Brief Safer Sex Intervention for HIV Outpatient Clinics

1. Brief Safer Sex Intervention for HIV Outpatient Clinics Partnership for Health The Action of One, The Partnership of Two, The Power of Many Jean Richardson DrPH, Principal Investigator Sue Stoyanoff MPH, Joan M. Weiss MPH, Maggie Hawkins MPH

2. Prior Research • 44% of 577 of HIV+ men had unsafe sex with about 2 partners each during the previous 2 months;oral, vaginal or anal sex without condom. (DeRosa, 1998). • 20% of 168 HIV+ men & women had Unprotected Anal Sex with last partner (Wenger, 1994). • 59% of 131 men with AIDS had unprotected vaginal sex with female partners (Simon, 1998) • 22% of 323 men with AIDS had unprotected anal sex with male partners (Simon, 1998).

3. PfH Study • NIMH-funded study • Principal Investigator-Jean Richardson, DrPH • USC, UCSD, USF, Orange County, LAGLC, Santa Clara Valley MC

4. Unique Characteristics of the Program • HIV prevention for people living with HIV • Designed for HIV outpatient clinics • Teaches medical providers & staff to talk with HIV positive patients about safer sex and disclosure • Prevention integrated into routine care • Every patient counseled at every visit • Can be retained with very little expense • Can bring a change in clinic norms

5. Study Intervention • Provider initiates a 3 - 5 minute interaction focused on: • Patient Self Protection • Partner Protection • Disclosure of status to sex partners • Emphasizes the patient/provider partnership • Messages reinforced at every visit

6. Study Clinics • Research conducted with 6 clinics in Northern and Southern California during 1998-99 • Large number of patients surveyed (N=887) representing a diverse patient population • Only sexually active people were interviewed • The 6 clinics were divided by provider communication style: • Advantages (Gain) Frame • Consequences (Loss) Frame • Adherence to Medication (Control Group)

7. Demographic & Disease Characteristics of PfH Study Population (N=886 at Baseline) • Sex Partner MSM 634 72% Gender MSW 137 15% WSM 104 12% WSW 11 1% • Ethnicity African American 151 17% Hispanic 323 36% White 355 40% Other 57 7% • CD4 <200 192 22% >200 682 78%

8. Many HIV Positive Patients are Engaging In Unsafe Sex • Overall, 34% of participants had unprotected anal or vaginal sex (UAV) with at least 1 partner in the prior 3 months. • Of those with one partner, 26 % engaged in UAV • Of those with two or more partners, 51% engaged in UAV

9. Patients Not Routinely Counseled About Safer Sex & Disclosure • On a baseline patient survey (N=884) : • 32% said their medical provider NEVER talked to them about safer sex. • 55% said their medical provider NEVER talked to them about disclosure to sex partners.

10. Providers Feel Responsible ButAren’t Routinely Counseling • On a baseline provider survey (N=74) : • 97% felt they had some responsibility to talk about safer sex. • Only 51% said they often talk about safer sex at the initial visit. • Only 17% said they often talk about safer sex in the absence of STDs.

11. Summary of Research • Many HIV+ patients are having unsafe sex and are not disclosing their HIV status to sex partners. • Patients are not routinely counseled about these issues when visiting their medical provider. • Provider counseling and materials can make a difference • The Partnership for Health Program provides training to HIV clinic providers to talk with patients about safer sex and disclosure.

12. Changing Sexual Behavior Is a Gradual Process • Partial success can make a big difference in the epidemic. • While the message “All sexual interactions should be protected” is the goal, encouragement and acknowledgement must be given for progress toward that goal.

13. Half-Day Training Agenda 4 hour training for providers & staff at their clinic • Program background (PP presentation) and review of supporting materials • Behavior change theories and models • Communication skill building • How to conduct a brief counseling session • Patient profiles with role plays and discussion • Tips on helping patients build safer sex & disclosure skills • Final questions and comments

14. Materials • Comprehensive training manual • Video with sample scenarios • Posters for the waiting room & exam room • Brochures (English & Spanish) • Chart Stickers • 8 different Informational Flyers on related HIV prevention issues (English & Spanish)

15. Study Intervention Flow Chart Patient enters clinic & receives brochure Sees PfH posters on walls Reads brochure and takes it to exam room Provider discusses safer sex & disclosure Reviews brochure with patient Checks off sticker in patient’s chart • At next visit--provider asks about progress, addresses barriers and reinforces message.

16. Provider Communication Styles Advantages Consequences Not using condoms puts you at risk for getting STIs. Using condoms can help keep you free from STIs.

17. If you do this healthful activity, then something good will happen. “If you use a condom, you may feel better about yourself after having sex.” If you do this healthful activity, then something bad won’t happen. “If you use a condom you avoid feeling guilty after sex.” Framing Messages – AdvantagesThere are two ways to construct an advantages (gain) frame message:

18. If you don’t do this healthful activity, then something bad will happen. “If you don’t use a condom, you may feel bad about yourself after having sex.” If you don’t do this healthful activity, then something good won’t happen. “If you don’t use a condom you may not feel good about yourself after having sex.” Framing Messages – ConsequencesThere are two ways to construct a consequences (loss) frame message:

19. Sample Patient Profile

20. Explain what the Partnership for Health is Ask questions about sexual behaviors & disclosure Respond to questions & provide referrals Review behavioral goals Use good interpersonal communication skills If the patient is abstinent: Clarify “abstinence” Reinforce healthy behaviors Discuss what to do if he/she has sex in the future If the patient is sexually active, share these 3 messages: Protect yourself Protect your partner Disclose to sex partners Provider Intervention Outline

21. Role Play Discussion Questions • What were the patient’s barriers to practicing safer sex and/or disclosing? • Patient’s positive beliefs, behaviors or situations that can be reinforced? • What goals did you set as a team? What priorities? Any referrals given?

22. Prevention for Positives It’s good for the: • Patient • Provider • Clinic • Community

23. Thank you for your attention.Please fill out the brief survey. Partnership for Health The Action of One, The Partnership of Two, The Power of Many