Prevention With Positives

1. Prevention With Positives Practical Tools for brief interventions in your busy Practice

2. New generation of prevention programs targeting individuals who Current emphasis arises from What is Prevention with Positives (PwP)? On national, state and local levels there is growing acknowledgement that prevention programs for positive individuals need to be a routine component of care.On national, state and local levels there is growing acknowledgement that prevention programs for positive individuals need to be a routine component of care.

3. Why a New Initiative for HIV Prevention? 40,000 new HIV infections still occur in the United States each year One-quarter of the 850,000 - 950,000 PLWH/A in the U.S. do not yet know they are infected Recent increases in syphilis diagnoses among men who are HIV-infected suggests ongoingrisk behaviors among PLWH/A and their partners Historically, prevention efforts have focused on HIV negative individuals. If we are to prevent the spread of HIV, we must also work with HIV infected persons to decrease the rate of unsafe sex. Historically, prevention efforts have focused on HIV negative individuals. If we are to prevent the spread of HIV, we must also work with HIV infected persons to decrease the rate of unsafe sex.

4. Why the Emphasis on Prevention with Positives? Every person infected with HIV was exposed by a person who was HIV-Positive.

5. Sexual Risk Behavior Despite knowledge of HIV infection, many HIV-infected persons engage in high risk sexual behaviors Across studies of HIV positive MSM, women, and IDU 17-38% report unprotected vaginal or anal intercourse with partners who are HIV-negative or of unknown HIV status Gomez CA, Dawson Rose CS, Knight KR. Center for AIDS Prevention Studies Investigators Update: The Seropositive Urban Drug Injectors Study. 2000. � Erbelding EJ, et.al., Behavioral and biologic evidence of persistent high-risk behavior in an HIV primary care population. AIDS. 2000 Feb 18; 14(3): 297-301. Schreibman T, Friedland G. Human immunodeficiency virus infection prevention: strategies for clinicians. Clin Infect Dis. 2003 May 1; 36(9): 1171-6.

6. Incorporating HIV Prevention into the Medical Care of PLWH/A

7. Why integrate Prevention Activitiesinto Routine Care? Benefits persons living with HIV (PLWHA) and their sex partners Reaches large number of HIV+ persons Integrates behavioral prevention with routine medical care Exposes patients to repeat brief interventions across time Providers have a unique opportunity to educate their patients and to support them in maintaining safer sexual practices. Providers have a unique opportunity to educate their patients and to support them in maintaining safer sexual practices.

8. Risk Screeningbrief assessment of behavioral and clinical factors associated with transmission to identify: Patients at greatest risk for transmitting HIV Patients who need more in-depth risk assessment Patients who need referral to substance abuse or other services

9. Initiate or increase discussions to explore: Number of sex partners Type of sex partners (main, casual) HIV status of sex partners Safer and unsafe sexual behaviors Importance of patient self-protective and partner-protective sexual behavior Importance of disclosure Ask open ended questions.Ask open ended questions.

10. Screen for Behavioral Risk Assess current sexual behavior & its potential relationship to current mental/physical health Assess current barrier method and discuss proper use and alternatives Ask whether their HIV status is ever discussed Assess recreational drug use and its relation to sexual behavior Open ended questions helps clinician gather details to make meaningful recommendations. Directed questioning useful for identifying patients with problems that should be more thoroughly discussed. Open ended questions helps clinician gather details to make meaningful recommendations. Directed questioning useful for identifying patients with problems that should be more thoroughly discussed.

11. Screen for Clinical Risk Factors Annually screen for STD and more frequent if patient is high risk Presence of STDs often suggest recent or ongoing behavior that may result in transmission Identification and treatment of STDs can reduce potential spread among high risk populations

12. Partnership for Health Program HIV Prevention Program that works with people living with HIV to Decrease the level of unprotected sex they engage in Increase disclosure of their status to their partners

13. Partnership for Health Method At routine visits, the provider initiate a brief 3-5 minute discussion with focus on: protection of self Protection of partner disclosure PfH is a program that works with HIV infected persons to: Decrease the level of unprotected sex they engage in and increase disclosure to their partners. PfH is a program that works with HIV infected persons to: Decrease the level of unprotected sex they engage in and increase disclosure to their partners.

