HIV Risk Screening & Risk Reduction

1. HIV Risk Screening & Risk Reduction ANTHC MW AETC

2. There are no conflicts of interest or relationships to disclose.This presentation is intended for educational use only, and does not in any way constitute medical consultation or advice related to any specific patient.

3. Please fill-in the blanksYour Unique Identifier First 2 letters of First Name, and…. First 2 letters of Last Name, and then… 2-digit birth month and 2-digit birthdate. Example: Abe Lincoln, February 12, would be ABLI0212.

4. Learning Objectives • Describe how to use an HIV Risk Screening • Review how HIV risk can be associated with a history of unresolved trauma • Review how to use an HIV risk reduction plan with your clients

5. Have you ever worked with an HIV positive client? • Yes • No

6. Would you feel uncomfortable talking with a client about HIV testing? • Yes • No • Don’t Know

7. Where does HIV testing occur in your community? • Hospital • Clinic • Jail • School • Other

8. HIV Risk Screening

9. Why screen for HIV risk? • An HIV risk screening helps to identify client behavior that places them at risk for contracting HIV • If a client is diagnosed HIV+ they can be helped, by encouraging them to seek medical care • Screening & referring clients for HIV testing helps them know their HIV status • HIV screening helps a client to develop their personalized risk reduction plan & goals

10. Benefits of a Risk Screening for HIV • Opens door to discuss risks • Clients want information and don’t know how to get it • Basis for behavior change discussions • Opportunity to initiate, develop and enhance relationship with client

11. Youth and risk • During adolescence, patterns in relationships, communication skills, sexual behaviors, & use of health care services, are often established • Many youth lack comprehensive information about sexual health, sexuality, & building respectful relationships • Most youth say they have never had a conversation with a health care provider about HIV and STIs, condoms, or birth control • Tribes have worked at developing youth based sexual health websites (wernative.org, iknowmine.org) Wernative “native love is community”/relationship videos

12. Barriers that Hinder HIV Screening & Testing Unresolved identity Issues Unresolved trauma Mental Health Issues Perceived Lack of Confidentiality Substance use Perception of Stigma

13. Confidentiality • Protects client rights to privacy of health information • Limits unauthorized sharing of medical & counseling records • A review of confidentiality with client occurs at first contact and includes how privacy of medical & counseling health information is maintained by agency • Discussion helps build trust, safety, & an explanation of the counseling process & structure

14. Case Scenario--#1 • Margaret, 20 years old • Alaska Native raised in Anchorage by mom who was a binge drinker • Margaret left home at 16 years old with an older boyfriend • She arrives for a first counseling appointment • Would like to enter counseling and needs help reading & answering questions • How would you explain confidentiality to Margaret?

15. Moving away from Trauma

16. Intergenerational Trauma • Intergenerational trauma is the cumulative emotional wounding across generations provoked by critical incidents that occurred in the past • The trauma is held personally & collectively • For Alaska Native includes—infectious disease epidemics, boarding schools, limitation and discounting of traditional healing ways • For immigrants and refugees can include memories of war, loss and death • The behavior of many children of trauma survivors has often been misunderstood & treated harshly (reinforcing trauma experiences) YellowHorseBraveHeart, & DeBruyn, (2000)

17. The Adverse Childhood Experiences Study (ACE) • Examined the childhood origins of traumatic experiences as a pathway to social, emotional,& cognitive impairments that lead to increased risk for unhealthy adult behaviors, risk of violence, disease, disability, premature mortality • Research collaboration between CDC & Kaiser Health Plan’s Department of Preventive Medicine in San Diego, CA • The study population consisted of 17,337 consumers with 54% women, 46% men, mean age of 56 years, 36% some college, 7% not graduated from high school Anda, Felitti, Walker, et al, (2006)

18. Adverse Childhood Experiences Household Challenges Abuse Neglect

19. What we know about traumatic childhood experiences • 81% off clients from substance abusing families, reported at least one other ACE & the majority experienced 3 or more ACEs • Child maltreatment impacted adult ability to self-manage negative emotions (which placed strain on social relationships) • A study by Kenney (2016) found a higher prevalence for depression, anxiety, & ADHD among Natives which was associated with multiple ACEs(Kenney & Singh, 2016) • Overall childhood maltreatment was found to be associated with long-term changes in brain structure & function

