Prevention Strategies 1 minute  Introduce yourself and the purpose of Module 2. Goal: To enhance the provider’s ability to intervene with effective prevention strategies tailored to the patients behavioral circumstances to reduce HIV/STD transmission. Trainer Note: All slide references are included as Handout 5 in the participant packet. “In order to meet this goal, lets review the objectives for this module.” Effective Prevention in HIV Care Module 2 Prevention Strategies Developed by: The National Network of STD/HIV Prevention Training Centers, in conjunction with the AIDS Education & Training Centers  Module 2 (Slide 1)

Learning Objectives Module 2  1 minute  Emphasize that Module 2 focuses on these objectives  Upon completion of training, providers who care for PLWH will be able to: Deliver prevention messages Address misconceptions Use brief behavioral counseling to assess patient’s readiness for behavior change & develop a risk reduction plan Refer for more intensive prevention interventions and other support services At the end of this training, the participant will be able to: Deliver prevention messages Address misconceptions Use behavioral counseling to assess patient’s readiness for behavior change & develop a risk reduction plan Refer for more intensive prevention interventions and other support services  Module 2 (Slide 2)

Individual-Level Education and Behavioral Strategies  1 minute Discuss individual risk reduction strategies.  The “menu” of behavioral strategies for HIV/STD prevention for is large. Various types of behavioral interventions targeting sexual health and substance use have been shown to be effective, as well as public health strategies designed to support linkage and engagement in care. Individual risk reduction strategies include: learning to disclose HIV status to partners, reduction in the number of sexual partners, and reducing or quitting needle use or sharing. Utilizing a strength-based approach to sexual and substance use strategies is important to assist patients in overcoming adversity and feeling empowered to make safer decisions to promote their sexual health. “As providers we have multiple opportunities to improve engagement in care for PLWHA , we will now the spectrum of engagement of care in the United States.” Public Health Strategies Linkage to care Retention in care Re-engagement in care Adherence to ART Disclosing HIV status Condom distribution Negotiating safer sex STD screening & Tx Partner services Education Brochures, posters Prevention messages Addressing misconceptions Sexual Health and Substance Abuse Disclosure of HIV status Reduction of sexual partners Reducing or quitting needle use or sharing  Module 2 (Slide 3)

The Challenge of High Impact HIV Prevention  2 minutes  Emphasize the challenge of High Impact Prevention and the importance of PLWH engaged in care.  Viral suppression using ART reduces morbidity and mortality for PLWH, and has been shown to decrease sexual transmission of HIV by over 95%. However, most PLWH in the U.S. are not taking ART, either because they have not yet tested positive, or they encounter barriers to linkage and engagement in care and treatment. This slide shows a model of the spectrum of engagement in care in the U.S.  In December 2011, the CDC reported findings from an analysis, which used 3 surveillance data sets with data reported thru 2010 to estimate percentages of adults living with HIV along this continuum of care. CDC’s estimate was that 28% of all PLWH in the U.S. have a suppressed viral load.  Linkage to healthcare and adherence to care interventions, in addition to interventions that support behavior change are needed to slow the rate of HIV transmission. TRANSITION: “Our focus together now is on brief, individual –level education and tailored behavioral strategies, specifically delivering prevention messages, identifying and addressing misconceptions patients may have about HIV transmission, and brief behavioral counseling.” Only 28% of HIV+ are adequately managed Spectrum of engagement in HIV Care in the United States  Gardner, E. (2011). The spectrum of engagement in HIV care and its relevance to test-and-treat strategies in the clinical setting. Clinical Infectious Disease, 52(6), 793-800.  Centers for Disease Control and Prevention (CDC). (2011). Vital signs: HIV prevention through care and treatment-United States. MMRW, 60(47), 1618-1623.   Gardner, CID, 2001. CDC, Vital signs: HIV prevention through care and treatment – United States, 2011. Module 2 (Slide 4)

Behavioral Strategies for STD and HIV Prevention  1 minute  To define tailored behavioral strategies as discussed in this module.  Convey slide content  Knowledge, attitudes and skills are behavioral determinants, which must change before behavior can change. When selecting an strategy to intervene, assess needs of the patient (Are there knowledge deficits? Negative attitudes re: condom use? Lack of skills?), and choose appropriate strategy tailored to the patients circumstances. “Now lets talk about the research documenting the effectiveness of delivering HIV prevention in clinical settings.” Strategies designed to change: knowledge attitudes skills behaviors practices in order to reduce personal health risks or risk to others for sexual and needle sharing behaviors  Centers for Disease Control and Prevention (CDC). (2003). Incorporating HIV prevention into the medical care of persons living with HIV: Recommendations of CDC, the Health Resources and Services Administration, the National Institutes of Health, and the HIV Medicine Association of the Infectious Diseases Society of America. MMWR, 52 (#RR-12), 1-24.  CDC, MMWR (Table 4), 2003. Module 2 (Slide 5)

