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

1. The Options Project: A Clinician-Initiated Interventionfor Reduction of HIV Risk BehaviorAmong HIV+ Patients in Clinical Care(NIMH grant 1R01 MH594378)William A. Fisher, Ph.D.Center for HIV Intervention and PreventionUniversity of ConnecticutDepartments of Psychology and Obstetrics and GynaecologyUniversity of Western Ontario(email: fisher@uwo.ca)

2. Project Staff Jeffrey D. Fisher, Ph.D, Principal Investigator University of Connecticut 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. The ProblemHIV+ persons in clinical care may engage in risky behaviors that adversely affect their own and others’ health.

4. Exploring HIV Risk: The Options Project HIV+ Clinical Care Sample

5. Gender and Ethnicity(N=489) Mean Age: 43.38 (7.69) Age Range: 22.93 to 70.06

6. Modes of HIV Transmission(N=489)

7. Three Month Risk Behavior Data: Options Project HIV+ Clinical Care Sample

8. Sexual Partners Potentially Exposed to HIV 52 HIV+ Patients Engaged in 1072 Risky Vaginal or Anal Sex With 197 HIV- or HIV Unknown Partners

9. Injection Drug Use Partners Potentially Exposed to HIV • 29 HIV+ Patients Who Injected Drugs Last Month Borrowed or Lent Uncleaned Works or Needles With: • 210 HIV- partners • 200 HIV unknown partners • 75 HIV+ partners

10. Substantial risk behavioramong HIV+ patients in clinical care.

11. Towards a Solution:Clinician-Initiated Interventions in Clinical Care Settings

12. Clinical Care Setting: Outstanding Opportunity to Promote Safer Behaviors Among HIV+ Persons • Efficient and most nearly universal access to HIV+ persons. • Clinicians have repeated contacts with HIV+ persons over course of illness. • Clinicians very often have strong and trusting relationships with patients.

13. HIV clinical care setting affords opportunity for clinician-initiated interventions that are brief, repeated, and potentially possess powerful cumulative effects.

14. A collaboration between HIV care clinicians, HIV+ patients, and researchersto assist address HIV risk behaviors The Options Project

15. Specific Aim of The Options Project: Design, implement, and evaluate a clinician-initiated HIV risk reduction intervention for HIV+ persons in clinical care settings. Craft intervention that is brief, delivered on multiple occasions over time, and in the course of routine care.

16. Options Intervention Theoretical Foundation: 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)

17. Options Intervention Delivery Vehicle:Motivational Interviewing Patient Centered Techniques Deliver Information-Motivation-Behavioral Skills Content

18. Options Project Protocol for Clinician-Patient Interactions

19. Step 1: Setting the agenda. • “There are a couple of things that I talk about with all of my patients – safer sex and safer drug use. I would like to spend a few minutes talking with you about these issues, if that is okay with you.”

20. Step 2: Assessing risk • “Many of my patients find it challenging to practice safer sex and safer needle use on a day to day basis. What works for you and what doesn’t, when it comes to safer sex?…clean needle use?”

21. Step 3: Ask patients to rate the “importance” of changing a risk behavior and their “confidence”that they could change it.

22. Assessing Importance: “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 risk behavior? You said it was x important to change this risk behavior. Why did you say x and not less? Whatwouldittake to make it more important to you to change this risk behavior?”

23. Assessing Confidence: “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 could change this risk behavior? You said you were x confident that you could change this risk behavior. Why did you say x and not less? Whatwouldittake to make you more confident that you could change this risk behavior?”

24. Step 4: Negotiate goal or action plan and record on Options Prescription Pad. • Allow the patient to choose a goal that is realistic and attainable in the context of his or her life.

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

26. 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)

27. Subsequent Options Meetings • Explore what, if any, progress the patient made toward achieving the goal set on the last visit. • Reassess Importance and Confidence concerning maintenance or new goal. • Negotiate an attainable goal for the next visit. • Give patient a new Options Prescription.

28. Training Providers in the Options Protocol Four-hour didactic and interactive training with substantial role-playing. (Feed Them and They Will Come)

29. Feasibility of the Options Project Intervention • 22 HIV care clinicians have been trained to criterion. • Options intervention is very consistently implemented, despite clinician time constraints. • 70%-80% of all patient medical visits include the Options intervention.

30. PreliminaryOptions Project Intervention Outcomes

31. Rivet Amico: Chi Square of successful reduction in high risk events OR in maintaining safer behavior versus increases or maint of high risk behavior showed that 10% of control group increased high risk (vs 2% in exp arm) and 91% in control group maint safer beh or decreased risk (vs 98% in exp arm) Six Month Follow-UpIntervention Outcome Results A greater proportion of intervention vs control participants successfully maintained safer sexual behavior or reduced sexual risk behavior over a six-month interval, despite having had only one to two clinician-initiated intervention interactions, Chi Square 8.215, p = .004.

32. Conclusion:Prevention can and should be linked to care for HIV+ patients.

33. Special Thanks to All ParticipatingHIV+ Patients and HIV Care Clinicians 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; Sandra Springer, MD; Lydia Aoun-Barakat, MD