20. Transition to Adulthood • Traumatic experiences in early childhood have long-lasting effects on brain development (ventral striatum) which parallels behavioral development (reward, decision-making) • As adults, trauma impacts motivation, positive moods & depression • Childhood trauma can impact adult: drug use, mental health issues &/or chronic illness Hanson, et al., (2015)

21. Identity within Trauma • Identity is the crossroad of culture, gender, nationality • It is changing & not stable • Frequently has the effect of creating new & difficult-to-comprehend identities for clients (being broken, damaged) • It is the “I am because of what happened” • Trauma can interfere with basic human expressions of self--particularly within a relationship

22. Questions • If my client presented with a trauma history, I would: • Prefer to refer to someone else • After counseling session, I would seek out more information • Consult with co-worker

23. Counselor tactics—Trauma • Assess for possible trauma history • Increase your internal capacity to work with trauma and start to develop affect regulation skills • Increase self-awareness about how you slow down your own trauma response (an important aspect of good counselor functioning) • Attend to and fully listen to client trauma experiences expressed through their emotions, beliefs and behaviors • Help your client increase the consistency of their positive social network • Take care of yourself & consult with a co-worker to halt your own vicarious trauma

24. An Intersecting Identity: LGBTQ • Living a different gender & sexual orientation in a biased society requires being a survivor • Guilt can be the result of being different • Developmental stages can include False self-identity, Dual Identity, Coming Out & Self Acceptance • Trauma & pain can be the result of individual & community rejection • Counselors can benefit from increased understanding of their own possible “internalized homophobia” • Counselors may need to confront their own “Heterosexism”

25. Not a Choice • Sexual orientation is not a choice • Influenced by combination of factors: Genetic, hormonal, environmental • During first counseling contact focus on: • Relationship building • Exploring client’s safety in community • How does family &/or community support this client’s self-identity?

26. Tips----What can you do? Be respectful Develop awareness Challenge your assumptions

27. Question • If my young adult client informed me that they identified as LGBTQ, I would: • Work with them • Refer to a co-worker • Don’t know

28. Substance Use (General Population) • In 2016, 20 million (adolescents & adults) met criteria for substanceuse disorder • Alcohol use disorder represented the majority of the 20 million • 4.5 million people reported use of a licit &/or an Illicit drug (methamphetamine, prescription pain relievers, designer drugs, heroin) • 2.0 million reported both heavy, frequent alcohol and drug use www.samhsa.gov NSDUH, (2017)

29. Substance Use & Trauma • Amaro (2007) reported that women who participated in counseling for their traumaexperiences remained engaged in substance abuse treatment for a longer period of time • Women who decreased their substance use demonstrated increased self-efficacy in their relationships & reported more equity in sexual decision-making & more personal control engaging in HIV protective behaviors(Amaro, 2007) • Heavy alcohol/drug use & sexual aggression by men while partying was perceived by peers only as a lapse of judgment & not necessarily a problem behavior(Devries, Free, & Saewyc, 2012)

30. Substance Use & HIV • Limited HIV research targeting women and adolescent substance users • Currently limited data available--to inform effectiveness of early linkage of HIV treatment & ongoing adherence to medical care for active episodic substance users • Evidence Based Practice treatment protocols need integration of rural residents and communities • Limited access of substance users into HIV treatment research studies

31. Substance use and communities • What about your community? • Opioid use? • Tolerance of substance use?

32. Mental Health • It is estimated that 1 in 4 adult Americans suffer from a diagnosable mental illness during a given year • Mental illness carries enormous stigma and remains one of the most challenging barriers for effective client care • General anxiety disorders are estimated to occur in approximately 50% of people who are HIV positive in any given year • An estimated 60% of people who are HIV positive will suffer from depression symptoms during any 12 month period HRSA CAREAction(January 2015)

33. Co-occurring Disorders • Studies have documented client substance use (meth, alcohol, prescription drug misuse) for self-medication of mental health concerns • Diagnosis of substance abuse occurs for approximately 45% of clients with serious mental health issues • Youth who experience social anxiety are more likely to increase alcohol use to reduce tension in social situations (Mushquash, 2014) Clinical Psychology Review, Special HIV Edition (1997)

34. HIV related Stigma • A social process which is linked to the desire for power & control • Based on attributes (housing, race, class…) or behaviors (drug use, mental health issues…) • Leads to status loss & discrimination for the stigmatized person • As part of an extended family, a person often inherits their family’s grievances, disagreements, and community perception of worthiness (Disagreements can extend over many generations and impact a person’s sense of well-being & security in their own community)

35. Why would someone be tested for HIV? • Testing can help move you forward to knowing about your health and what you can do about it • Testing can help educate you about the illness and be less critical of others who are HIV positive • A person has heard about someone in their community who has been diagnosed with HIV & is worried about their own health • A person knows minimal” about HIV transmission and has been feeling sick ”like the flu”

36. HIV Risk Screening • Substance Use History • 1. What have you heard about the link between drug & alcohol use, sexual intimacy, and HIV infection? • 2. If you use injection drugs what do you do with the needles and works? • Relationship History • 1. Within the last 3 months have you had more than one sexual partner? • 2. What do you know about the past sexual activity of your partner(s)? • 3. Have you felt safe in your past relationships? • HIV testing • 1. Have you been previously tested for HIV? • 2. If so were you provided HIV education & counseling? HIV/AIDS Online Training Modules/ Indian Health Service

37. Referrals • Establish & maintain contacts with agencies, spiritual communities, schools, community-at-large • Continuously assess & evaluate referral resources to determine their appropriateness—nurture collaborative relationships, referral feedback, client feedback • Differentiate between situations where it is most appropriate for client to self-refer and instances requiring counselor referral—assess client’s readiness, educate your client about how to advocate for themselves & family • Review confidentiality with client & use of Release of Information form before you share information with outside referral agency/clinic • Evaluate the outcome of the referral

38. HIV Risk Reduction Planning

39. Harm Reduction & HIV Risk Reduction • Public health approach & intervention for behaviors that harm individuals & their communities • Focus on improving the health of the public as well as decreasing the harmful behavior of the individual • The focus is on ”one behavior at a time” • Requires checking in with each client regarding their “change” goal at each client visit or contact

40. Using Harm Reduction • Pragmatism, being practical • Focusing on a target behavior • Aiming at a goal • Providing ongoing education about targeted behavior • Exploring steps with client to meet the goal

41. HIV Risk Reduction Plan Behavior to Target: Steps:  1. 2. 3. Where can I get support?

42. Readiness to Change • So how do we help decrease HIV risk with our clients? • Assess client’s readiness to change • Listen and use “problem solving” based on client readiness to change

43. Stages of Change/Readiness to Change Source: Prochaska and DiClemente, 1983

44. Working with client risk behaviors • Encourage positive self-talk about changing behavior • Be aware that learning new self-advocacy skills can cause tension & discomfort • New skill acquisition can be both positive and negative (depending on who your client is talking with) • New skills require time, curiosity, persistence, practice and patience

45. Three Steps 1. Use client’s risk screening responses to identify target behavior • (Identify client’s personal perception of risk) 2. Work with client to explore the target behavior • Identify client’s level of readiness for change • Assess strengths & barriers 3. Develop a personalized action plan • Assist development of realistic steps • Refer to specialized services, if needed

46. Counseling Tip: Providing Reassurance • We all have regular ups & downs • The goal is to have clients realize the occurrence of these ups & acknowledge and let go of the downs • HOW TO? • Increase awareness that emotions are often like “passing weather” • Increase awareness that negative emotions may last for a few minutes, a day, and often flit from one emotion and thought to the next • Use examples or metaphors • Encourage client to decrease judgment of their emotions or thoughts Focus on breath for 30 seconds

47. Case Scenario--#2 • Margaret is a 20 year old woman • She recently completed an inpatient substance abuse treatment program • She reports a past partner being recently diagnosed with HIV • She is ambivalent & confused about whether to be tested for HIV • Expresses fear of HIV stigma • ************************************************************** • One counselor, one client, & observer(s) • Explore ambivalence about HIV testing

48. Steps 1 & 2--HIV Risk Screening/Select Behavior • 1. Use HIV Risk Screening form to identify target behavior • 2. Explore barriers to & strengths for success associated with target behavior

49. Step 3Develop a Realistic, Simple Plan • 3. Target behavior Steps: Help client select & review steps to success Explore social support: Help client select one person to talk with about their plan

50. Review & Summarize Client Risk Reduction Plan