HIV Prevention in Care Interventions  2 minutes Identify interventions using provider delivered prevention interventions that show efficacy for HIV+ patients  Research reveals that these interventions show efficacy for HIV+ patients: All took place in clinic settings All delivered by HIV clinicians All compared intervention group to standard of care group Options Project – brief counseling intervention using motivational interviewing approach based on Information Motivation-Behavioral Model that asserts HIV prevention information, HIV prevention motivation, HIV prevention behavioral skills are the fundamental determinants of HIV preventative behavior (Fisher). Positive Steps- Client-centered approach to counseling patients about risk reduction, provider initiated safe sex discussion and risk reduction plan completed quarterly (Thrun). Partnership for Health – delivery of gain-framed vs. loss-framed prevention messages prevention messages (Richardson). Handout 5: References for more information on these research trails see citations provided “Despite proven efficacy of interventions to change patient behavior demonstrated on this slide, it is important to remember that there may be factors outside of a patients control impacting sexual and substance use behaviors.” Brief (5-7 min) interventions delivered at every visit in HIV clinics All delivered by HIV clinicians (MD, PA, NP) All interventions were effective in reducing reported risk (unprotected sex)  Fisher et al. (2004). Clinician-initiated HIV risk reduction intervention for HIV-positive persons: formative research, acceptability, and fidelity of the options project. Journal of Acquired Immune Deficiency Syndromes, (37), S78-S87.  Richardson et al. (2004). Using patients risk indicators to plan prevention strategies in the clinical care setting. Journal of Acquired Immune Deficiency Syndromes, (37), S88-S94.  Thrun et al. (2009). Improved prevention counseling by HIV care providers in a multisite, clinic-based intervention: Positive Steps. AIDS Education and Prevention, 2, 55-66.  Fisher et al, JAIDS, 2004. Richardson et al, JAIDS, 2004. Thrun et al, AIDS Edu Prev , 2009. Handout 1 Module 2 (Slide 6)

Other Factors Impact Risk 1 minute To discuss factors other than an individual’s behavior can affect their risk for acquiring or transmitting HIV. These larger social determinants of health are often outside of the individual’s control or influence. (This slide is covered in Module 1, if doing all three modules trainer can hide this slide)  World Health Organization definition of Social Determinants of Health: “The social determinants of health are the conditions in which people are born, grow, live, work and age, including the health system. These circumstances are shaped by the distribution of money, power and resources at global, national and local levels, which are themselves influenced by policy choices.”  It is important for providers to consider the impact that particular determinants such as, stigma, socio- economic status, cultural identification, and others have on HIV risk, prevalence and access to services. It is difficult for some of our patients to consider changing their sexual risk behaviors if their housing or livelihood (e.g. commercial sex work or exchanging sex for living situation) is dependent on these behaviors.  When discussing patient behavior if factors outside of the patients control are impacting their risk behavior a referral to assist with these factors may be all that you can do. Social Determinants of Health STD/HIV disparities by race/ethnicity Stigma and discrimination Socio-economic status Education Cultural identification Physical environment ( housing, crowding, transportation)  Centers for Disease Control and Prevention (CDC). (2010). Establishing a holistic framework to reduce inequities in HIV, Viral Hepatitis, STDs and Tuberculosis in the United States: An NCHHSTP white paper on social determinants of health. http://www.cdc.gov/socialdeterminants  CDC, Establishing a holistic framework to reduce inequities in HIV, viral hepatitis, STDs, and tuberculosis in the United States, 2010. http://www.cdc.gov/socialdeterminants/docs/SDH-White-Paper-2010.pdf Module 2 (Slide 7)

Effective HIV Prevention in Routine Care  30 seconds  To emphasize the importance of INTERVENING for behavioral change with PLWH. “Now that we have talked about individual level interventions, and research indicating the efficacy of HIV/STD prevention messages, lets begin to look at how we can intervene to assist patients with sexual risk behavior through brief tailored behavioral strategies.” Effective HIV Prevention in Routine Care Ask Intervene Screen  Slide is animated: Initial: Full screen view with all words 1st Click: Intervene moves to the center of the screen  _____ _____ _____  _____ ___ _____ _____  _____ _____ _____ Module 2 (Slide 8)

Education vs Counseling  2 minutes To show that patient education is only a small part of behavioral counseling.  Brief, behavioral counseling should address these additional factors, and thus have shown more effectiveness in influencing behavior change.  Providers have unique opportunities to provide brief behavioral counseling with patients because: Patients respect your opinions Trust has been established Patients want to talk about these issues!  Important to acknowledge challenges to providing behavioral counseling: Lack of sufficient time Don’t want to impose on patient privacy ‘Not my role’ attitude Lack of skills to effectively deliver brief interventions Lack of awareness of community resources  We will now focus on how to enhance your skills in delivering brief behavioral counseling and use of referrals in your clinical setting and address some of these challenges. This is not truly an interactive discussion, but emphasizes that behavior change is difficult and often does not result from only learning new information. Do NOT elicit answers from participants. Say: “Think of a behavior you’ve been trying to change for some time (e.g., quit smoking, lose weight, exercise, etc)” Ask: “ Did you change your behavior just because you knew it would be good for you?” Point out that the same is true of our patients, but even more complicated because they engage in these behaviors with others Patient Education Knowledge Behavioral Counseling Knowledge Attitudes/ Beliefs Readiness Skills Behaviors Circumstances Practices  Slide is animated: Initial: Slide title and boxes appear 1st Click: the title “Patient Education” appears 2nd Click: the title “Behavioral Counseling” appears 3rd Click: “Knowledge appears under “Patient Education” 4th – 10th Click: Individual bullets appears under “Behavioral Counseling”  Module 2 (Slide 9)

Deliver Prevention Message Opportunities to Intervene to Change Patient Behavior: 1 minute To describe the three main ways a provider can intervene to change behavior covered in this module.  This slide shows the different opportunities providers have to intervene to change patient behavior. We will discuss each of the steps illustrated on the slide. Often times the risk assessment alone (discussed in module 1) provides an opportunity for self-reflection about risk behaviors and can help reduce risk. By delivering a prevention message personalized to the patients situation identified in risk assessment may also be sufficient.  If you identify misconceptions the patient has about HIV transmission or STD acquisition it is also important to address. Not all patients will have misconceptions and for some patients by identifying misconceptions they have they will change their behavior to be more protective.  A smaller percentage of patients will need more tailored behavioral counseling. We will discuss the steps to delivering behavioral counseling and provide an opportunity to practice these steps later in the module. “We will now discuss in more detail delivering prevention messages.“ Deliver Prevention Message Address Misconceptions Brief Behavioral Counseling  Module 2 (Slide 10)

Giving Prevention Messages  2 minutes  To define prevention messages  Remind participants that patients think prevention messages are an important part of their care.  Read definition of prevention messages  Clinicians are used to giving general prevention messages; therefore, we won’t spend much time on it. Ask: “What do you think are important prevention messages for persons living with HIV/AIDS?” List 5-10 of the participants’ responses on easel Note: If time is limited or an easel is not available, quickly brainstorm this activity with participants Statements that emphasize the need for safer behaviors to protect both the patient’s health & the health of their sexual or needle-sharing partners  Slide is animated: Initial: Only title will appear 1st Click: Definition box will appear  Module 2 (Slide 11)

HIV Prevention Messages  1 minute  Identify prevention messages that may not be so obvious  Examples of prevention messages: STDs can facilitate the transmission of HIV Injection drug use risk is often overlooked Suppressed viral load significantly reduces transmission. However, an suppressed viral load does not mean that HIV is not present (therefore the risk of transmission is not zero). Condoms prevent HIV transmission Handout 1: Sample Prevention Messages Handout 6: Reference for citations that support the slide  Handout 1 contains a list of sample prevention messages for condom use, partner reduction, abstinence, HIV disclosure, referral to partner services, and STDs increase transmissibility of HIV. TRANSITION: “Many of these prevention messages highlight the importance of early ART to reduce transmission, lets briefly talk about the evidence to support these messages.” STDs facilitate transmission of HIV Increase susceptibility to HIV Increase transmissibility of HIV Suppressed viral load significantly reduces HIV transmission. However, a suppressed viral load does not mean that no HIV is present Sharing injection drug equipment can transmit HIV Condoms prevent transmission of HIV Smith et al. (2004). Incidence of HIV superinfection following primary infection. Journal of the American Medical Association, 292,1177-1178. Blackard et al. (2004). HIV superinfection in the era of increased sexual risk taking. Sexually Transmitted Diseases, 31, 201-204. Jost et al. (2002). A patient with HIV superinfection. New England Journal of Medicine , 347, 731-736.  Smith, JAMA, 2004 Blackard, Sex Trans Dis, 2004 Jost, NEJM, 2002 Handout 1 Module 2 (Slide 12)

ART Prevents Transmission  2 minutes To demonstrate the importance of early ART to reduce HIV transmission  This study was a prospective evaluation of ART for prevention of HIV transmission. The study enrolled 1,763 HIV-serodiscordant couples (couples that have one member who is HIV infected and the other who is HIV uninfected), the vast majority of which (97 percent) were heterosexual. The study was conducted at 13 sites across Africa, Asia and the Americas. The HIV-infected person was required to have a CD4 cell count between 350-550 per cubic millimeter (cells/mm3) at enrollment, and therefore did not require HIV treatment for his or her own health. Couples were randomized to one of two groups. In one group, the HIV-infected person immediately began taking ART (immediate ART group).  It is the first randomized clinical trial to show that treating PLWH with ART can reduce the risk of sexual transmission of HIV to an uninfected partner.  However, even though transmission was significantly reduced it does not 100% eliminate risk. Viral load in genital secretions is not eliminated, while transmission risk is significantly reduced with a lower viral load,genital secretions (especially in the presence of STD) may not correlate with blood viral load. Further studies are needed to show if transmission is completely eliminated in all cases if less than 400 copies. Handout 6: citation provided for slide Study published in 2011 showed ART reduced the risk of transmitting HIV to sexual partners Randomized clinical trial 1,763 serodiscordant couples, CD4 350-500 Immediate vs delayed initiation of ART 96% reduction in HIV transmission  Cohen, M. (2011). Prevention of HIV-1 infection with early antiretroviral therapy. New England Journal of Medicine, 365, 493-505.  Cohen, NEJM, 2011 Module 2 (Slide 13)

Addressing Misconceptions  2 minutes  To define misconceptions  Read definition of misconceptions  Often misconceptions occur because people have misinformation about something. In some cases, misinformation is heard from their friends or peers. Interactive: Ask: “What misconceptions have your patients shared with you or what misconceptions have you heard?” Take a moment to discuss these with the group Give an example to the group of a misconception that you have heard from a patient OR Use an example from this list: I’m always the bottom and bottoms can’t transmit My viral load is undetectable so I don’t have any virus to pass on It is impossible to get clean injecting equipment Incorrect assumptions or beliefs patients may have about HIV transmission  Slide is animated: Initial: Only title will appear 1st Click: Definition box will appear  Module 2 (Slide 14)

Common Areas of Misconception  2 minutes List the most common misconceptions about HIV transmission.  Here are several areas that patients may have misinformation or misconceptions about.  Risks associated with specific sexual or drug- using acts: Not all patients are aware of the continuum of risk that ranges among varying sex acts. They may often incorrectly assume that a specific act is safer than it really is. For example, many persons who are HIV infected assume that if they are the receptive partner during anal sex, they cannot transmit HIV. Although being the receptive partner may be less risky for HIV transmission than being the insertive partner, there is still risk for transmission. Patients may believe that a suppressed viral load means that HIV transmission cannot occur.  Patients may not know STDs are associated with increased HIV transmission and acquisition. STDs increase the amount of HIV shed at the genital mucosa, may increase viral load, and produce breaks in the mucosa and inflammation.  Use handout for examples: Handout 2: Common Statements Revealing Misconceptions and Attitudes “Lets look more closely about the continuum of risk for sexual behaviors.” HIV Transmission risk varies with: Type of sexual and drug-using behaviors/practices Viral load - high vs ‘undetectable’ Co-infection with other STDs Smith et al. (2005). Antiretroviral postexposure prophylaxis after sexual, injection-drug use, or other nonoccupational exposure to HIV in the United States. MMWR, 54(2), 1-20.  Smith et al, MMWR, 2005. Handout 2 Module 2 (Slide 15)

Some Behaviors are More Risky than Others  2 minutes  To review the risk of HIV transmission based on specific sexual behaviors  This graph depicts the “per-act” relative risk of acquiring HIV from an HIV-infected person. The behaviors listed are from the perspective of an HIV-negative partner of an HIV- infected person. Simply put, not all sex acts are of the same risk. Generally speaking, anal sex has greater risk of HIV transmission than vaginal sex which has greater risk than oral. Receptive sex is inherently riskier than insertive.  It may be important to point out that this graph shows needle-sharing IDU as the most risky behavior, increased risk is a result of multiple injections for cumulative exposure, and increased transmission through direct blood contact It is important to note, this data is in PLWH without a concurrent STD (STDs may increase HIV transmission risk 2-5 fold). Handout 6: citation provided for slide TRANSITON: “How can you identify misconceptions?” Relative risk Anal>Vaginal >Oral Receptive> Insertive  Smith et al. (2005). Antiretroviral postexposure prophylaxis after sexual, injection-drug use, or other nonoccupational exposure to HIV in the United States. MMWR, 54(2), 1-20.  Smith et al, MMWR, 2005. Module 2 (Slide 16)

Identifying & Addressing Misconceptions  2 minutes  For new patients, it is important to assess what the patient knows and his/her concerns about HIV/STD transmission.  Misconceptions may be the result of lack of knowledge or attitudes and beliefs that are part of a person’s or community’s perceptions.  Questions may help you in understanding your patient’s level of knowledge and concern. In order to adequately address misconceptions, it is imperative to ask more in-depth questions regarding the patients perspective and understanding of transmission risk. : Ask participants to share other questions that could be used to assess knowledge: Discuss the benefit of open-ended questions for risk reduction but also for all behavior change (medication adherence, Partner Services, smoking cessation, etc.) Discuss how these can be used in a clinic visit : Demonstrate the difference between open vs. closed-ended questions. (Note- You do not need to hear the answer to the following questions. They serve as examples only.) Ask: Do you know how HIV or an STD is transmitted? (example of a closed-ended question) Then ask: Tell me about how HIV/STD is transmitted. (example of an open-ended question.)  Closed-ended questions elicit very specific information (such as those used in risk assessment-Module 1), while open-ended questions (tell me about……) can elicit in-depth information from the patient and direct the provider to key issues or misconceptions to address. “Now we talk about steps for brief behavioral counseling for patients that might need more then prevention messages or their misconceptions addressed.” Assess Knowledge What do you know about how people get STDs? What do you know about how people get HIV? Assess Attitudes/Beliefs What are your concerns about giving HIV to someone else?........explore rationale & address misconceptions What are your concerns about getting an STD or hepatitis? ………..explore rationale & address misconceptions  Slide is animated: Initial: Only title appears 1st Click: “Assess Knowledge appears 2nd Click: “Assess Attitudes/Beliefs” appears 3rd & 4th Click: Questions appear under “Assess Knowledge” 5th & 6th Click: Questions appear under “Assess Attitudes/Beliefs”  Module 2 (Slide 17)

Using Behavioral Counseling  30 seconds  To define behavioral counseling  Some our patients may be engaged in sexual risk behaviors that require brief behavioral counseling to address the factors influencing behavior. We will now discuss the steps for delivering brief behavioral counseling in clinical settings. Brief, provider-delivered interventions to change behavioral determinants known to influence behavior change  Slide is animated: Initial: Only title will appear 1st Click: Description box will appear  Module 2 (Slide 18)

Effective Brief Behavioral Counseling  1 minute  This slide discusses elements common to all effective brief behavioral counseling  All EFFECTIVE brief counseling interventions have 4 common elements identified by CDC. Interactive: The patient is engaged and talking rather than listening passively to the provider Based on individual circumstances: Risk behavior does not occur in a vacuum; when, where, and with whom is what we mean by circumstances. Based on patient’s readiness to change. Uses a harm-reduction approach: helping patients to reduce or minimize the adverse health and social consequences associated with their behavior. In this case, the patient would reduce the likelihood of transmitting HIV to partners. The immediate goal is not harm-elimination, but reducing the likelihood of harm by small, successive steps. Interactive Based on patient’s individual circumstances Based on patient’s readiness to change Uses a harm-reduction approach  Slide is animated: Initial: Title appears 1st – 4th Click: One bullet appears per click  Module 2 (Slide 19)

Steps for Brief Behavioral Counseling 2 minutes To discuss a 5-step model (after risk assessment) for conducting behavioral counseling in a clinical setting.  Here is a 5-step model for brief risk-reduction counseling that incorporates those 4 common elements: Summarize behavior that may be putting patient at risk (covered in module 1 the “ask” part of the ASI framework). Identify patients perception of risk and barriers for change. Assessing the patient’s readiness for change for a behavior they feel able and willing to change. Set a safer behavior goal based on the identified behavior. Finding a first step or steps towards achieving this goal  These steps can be used for a variety of patient behaviors that may require brief counseling such as medication adherence, keeping appointments, smoking cessation, etc. “Now lets discuss each of these steps in a little more detail.” 1) Summarize patient risk behavior (refer to ASI Module 1) 2) Identify patient perception of risk and barriers for change 3) Assess readiness for change 4) Set a safer goal 5) Negotiate a first step  Module 2 (Slide 20)

Step 1) Summarize Patient Risk Behavior 1 minute  To show how to summarize patient risk behavior as the first step in delivering brief behavioral counseling. Review patient risk behaviors for sexual or drug-use obtained through the risk assessment that may be putting them at risk for transmitting HIV or acquiring an STD. It is necessary to understand WHO the behavior is occurring with since changing risk behavior may require changes in a relationship. WHAT behaviors they are engaged in and putting them at risk should also be summarized. Finally, HOW the patient is protecting themselves is also important to understand. Any protective behaviors the patient is engaged in should be acknowledged.  Statements from the patient might uncover attitudes about risk such as “If I had an STD, I would know, I would have symptoms.” A question such as “What are your concerns about getting an STD or giving someone HIV?” will also uncover attitudes about risk behaviors.  Discuss any dissonance that may surface regarding the patients behavior: “You say you are concerned about transmitting HIV to your partner but yet you don’t like wearing condoms because they don’t feel good.” WHO: Sexual & substance using partners: gender, concurrent, serial……main or casual WHAT: Sexual & substance use behaviors & practices HOW: Condoms, substance use, partner status  Slide is animated: Initial: Title appears 1st Click: “What” appears 2nd Click: sub-bullet under “What appears 3rd Click: “With Whom” appears 4th Click: sub-bullet under “With Whom” appears  Module 2 (Slide 21)

Step 2) Assess Patient’s Perception of Risk What concerns do you have about giving HIV to someone else? What concerns do you have about getting an STD or hepatitis? What do you see as the riskiest thing you are doing now? 1 minute To describe step 2 of brief behavioral counseling, how to assess patients perception of risk.  Here are some examples of questions to help the patient think about their risky behaviors, and which one they would be willing to work on changing. These questions will also reveal the patient’s knowledge and misconceptions about HIV/STD transmission.  Discuss with the patient their own perception of risk. What circumstances are associated with/or lead to risky behavior? Which risks are they most concerned about? Do they feel ready and capable of changing that behavior? What are the barriers for changing the behavior? It is necessary to understand what might impact the patients ability to make a change in behavior, and discuss options for reducing or removing barriers. If the barriers are to substantial for the patient a referral might be necessary.  It is important to understand how an individual perceives risk. Are they concerned about acquiring an STD (personal risk) or transmitting HIV (partner risk)? Once perception has been identified the behavior goal set should be inclusive of this perception.  Module 2 (Slide 22)

Step 3) Assess Readiness for Behavioral Change Counseling needs to be different depending on patient’s readiness…… Don’t see a need to change See a need, but have barriers Ready to try a behavior change

Readiness:Stages of Change Precontemplative “What problem?” Client sees no need to change behavior Raise risk awareness Discuss impact of behavior on others Contemplative “Yes, but…” Sees the need to change behavior, but has barriers Discuss pros & cons, ambivalence/barriers Ready for action “Let’s do it” Is ready to change behavior and may have already taken some steps Assist in goals Teach skills Develop a plan Action Doing it Has changed behavior for a short period of time Reinforce goals Reinforce skills Maintenance Living it Has changed behavior for a long period of time Praise success Promote self-efficacy 1 minute Discuss strategies based on patients readiness to change  Use strategies based on patient’s ‘Readiness’ Patients who are precontemplative and see no need for any behavior change need different strategies than those who want to change but have barriers, or those who are ready to start trying to make the change. This module will focus on clients who are contemplative or ready for action. For those patient’s that are precontemplative, continue to highlight risky behaviors and offer continued support until they are ready to make changes or they may need a referral for more intensive services.  Prochaska et al (1992). Stages of change in the modification of problem behaviors. In M. Hersen, P. Miller & R. Eisler (Eds.), Progress in Behavior Modification (Vol. 28). New York: Wadsworth Publishing.  Prochaska et al, Stages of change in the modification of problem behaviors, 1992. Module 2 (Slide 24)

Ask about Patient’s Readiness & Barriers 1 minute  This slide shows how to ask about a patients readiness and questions that can be used to identify barriers to change.  Help your patient to assess their own risks and readiness to change by asking questions like these.  Assessing readiness and barriers to change will help ensure the behavioral goal identified is realistic for your patient and something they are motivated to change. If barriers come up for your patient, help the patient plan for the barrier (put condoms in the nightstand, limit number of drinks so you can discuss status, etc.). Handout 2: Using Stages of Change to Address Barriers to Condom Use. Do you see a need to ……………. Use condoms with your main partner Talk about HIV status with partners Get your partner to get HIV tested What makes it difficult for you to…….. Use condoms with your main partner,  Handout 2 Module 2 (Slide 25)

Step 4) Negotiate a Behavioral Goal 1 minute Describe how to acheive a safer behavioral goal.  The behavioral goal is what the patient will work towards an option for change in behavior the patient is willing and ready to make. Again, not harm elimination, but harm reduction. Ask your patient what they think is a realistic goal for themselves. Handout 4: Reaching Safer Behavioral Goals Identify a behavioral goal the patient is most ‘ready’ to try How would your sexual/drug practices have to change for you to stay safe? What do you feel ready to do to reduce your risk of HIV or STDs?  Handout 4 Module 2 (Slide 26)

Examples of Safer Behavior Goals 1 minute  Demonstrate different behavioral goals patients might have.  Listed here are a variety of behavioral goals toward which we may guide our patients.  Offering patients an array of options – not just a list of directives – may help them to take control. Some patients might have a difficulty determining a specific behavioral goal, if this occurs offer options and let the patient decide which goal is most realistic and which one they are most motivated to change.  Getting screened for STDs and ensuring your patients partners get screened for HIV and STDs is the responsibility of BOTH patients AND providers. Providers should encourage their patients to get tested and to talk to their partners about getting tested. Abstinence Monogamy Condom use Reduce number of partners Disclose to partners Asking partners’ status Routine STD screening Refer partners for STD/HIV testing Stop injection drug use Use clean or new injecting equipment Do not share injection equipment Re-engaging in care Starting ART Treatment adherence  Most participants are well aware of these – determine from participant input how much time you really want to spend on this slide. If you don’t need to discuss these points, move on and save the time for the scenario and discussion.  Module 2 (Slide 27)

Step 5) Identify a First Step 1 minute Describe how to identify steps towards the behavioral goal the patient has identified.  Assist the patient in identifying a first step towards the behavioral goal. This step must be something that the patients feels is do-able for themselves. The steps identified should be: Concrete Incremental Individualized Realistic Back up plan  For example, lets say you have a patient who only engages in unprotected sex with multiple partners when he has too much to drink. He has identified that he wants to change his drinking habits and reduce the number of drinks he has. Thus his first step might be: reduce number of drinks to 2 when going out and to always carry condoms. Handout 4: Reaching Safer Behavioral Goals TRANER NOTE: Before continuing to skills practice you can demo the brief counseling model in action with the transcript provided for Tony and his provider. Utilizing another trainer or a brave participant read through the dialogue provided as a handout. Model how brief the demo was and all the information that was obtained. Also, emphasize the ongoing nature of these discussions as stated by the provider in this demo. Concrete Incremental Individualized Realistic Back up plan  Handout 4 Module 2 (Slide 28)

Skills Practice Practice elements of behavioral counseling:  15 minutes (total)  To practice the essential elements of brief behavioral counseling  Convey slide content Introduction to skills practice and reviewing scenarios – 5 minutes Practice with colleague – 10 minutes Group debrief – 5 minutes Here are the steps the participants should follow for this skills practice: 1) Summarize patient risk behavior 2) Assess patients perception of risk and options for change 3) Identify patient readiness to change 4) Negotiate a behavioral goal 5) Identify a first step Module 2 Skills Practice Pair up with a colleague (you can have participants count of 1 and 2). Take a moment to review the Skills Practice handout (tell the “ones” they are the patient first and the “twos” they are the provider, and then when you call time they will switch roles). Take 2-3 minutes to practice a behavioral risk assessment (work with patient to identify risk, a behavioral goal, and a first step towards goal) Then stop, switch roles and take another 2-3 minutes to practice. Refer to ASI provider card for questions for exercise (Handout 3 in Module 1) Practice elements of behavioral counseling: Summarize patient risk behavior Assess patients perception of risk and barriers for change Assess readiness for change Negotiate a safer behavior goal Identify a first step 1-2 acceptable & realistic steps toward the goal  Present this slide for the duration of the case study activity  Module 2 (Slide 29)

Skills Practice: DEBRIEFING 15 minutes (total)  Use the following questions to debrief with the group, convey slide content. “Now lets talk about how to document counseling in the patient record and how to check in regarding patient progress.” How did you assess the patient’s readiness to change? What behavioral goal did you negotiate? What first step did your patient choose? What was difficult about this exercise?  To debrief the skills practice, have participants share their experiences as both the provider and the patient.  Present this slide to facilitate discussion after the exercise.  Module 2 (Slide 30)

Document Counseling in Patient Record  1 minute  A note about the brief counseling outcomes should be noted in the patient’s chart.  This may be important for reimbursement purposes, particularly if more preventive services such as this are reimbursable as various aspects of health care reform are phased in.  Documentation will also ensure this is an ongoing conversation saving time by starting right where you left off at next visit. “Documentation of counseling also makes it easier to check in about patient progress at the next visit.” Results of behavioral risk assessment Patient readiness & barriers to change Goal identified & first step agreed upon  Module 2 (Slide 31)

