August 3, 2001 Conference sponsored by the Center for Mental Health Research on AIDS, National Institute of Mental Healt

1. Physician-Delivered Interventions: The Options Project(NIMH grant 1R01 MH594378)Jeffrey D. Fisher, Ph.D., DirectorCenter for HIV Intervention and PreventionUniversity of Connecticut(email: jfisher@uconnvm.uconn.edu) August 3, 2001 Conference sponsored by the Center for Mental Health Research on AIDS, National Institute of Mental Health (NIMH)

2. Project Staff Jeffrey D. Fisher, Ph.D, Principal Investigator University of Connecticut William A. Fisher, Ph.D., Co-Principal Investigator University of Western Ontario Gerald Friedland, M.D., Co-Principal Investigator Yale University Deborah H. Cornman, Ph.D., Project Manager University of Connecticut Rivet Amico, Ph.D., Assistant Research Professor University of Connecticut

3. Project Staff (Continued) Tim Evans, Health Educator University of Connecticut Liz Harmon, Health Educator University of Connecticut Christine Woolley, Health Educator University of Connecticut Stephen Arnold, Abby Levine, Ianita Zlateva University of Connecticut Jack Ross, M.D., Investigator Hartford Hospital

4. Special Thanks to Participating Health Care Providers: Ken Abriola, MD; Frederick Altice, MD; Nancy Angoff, MD; Martha Buitrago, MD; Elizabeth Cooney, MD; Steve Farber, PA; Tim Hatcher, PA; Michael Kozal, MD; Michael Lawlor, MD; Neil Olson, MD; Phillip Pierce, MD; Tanya Schreibman, MD; Lynn Sullivan, MD; Jonathan Tress, MD; Holenarasipur Vikram, MD; Ann Williams, PhD; Madeline Wilson, MD; Hussein Zaioor, MD

5. The Problem: HIV+ patients in clinical care may engage in risky behaviors that can adversely affect their own and others’ health.

6. Evidence on Risky Behavior from Options Project Data on Patients in Clinical Care

7. Demographics of our Clinical Care Sample

8. Gender, Ethnicity, and Age(N=315) Mean Age: 43.92 (7.66), range 22.93 to 66.96

9. Modes of HIV Transmission(N=307)

10. Risk Behavior Data from Options Project Patients in Clinical Care

11. Past and Present Injection Drug Use About 62% of participants who were questioned reported ever having used injection drugs, while 25% reported injection drug use in the past month. • Of those who used injection drugs in the past month, 28% borrowed or lent uncleaned works or needles during this interval. 61% of those who have ever used injection drugs have been in recovery for a year or more.

12. Sexual Events in the Preceding Three Months(N=315 participants) 49% (155) of the whole sample reported engaging in a vaginal and/or anal sexual event in the preceding three months. 42% (65) of these individuals reported some degree of risk (events with no condom use) during one or more of these events.

13. In the preceding three months, 155 participants engaged in 3838 Vaginal and/or Anal Sex events 63% 2432 sex events were protected 37% 1406 sex events were unprotected

14. Of the 1406 unprotected sex events reported by the 65 participants reporting risky sexual behaviors: 34% (482 events) involved HIV Positive Partners 66% (924 events) involved HIV Negative and/or Unknown Partners

15. Potential Partners Exposed to HIV Our estimates indicate that in the past three months, participants engaged in risky vaginal and/or anal sex with a minimum of 391 partners of negative or unknown HIV status.

16. Clearly, there issubstantial risk behaviorin our clinical sample

17. Given mounting evidenceof the transmissionof resistant strains of HIV, this is even more problematic than in the past

18. Co-existing with this risk, substantial numbers of patients were in Prochaska’s maintenance stage of behavior change (consistently using condoms during sex for 6 months or more)

19. 55% of 174 participants reporting sex events over the last 3 months were in Prochaska’s maintenance stage of condom use behavior.

20. Health care providershave an excellent opportunity to address risky and reinforce safer behaviors in their HIV+ patients • Many have a trusting relationship with their patients. • Many have repeated contacts with their patients over long periods of time.

21. This affords the opportunity for brief, repeated, provider-initiated interventions with powerful cumulative effects

22. But health care providers’ interactions with patients about patients’ risky and safer behaviors are relatively infrequent

23. Research reveals that sexually active HIV+ patients do not receive adequate HIV prevention counseling (Janssen et al., 2001). • There is great variability between health care providers in the extent to which they initiate HIV prevention discussions with HIV+ patients (Wilson & Kaplan, 2000).

24. A recent literature review found little evidence of rigorously evaluated, effective interventions involving health care providers attempting to assist HIV + patients with safer sex behavior (Janssen et al., 2001).

25. Why health care providers do not discuss HIV prevention Information Factors • Many health care providers have minimal knowledge about risk reduction strategies (Epstein et al., 1999). • Most have not participated in educational programs to heighten their ability to perform such interventions (Epstein et al., 1999). Motivational Factors • Other issues involve lack of time, physician/patient discomfort, and confidentiality (Elford et al., 2000). • Some physicians are especially uncomfortable discussing sexual and drug related issues.

26. Reasons why health care providers do not discuss HIV prevention(continued) Behavioral Skills Factors • Many health care providers lack the necessary skills to discuss HIV risk reduction (Elford et al., 2000). • Communication barriers to providers engaging in HIV risk reduction include: lack of a good “opening line,” vague language, and the provider-centered interview style (Epstein et al., 1999).

