Safer Sex Skills Building: An Evidence Based Intervention

1. Safer Sex Skills Building: An Evidence Based Intervention Trainers: Sarah Gainey MSW, LISW-CP Louise Haynes MSW Therese Killeen PhD Beatrice Koon MSW

2. Acknowledgements • Susan Tross, Principal Investigator • Aimee Campbell, National Project Director

3. HIV Risk in Women • Heterosexual women are among the fastest growing subgroups of people with HIV in the US • Women comprise 27% of new HIV infections; 80% via heterosexual transmission (CDC, 2008) • African American and Latina women at disproportionate risk • Women at greatest risk through primary male sexual partners (St. Lawrence et al., 1998; Weiss, 2000) • Critical factors associated with HIV risk and substance use

4. Features of Effective HIV Prevention Interventions For Women • Gender-specific • Comprehensive, includes skills-building • 4 or more sessions Prendergast et al., 2001; Semaan et al., 2002; Exner et al., 1997

5. Safer Sex Skills-Building (SSSB) HIV Risk Reduction Intervention Session 1: HIV/STI information, testing & counseling Session 2: Personal risk assessment, triggers, supports Session 3: Condom skill building, problem-solving Session 4: Negotiation Session 5: Slips, review, and graduation

6. Theory Social Cognitive Learning Theory Behavior is learned through the social processes of observation, modeling, skill rehearsal, and feedback, especially with one’s peer group Empowerment Theory Individuals are empowered to action by the processes of skill mastery, peer support, and ability to impact on one’s world

7. Overview of Manual • Manual, workbook, flip chart • 2 day training to introduce manual, demonstrate some of the content, chance to practice and receive feedback • More practice at home • End of the training will discuss implementation

8. Intervention ComponentsUnderlying PrinciplesSkill Building Procedures • Manual pages 5-11

9. Group Leadership Skills • “Manualized therapy” • Manual page 13

10. NIDA CTN Safer Sex Skills Building Protocol for Women • 12 Community-based treatment programs across 9 U.S. states • 7 Methadone Maintenance • 5 Outpatient psychosocial • Recruited between May 2004-October 2005 • N=515 women • Intervention co-facilitators and supervisors were recruited directly from participating programs

11. Observed (Baseline) and Predicted Means (3, 6 Months) for USO

12. Observed and Predicted Means for USO among Completers

13. SSSB among the CDC’s Good-Evidence Interventions http://www.cdc.gov/hiv/topics/research/prs/evidence-based-interventions.htm

14. SSSB Manual: CTN Dissemination Library Website http://ctndisseminationlibrary.org

15. Skills-Building Procedures • Information, Instruction, Discussion • Modeling • Rehearsal with Feedback and Coaching • Role-playing • Problem Solving

16. Components of the Intervention • Increase knowledge about HIV risk, STD and other risk behaviors for health • Increased perceived vulnerability for HIV. STD and unhealthy behavior • Enhance self-efficacy: safer sex, take care of health and help seeking • Learning to set personal goals • Condom use • Skills development • Enhance social support • Prepare for slips

17. Session 1: Introduction and HIV/STD Education • WORTH (Women on the Road to Health) Introduction: Purpose; (Counselor & Participant roles) • Warm-Up: Why I Want to Take Care of Myself • HIV Information • STD Information • HIV Testing and Counseling • Living with HIV (including HIV Treatment Information) • Closing: Homework; Worth Affirmation

18. Worth Affirmation • I am __________and I will stay healthy • I am __________and I will protect myself • I am __________and I will find support for my health • I am __________and I am WORTH IT! WORTH IT! WORTH IT!

19. You made it through Session 1

20. Session 2: Making it Real: HIV and STDs in Our Lives • Check-in • HIV in Our Lives • HIV Risk Rationalizations • Challenging Rationalizations: Story • Challenging Rationalizations: Own • Triggers for HIV/STD Risk Behavior: People, Places, things • Identifying Our Supports for Taking Care of Ourselves • Closing: Homework; Worth Affirmation

21. Session 2: Making it Real: HIV and STDs in Our Lives • 1. Check-in • Re-introduce • Read homework • Discuss any issues that arose

22. Session 2: Making it Real: HIV and STDs in Our Lives • 2. HIV in Our Lives • Objective: Make HIV/STDs more real in our lives • Being tough and untouchable may translate into not taking care of our bodies • “Nothing can happen to me” • Each member thinks of a woman they know who has/had HIV/STD

23. Session 2: Making it Real: HIV and STDs in Our Lives • 3. HIV Risk Rationalizations • Objective: Increase participants’ awareness of the attitudes that put them at risk of getting HIV or STDs • Define “rationalizations” & how they may make us feel invulnerable to HIV/ STDs • Answer Qs in workbook p16-17 • Discuss & write out answers using flip chart #9 • Importance of 1. recognizing rationalizations & 2. challenging them

24. Session 2: Making it Real: HIV and STDs in Our Lives • 4. Challenging Rationalizations: Story * • Objective: Strengthen participants’ ability to challenge risk rationalizations • Act out Jesse & Mathilde • Flip chart #11: Engage group & write out Rationalizations & Challenges • Resume role-play & have participants challenge each rationalization • Talking with friends helps them & strengthens your own commitment

25. Session 2: Making it Real: HIV and STDs in Our Lives • 5. Challenging Rationalizations: Own • Objective: Strengthen participants ability to challenge their risk rationalizations • Break into pairs & turn to answers in Workbook p 15-16 • Tell partner #1 rationalization for risky behavior • Role play: partner is You and you try to challenge rationalizations