Ask about Progress at Next Visits  1 minute  It is important to remember that we have a great opportunity to make this dialogue ongoing, especially since most PLWH will be seen fairly regularly.  Convey slide content, emphasize importance of this ongoing dialogue.  This means that we don’t necessarily have to have one huge conversation that takes a long time. Rather this discussion could take place over several visits.  In addition, it gives us the opportunity to give ongoing positive reinforcement for positive behavior change. Be sure to praise the patient for progress they have made towards their goal and for protective behaviors they are already engaged in.  It’s important to reassess any changes in the patient’s life, such as new sexual activity or changes in current relationships, since none of us have completely static lives. “Now lets review resources that are available to patients for more intensive prevention services in your community.” If patient is meeting the goal: positive reinforcement identify next steps anticipate new problems or changes (Ask “what if . . .?” questions) What happens if you start a new relationship? If patient is not meeting goal: further assess circumstances, attitudes, readiness revise steps consider referrals  Module 2 (Slide 32)

Identify Resources in Your Area  1 minute  To give a list of possible resources  It is important to know about local resources at the health department or community-based organizations in your area.  CDC supports the use, or “diffusion”, of a variety of science-based HIV prevention interventions that have been shown to be effective for PLWH . These interventions have all met rigorous study and evaluation design, many with randomized controlled trails thus they are considered to be effective.  These interventions are often provided by community based organizations and/or local health departments. CDC maintains a website (given here) with a training calendar. Referring patients for individual interventions means working with CBOs and the health department in your area to find out which interventions are available. Contact local/state health department about more intensive HIV prevention interventions offered by: Health Department Community-based organizations Nurses, social workers, case managers, counselors, & health educators know about local support services  www.effectiveinterventions.org Module 2 (Slide 33)

Higher-intensity risk reduction interventions Make Referrals Case Management Patient Navigator programs Higher-intensity risk reduction interventions Individual, group, community Partner Services (Module 3) Other services Substance use, mental health, family planning, housing, prenatal care  1 minute  To give referral resources  As briefly discussed earlier, some patients may greatly benefit from more in-depth services to assist with challenges or barriers to reducing high-risk behaviors.  Determine what referral services your patient needs: “You have mentioned a few things that you might need help with. Which of those would you like to pursue today?”  Not all patients will use referral services: It is important to determine comfort or readiness to access these services You can always provide referrals at a later visit after the patient has thought about it for a period of time Services need to be responsive to the patient needs and appropriate for the patient’s culture, age, language, sex, sexual orientation, and development level. Determine how your clinic/setting will handle referral process If your clinic does not have an active referral list, create one and determine contacts at other agencies to ensure referrals will be a success.  Module 2 (Slide 34)

How to Get More Training & Technical Assistance 1 minute To offer participants various resources for ongoing training and training assistance. Handout 5: References Handout 6: Resources www.nnptc.org www.aidsetc.org www.effectiveinterventions.org Access technical assistance through state/local health department HIV prevention services  Module 2 (Slide 35)

 1 minute  To have a discussion about what the participants plan to do differently in their practices  Reiterate what was covered (Convey slide content). Ask: “Following this module discussing prevention interventions, what might you do differently in your practice now?” “Module 3 will address how the health department can assist you in offering partner services to your patients and their partners.“ Based on this presentation, what do you plan to do differently in your practice?  Module 2 (Slide 36)

ASK SCREEN INTERVENE PARTNER SERVICES BRIEF BEHAVIORAL INTERVENTIONS  1 minute  To remind participants this is a multi-module course and to illustrate topics to be covered in subsequent modules  Mention topics to be covered in upcoming (and previous) modules: Module 1: Risk Screening and STD Screening The rationale of implementing this curriculum is based on emerging trends and current national prevention efforts. Give ways to overcome existing barriers to risk screening and assessment. Provide examples of risk assessment techniques that enhance the type of information gathered. List the benefits, types of tests, when and where of STD screening. Module 2: Prevention Interventions Prevention messages can help guide patients toward safer behavioral goals. Misconceptions of patients can be identified and addressed. Brief behavioral prevention interventions/ Brief risk reduction counseling. Module 3: Partner Services Describe local laws and regulations relevant to partner notification and disclosure. Multiple disclosure options exist. Bring up partner disclosure with all patients. PARTNER SERVICES BRIEF BEHAVIORAL INTERVENTIONS ADDRESSING MISCONCEPTIONS PREVENTION MESSAGES STD SCREENING RISK SCREENING  Module 2 (Slide 37)