27. The Options Project: A collaboration between health care providers, HIV+ patients, and researchersto assist HIV+ patients address risky behaviors

28. Specific aims of The Options Project: • Conduct elicitation research: • To better understand the dynamics of HIV risk behaviors among HIV+ patients in clinical care. • To assess health care providers’ views about performing HIV prevention interventions.

29. Specific aims (continued) (2) Work with health care providers and their patients: • To elicit recommendations about effective provider-initiated HIV prevention interventions for HIV+ patients in clinical care. • To elicit recommendations about how best to integrate HIV prevention into the day-to-day clinical care routine.

30. Specific aims (continued) (3)Based on elicitation findings: • Design and implement the Options Project, a theoretically and empirically based provider-initiated HIV prevention program.

31. Specific aims (continued) (4) Conduct long-term intervention outcome research comparing the experimental intervention condition with a standard of care control condition.

32. Conceptual Basis of the Options Project

33. The Information - Motivation - Behavioral Skills Model of HIV Prevention HIV Prevention Information HIV Preventive Behavior HIV Prevention Behavioral Skills HIV Prevention Motivation (J. Fisher & Fisher, 1992, 2000; W. Fisher & Fisher, 1993)

34. Motivational Interviewing is used as a vehicle to deliver an Information-Motivation- Behavioral Skills intervention.

36. Options Project Protocol for Provider Interactions with Patients

37. Step 1: Setting the agenda to discuss safer sex and safer drug use • “There are a couple of things that I talk about with all of my patients – safer sex and safer drug use. I know that these are not easy issues to talk about, but I do think that they are important ones. So I would like to spend a few minutes talking with you about these issues, if that is okay with you.”

38. Step 2: Assessing risk behavior • “Many of my patients are finding it challenging to practice safer sex and safer needle use on a day to day basis…Now, I don’t know if these are issues for you, but if they are, I would appreciate it if you would help me to understand what this struggle is like for you. What works for you and what doesn’t, when it comes to safer sex?… [or clean needle use?]”

39. Step 3: Summarize risky behaviors, and ask the patient to choose one behavior on which to focus • “You said that you are doing [riskbehavior x] and [risk behavior y]. Let’s just focus on one of these areas for today. Which one would you prefer to talk about?”

40. Step 4: Determine how to proceed by first having patients rate the “importance” of changing the risk behavior they chose, and then their “confidence” that they could change it.

41. Importance and confidence ratings inform the provider about how to proceed by reflecting the patient’s: • Stage of change • Level of Information, Motivation, and Behavioral Skills

42. Assessing Importance and Confidence: I would like to better understand how you feel about [changing behavior x or y]. Can you help me by answering a couple of questions?… • (1) On a scale from 0 to 10 where 0 is ‘not at all important’ and 10 is ‘extremely important,’ how important is it to you to [change or maintain this behavior]?… • (2) On a scale from 0 to 10 where 0 is ‘not at all confident’ and 10 is ‘extremely confident,’ how confident are you that you can [change or maintain this behavior].

43. Step 5: Based on Importance and Confidence scores and the Options algorithm, further explore either Importance OR Confidence

44. IS RATING FOR IMPORTANCE < 7 ? WHICH RATING IS LOWER? IF SAME, CHOOSE IMPORTANCE YES LOW IMPORTANCE LOW CONFIDENCE YES PROBLEM-SOLVE STRATEGIES FOR OVERCOMING BARRIERS (OR PREVENTING RELAPSE) START HERE Options/Opciones Project Algorithm ARE RATINGS FOR BOTH IMPORTANCE AND CONFIDENCE 9 OR 10? (often true for maintenance) NO NO DISCUSS BARRIERS TO CHANGING BEHAVIOR (OR DO RELAPSE PREVENTION IF NOT ENAGING IN ANY RISKY BEHAVIORS) ASK: (1) Why is importance that score and not lower? (elicits self-motivating statements) (2) What would need to happen to raise that score? (directs provider on how to proceed) ASK: (1) Why is confidence that score and not lower? (elicits self-motivating statements) (2) What would need to happen to raise that score? (directs provider on how to proceed)

45. Step 6: Summarize the patient’s responses, and then elicit a menu of specific strategies from the patient for raising his or her score. • If the patient does not offer any strategies, ask permission to suggest some, and then provide a menu of strategies.

46. Step 7: Negotiate a goal or action plan with the patient by having the patient select a goal for the next clinic visit from a menu of goals. • Allow the patient to choose a goal that is realistic and attainable in the context of his/her life.

47. Step 8: Record the goal or action plan on the Options Prescription Pad and give the “behavioral prescription” the to patient.

48. Prevention Date:________________ Name:____________________________________ Plan:_____________________________________ _________________________________________ _________________________________________ _________________________________________ _________________________________________ _________________________________________ ____________________________ Prevention Prescription Date:________________ Name:____________________________________ Plan:_____________________________________ _________________________________________ _________________________________________ _________________________________________ _________________________________________ _________________________________________ ____________________________ Signature

49. Subsequent Options Meetings • Review documentation from last visit. • Explore what, if any, progress the patient made toward achieving the goal set on the last visit. • Reassess Importance and Confidence. • Negotiate an attainable, specific goal for the next visit. • Document the new goal on the Options Prescription Pad and give the new behavioral prescription to the patient.

50. Training Providers in the Options Protocol • We have used a four-hour didactic and interactive training (including substantial role-playing) with the following agenda: