Options Project Staff Jeffrey D. Fisher, Ph.D, Principal Investigator University of Connecticut

2. The Options Project:Physician-Delivered Interventionfor HIV+ Patients in Clinical CareWilliam A. Fisher, Ph.DUniversity of Western OntarioDeborah Cornman, Ph.D.University of ConnecticutRivet Amico, Ph.D.University of Connecticut (NIMH grant 1R01 MH594378)

3. Options 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

4. 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

5. Special Thanks to Participating Health Care Providers and HIV+ Patients: 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 And All Patient Participants

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

7. Evidence of Risky Behavior:Options Project Data from HIV+ Patients in Clinical Care

8. Demographics: Options Project HIV+ Patients in Clinical Care

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

10. Modes of HIV Transmission(N=307)

11. Risk Behavior: Options Project HIV+ Patients in Clinical Care

12. Vaginal and Anal Sexual Eventsin the Past Three Months(N=315) • 49% (155) of all HIV+ patients reported vaginal or anal intercourse during the past three months. • 42% (65) of these HIV+ patients reported some degree of risk -- no condom use -- during one or more vaginal or anal intercourse event.

13. In the past three months, 155 HIV+ patients--49% of sample--engaged in 3838 vaginal or anal sex events 37% (1406) unprotected sex events 63% (2432) protected sex events

14. In the past three months, 65 HIV+ patients--21% of sample--reported1406 unprotected vaginal or anal sexual events 34% (482 events) with HIV positive partners 66% (924 events) with HIV negative or unknown partners

15. Partners Potentially Exposedto HIV HIV+ patients engaged in unprotected vaginal or anal sex with a minimum of 391 HIV negative or status unknown partners in past three months.

16. Viral load of HIV+ patients engaging in risky vaginal or anal sex with HIV negative or status unknown partners: • 61% had detectable viral loads • 48% had viral loads at or above 1500 Estimated from 23 high risk participants whose viral load indices were available as of July 2001.

17. Injection Drug Use • 25% (46) of patients who were questioned reported injection drug use in the past month. • 28% (13) of those who used injection drugs in the past month borrowed or lent works or needles.

18. Substantial risk to self and othersclearly exists in an HIV+ patient clinical sample

19. Mounting evidence of transmission of resistant strains of HIV makes this even more problematic

20. The Options Project Collaboration of Clinical Care Providers, HIV+ Patients, and Researchersto Assist HIV+ Patients Address Risky Behaviors

21. Clinical care providers have an outstanding opportunity to address safer sex and safer needle use with HIV+ patients: --Repeated contact --Trusting relationship

22. Linking Treatment and Prevention: Essential, Efficient, and Potentially Highly Effective Brief, repeated, clinician-initiated interventions with potentially powerful cumulative effects.

23. Clinicians rarely address safer sex and safer needle use with HIV+ patients (Janssen et al., 2001; Wilson & Kaplan, 2000).

24. Why health care providers do not discuss HIV prevention Information Factors • Minimal knowledge about HIV+ patients’ risk reduction needs and risk reduction strategies (Epstein et al., 1999). Motivation Factors • Time pressure, physician and patient discomfort with topics of sex, drugs, and risk, and confidentiality concerns (Elford et al., 2000).

25. Why health care providers do not discuss HIV prevention(continued) • Clinicians lack specific skills necessary for HIV risk reduction counseling (Elford et al., 2000). • Lack of a good “opening line,” vague language, and provider-centered interview style (Epstein et al., 1999). Behavioral Skills Factors

26. The Options Project Elicitation Research • Dynamics of HIV risk behavior among HIV+ patients in clinical care. • Clinician recommendations concerning HIV prevention interventions that can be integrated into clinical care settings.

27. Intervention Development: • Design and implement the Options Project, a clinician-initiated HIV prevention program for HIV+ patients. • Guided by elicitation research and by the Information--Motivation--Behavioral Skills HIV prevention model.

28. 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)

29. Options Project Protocol for Provider Interactions with Patients

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

32. Step 1: Set 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.”

33. Step 2: Assess 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?]”

34. Step 3: Summarize risky behaviors, and ask 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?”

35. Step 4: Determine how to proceed by having patient rate:(1) “importance” of changing his/her risk behavior(2) “confidence” that he/she could successfully change that behavior

36. Importance and confidence ratings are indicative of patient’s: • Readiness to change • Level of Information, Motivation, and Behavioral Skills deficits

37. Assessing Importance and Confidence: “I would like to better understand how you feel about [changing this behavior]. 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 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 this behavior].”

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

39. IS RATING FOR IMPORTANCE < 7 ? NO YES LOW IMPORTANCE DISCUSS BARRIERS TO CHANGING BEHAVIOR (OR DO RELAPSE PREVENTION IF NOT ENGAGING IN ANY RISKY BEHAVIORS) 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? NO WHICH RATING IS LOWER? IF SAME, CHOOSE IMPORTANCE ASK: (1)WHY IS IMPORTANCE THAT SCORE AND NOT LOWER? (2)WHAT WOULD NEED TO HAPPEN TO RAISE THAT SCORE? ASK: (1) WHY IS CONFIDENCE THAT SCORE AND NOT LOWER? (2)WHAT WOULD NEED TO HAPPEN TO RAISE THAT SCORE?

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

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

42. Step 8: Record goal or action plan on Options Prescription Pad, and give “prescription for prevention” to patient.

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

44. Subsequent Options Meetings • Review documentation from last visit. • Explore progress patient made toward achieving goal set at last visit. • Reassess Importance and Confidence. • Negotiate goal for next visit. • Document new goal on Options Prescription Pad, and give to patient.

45. Training Providers in the Options Protocol • Four-hour didactic and interactive training including substantial role-playing, with the following agenda:

46. Provider Training Agenda I. Overview of Training II. Project History, Background, and Theory III. Behavior Change Exercise IV. Introduction of Motivational Interviewing V. Overview of Intervention Protocol VI. Video Demonstration of Protocol VII. Step-by-Step Practice of Protocol VIII. Practice of Entire Protocol IX. Logistics of Implementation

47. Evaluating and Ensuring Intervention Fidelity Multiple methods were used: • Role-play of protocol with simulated patients • In-vivo observation of actual protocol delivery • Patient Exit Questionnaires • Patient Record Forms

48. Feasibility of the Intervention • Intervention was consistently implemented, despite providers’ demanding schedules and time constraints. • On average, an Options patient received intervention protocol on 80% (median) of his/her medical visits.

49. Sample Options Protocol Implementation

50. For more information... Bill Fisher: fisher@julian.uwo.ca Debbie Cornman: dcornman@uconnvm.uconn.edu Rivet Amico: ramico@uconnvm.uconn.edu CHIP website: http://psych.uconn.edu/chip.html