14. Four Key Communication Skills Understanding the patient perspective Active listening Redirecting Framing communication messages 1. Framing communication messages Consequences versus Advantages 2. Understanding the patient�s perspective Empathy, thinking & feeling 3. Active Listening Remain quiet while client is talking Ask questions or restate at the end Use open-ended questions to ensure that client has voiced their concerns/issue Watch your body language! 4. Redirecting �I�d love to hear more about that, but since we�re short on time I want to be sure we talk about�� Relaxed interaction and comfort with discussing sensitive issues1. Framing communication messages Consequences versus Advantages 2. Understanding the patient�s perspective Empathy, thinking & feeling 3. Active Listening Remain quiet while client is talking Ask questions or restate at the end Use open-ended questions to ensure that client has voiced their concerns/issue Watch your body language! 4. Redirecting �I�d love to hear more about that, but since we�re short on time I want to be sure we talk about�� Relaxed interaction and comfort with discussing sensitive issues

15. Framing Messages  Framing links a behavior with an outcome Gain frame emphasizes the advantages of safer behaviors Loss frame emphasizes the consequences for high risk behaviors Give examples: If you use a condom, you reduce your risk of getting an STD.Give examples: If you use a condom, you reduce your risk of getting an STD.

16. Partnership for Health Study 6 clinics in California (1998-99) Approx 9000 patients 75 primary care providers and 100 support staff Recruited 866 sexually active patients at baseline; follow-up on 2/3 of them Clinics divided into 3 conditions (10 mo intervention period) Advantage (gain) Frame safer sex counseling Consequence (loss) Frame safe sex counseling Adherence to Medication (control) group

17. Conclusion from Follow-up Data Consequence frame intervention was effective among persons with multiple partners (38% reduction in UAV) The consequence frame intervention was effective among persons with casual partners Neither frame was effective among those with only one partner Richardson et al. AIDS May 21,

18. Core Elements Integrating the prevention message into clinic visits so that every patient is counseled at every visit Providing referrals to needs that require more extensive counseling and services

19. Theories of Behavior Change

20. Knowledge Accurate information about risky behaviors Information about effective use of condoms

21. Skills Negotiate safer sex Correct use of condoms Talking with sexual partner about sex and HIV status

22. Motivation Does the person want to protect themselves and partner? If not, why not? Does the person think they can be successful? Does the person believe that barriers will be effective? Motivation is key! Someone might not care that he/she is exposing a casual partner he picks up at a club on week-end. But he might be motivated to protect self when he learns that he could be re-infected himself with resistant virus.Motivation is key! Someone might not care that he/she is exposing a casual partner he picks up at a club on week-end. But he might be motivated to protect self when he learns that he could be re-infected himself with resistant virus.

23. Resources Does the person have money to pay for condoms? Where to get them free? Are they engaged in survival sex? Are they being referred to get help with substance abuse, domestic violence, mental illness, etc that impact ability to disclose?

24. Support How much support does the person need to change? Does this vary based on needs? Where can they get support? Source: provider, mental health, helping them to identify resources

25. Transtheoretical Model (Prochaska & DiClemente, 1984) Precontemplation: Not even thinking about it Contemplation: Thinking about it Preparation: Taking steps to start behavior Action: Person tries behavior Maintenance: Person does behavior regularly Relapse: Person slips up & needs to make adjustments Key assumptions of the model is that is change is an incremental process and not a discrete outcome. Change takes time. Relapse is rule, not the exception. Key assumptions of the model is that is change is an incremental process and not a discrete outcome. Change takes time. Relapse is rule, not the exception.

26. Transtheoretical Model of Behavior Change Patients come to us a various stages of readiness; they may be anywhere along the continuum. Assess where they are.Patients come to us a various stages of readiness; they may be anywhere along the continuum. Assess where they are.

27. First Things First! Work with the patient to identify a behavior to be targeted for change Identify where the patient stands on the readiness-to-change continuum Establish with the patient incremental goals � appropriate to their readiness - to move toward the desired change

28. Where will I find the time?

29. Suggestions Structure clinic or office to support/enhance prevention Provide ALL patients with printed information about transmission risks Visual Cues containing prevention messages Have condoms readily available Reinforcing prevention messages throughout clinic visits underscores its importance and increases likelihood that it will be remembered.Reinforcing prevention messages throughout clinic visits underscores its importance and increases likelihood that it will be remembered.

30. More Suggestions Have nurse /MA ask pertinent questions before client sees doc. Use Self-administered questionnaire Utilize checklist on chart as reminder and to note what was addressed Posters, brochures etc. Ask open ended questionsAsk open ended questions

31. Ongoing Delivery of prevention Messages Multidisciplinary Approach -Nurse -social worker -Health educator Skills vary among staff from different disciplines. Patient may be more receptive to discussing prevention issues with one team member than another.Skills vary among staff from different disciplines. Patient may be more receptive to discussing prevention issues with one team member than another.

32. Summary Screen Risk Behaviors Brief Prevention Message Q visit Positive Reinforcement Identify/Treat STDs Refer for Mental Health/Substance Abuse Partner Notification

33. Resources are available! No need to reinvent the Wheel