regular care Adhere to prescribed treatments Accept referrals for case management

Assess Client’s readiness to  adopt or adhere to the target behavior

Stage of change/readiness Precontemplative=client does not see the need (PC) Contemplative=client sees the need but has barriers (C) Ready for action=ready to start or has started behavior (RFA) Action=Consistent use for 3-6 months (A) Maintenance=Has been doing it for more than 6 months (M)

Issues to cover in assessment Client’s knowledge Client’s perception of risk Sexual relationship history Attitudes towards condom use Attitudes towards drug abuse Attitudes towards partner disclosure Attitudes towards health care seeking

To translate….. Precontemplative=“no way, not me” Contemplative=“yes…but (not right now)” Ready for action=“Let’s do it now!” Action=“Doing it” Maintenance=“Living it” When stage is ascertained, select a counseling strategy

Counseling strategies PC C RFA A/M Story telling; information giving Explore ambivalence; discuss pros and cons; offer substitutes Develop a plan Identify supports to the new/desired lifestyle; avoid cues to the old lifestyle; find substitutes; identify rewards; become a role model

To review 1.  Identify a target behavior 2.  Identify stage of readiness 3.  Assess client’s readiness 4.  Use a counseling strategy that matches client’s stage of readiness

Other factors to rate in assessing provider performance Rapport between provider and patient Empathy towards difficulty of behavioral change Re-framing any failures in a positive way Reinforcing effort Responding appropriately to resistance Assessing HIV knowledge

Assessment Measures Patient intervention includes: Comprehensive risk factor assessment (baseline and every 6 months) submitted to coordinating center at UCSF Local (JHU) brief assessment on target risk factors (disclosure of HIV status; condom use; drug use/abuse) at each visit, usually scheduled every 3 months, for 1 year

Challenges/Providers Culture that fosters commitment to excellence among medical providers may also cultivate certainty that that care they are providing is already “best” practice Providers have tight schedules in clinic, raising concerns: interfering in the clinic flow finding time for training time for prevention counseling within encounter may displace other priorities Providers have a variety of backgrounds, e.g., physicians, physician assistants, and nurse practitioners,  and have different expectations for and response to training

Challenges/Patients Patients have different motivations: In some clinics, patients indicate they will participate in any research which furthers understanding of HIV/AIDS In others, data collection activities may be burdensome or arouse suspicion Fitting in with patient schedules Providing a sense of security for collection of sensitive information Encouraging patient to keep appointments/remain with study for 1 year enrollment

Facilitators/Providers Substantial interest in providing the best possible care Specific interest in prevention among some providers Emerging evidence that reducing transmission behaviors may improve treatment outcomes as well as public health outcomes

Facilitators/Patients Belief that study is in the patients’ best interest Rapport between recruiter, providers, and patients Stable clinic and good care Response to patient concerns about confidentiality, etc Useful incentives

In summary Our activities include: Expert training to build local capacity for stage of change skills (client instructor team) Expert introduction to provider training Maintain provider skills with booster sessions Respond to coordinating center activities Local survey/assessment Track and evaluate all of the above

Acknowledgement:  Many thanks to the staff of the Center for Health and Behavioral Training at the University of Rochester, New York, Patricia Coury-Doniger, PI, for their assistance.

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