26. Session 2: Making it Real: HIV and STDs in Our Lives • 6. Triggers for HIV/STD Risk Behavior: People, Places, things * • Objective: Help participants ID their own triggers & make connection between triggers & risky behaviors. • Define TRIGGERS & emphasize importance of being aware of TRIGGERS • Flip Chart #12: Engage & explore PEOPLE, PLACES, THINGS & EMOTIONS that are triggers for unsafe sex. • Explore FEELINGS & ACTIONS associated with them • Participants answer for themselves in Workbook p18

27. Session 2: Making it Real: HIV and STDs in Our Lives • 7. Identifying Our Supports for Taking Care of Ourselves • Objective: ID people in participants’ lives who support/hold back in trying to stay healthy • Reiterate importance of identifying people who support us/hold us back • Workbook p 19 • Heart People • Handshake People • Small Talk People • Circle supports/ line through triggers

28. Session 2: Making it Real: HIV and STDs in Our Lives • 8. Closing: Homework; Worth Affirmation • Objective: ID 1 important trigger & 1 person who can help participants’ deal with trigger. ID situations in which they need support • Homework: Workbook p 20 • Flip Chart #13: WORTH Affirmation

29. Demonstration: Activity # 4: Challenging Rationalizations One day Vanessa and Mariah are talking about a man that Mariah was hanging out with the night before. Vanessa is trying to find out if Mariah was being safe. Mariah explains that she is not in danger of getting HIV. Vanessa: Hey Girl, who's that man you were hanging with last night? I haven't seen him before. He looks better than most of the men we’ve got around here. I know you said you’ve been taking care of yourself lately, so how’d last night go? You made him wrap it up, right? Mariah: What do you mean…make him use a condom? He doesn't need to! He isn't shooting drugs or anything. Besides, he isn't like that...he hangs out with nice people. He goes to church every Sunday, and he's clean, and eats good too. You know he works out...goes and lifts weights. He’s like the perfect man…how am I gonna get HIV from someone like him?

30. Demonstration: Activity # 4: Challenging Rationalizations • Flip chart #11: What are Mariah’s Rationalizations • What are some Challenges? • Resume role-play & have participants challenge each rationalization • Talking with friends helps them & strengthens your own commitment

31. Demonstration: Activity #6: Triggers for HIV and STD Risk Behavior • TRIGGERS- make us feel bad enough or good enough to do risky things • Being aware of TRIGGERS helps keep us safe • Flip Chart #12: Engage & explore PEOPLE, PLACES, THINGS & EMOTIONS that are triggers for unsafe sex. • Explore FEELINGS & ACTIONS associated with them • Participants answer for themselves in Workbook p18 & discuss their own triggers • Be sure to emphasize intimate partner violence & drug and alcohol use in risky sexual behavior

32. You made it through Session 2

33. Session 3: Making it Real: Turning Up Our HIV/STD Safer Sex Skills • Check in • Getting Smart About HIV/STD Risk, Yellow & Green Light Behaviors • Condom Use Practice and Feedback-Male • Condom Use Practice and Feedback-Female • Eroticizing safer sex • Self-Talk in Tough Risk Situations • Problem-Solving the SODAS Way • Closing: Homework; Worth Affirmation

34. Session 3: Objectives • To discuss in detail what behaviors put people at risk for HIV/STDs • To practice correct male and female condom Use • To identify ways of making safer sex sexy • To demonstrate the use of self-talk in identifying options for actions • To teach the participants a problem solving model that can help keep them from risky sexual and drug use behaviors

35. Activity 3 & 4: Condon Use Practice: Male and Female • Objectives: To teach participants how to use a male condom and female condom correctly. • Modeling, Rehearsal and Feedback

36. You made it through Session 3

37. Session 4: Making it Real: Making HIV/STD • Check-in • Identifying Barriers to Safer Sex • Safer Sex Negotiation and Refusal: The Basics • Safer Sex Negotiation: Demonstration and Discussion • Safer Sex Negotiation: Pairing Up • Assessing Risk of Partner Abuse and Making Safety Plans • Closing: Homework; Worth Affirmation

38. Session 4: Objectives • To help participants identify barriers to safer sex happening • To help participants identify and practice safer sex negotiation and refusal skills • To help participants assess risk of partner abuse from safer sex behaviors and make safety plans for their protection.

39. Activity #3:Safer Sex NegotiationObjective: To help participants observe and practive skills for negotiating safer sex and refusing risky sex. • Bianca just met a man named Donte at a party. She has seen him around before, and during the night, they end up going back to his place. Bianca feels a little uncomfortable with the situation, but on the other hand, she thinks Donte is sexy, and he definitely knows how to turn her on. She wants to have sex with him, but she also wants to be safe, because she doesn’t want to get anything.

40. Talking it Out! • What is Bianca’s problem? • What are Bianca’s options? • What are the consequences or outcomes of each option?

41. Taking it Apart! Let’s say Bianca decides to refuse to have sex, how can she do this? • Direct Ways of Refusing • Indirect Ways of Refusing • What are the possible consequences of each of these ways of refusing?

42. You made it through Session 4

43. Session 5: Keeping it Going • Check-in • Where we’ve been together: Review • Getting Ready: Common Slip Situations (Especially involving drugs & alcohol) • Slip Plans: The SODAS Way • Program Evaluation and Feedback • Graduation

44. You made it through session 5

45. Questions?

46. Resources • Manual and other materials for this intervention can be downloaded from: • http://ctndisseminationlibrary.org/display/398.htm • Condoms & Training Models • www.globalprotection.com • Flip Charts • www.megaprint.com • Special discount for WORTH trainees: $500/ flip chart