Incorporating Brief Safer Sex Interventions at HIV Outpatient Clinics Partnership for Health The Action of One, The Partnership of Two, The Power of Many Funded by the NIMH, CDC, UARP and PAETC Jean L. Richardson, DrPH, Principal Investigator

Using HIV Clinics For Prevention Activities Advantages 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

Involves primary care providers in prevention Changes clinic norms to incorporate prevention Identifies patients in need of referral for intensive counseling Easily diffused Using HIV Clinics For Prevention Activities Advantages

Using HIV Clinics For Prevention Activities Limitations Limited capacity for intensive counseling Misses HIV+ persons who are unaware of their status or not in care

Sexual Activity of HIV Positive Patients Summary distribution based on many studies 1/3 LOW RISK: PROTECTION OR LOWER RISK BEHAVIOR 1/3 HIGH RISK: UNPROTECTED ANAL OR VAGINAL SEX 1/3 ABSTINENT

Percent of HIV + Patients Reporting Specific Elements Discussed in Clinic Session Topic Discussed?Day of VisitPast 6 months Safer Sex25%53% Specific Sex Activities5.8%24% HIV Disclosure7%24% Condom Use1.5%7.5% Tested for STD6.5%31.4% (N=618) Source: Morin S., In press, 2004

Theoretical Basis for PfH Mutual Participation Model –Patient - provider partnership is key Loss/consequences framed messages more effective than gain/advantages framed –Emotional weight of messages –May require more cognitive processing –Involvement with the issue Stages of Change –Emphasize repetition and reinforcement

Gain Framed Safer-Sex Messages (In print and verbalized by provider) Framing links a behavior with an outcome Gain frame emphasizes the advantages of safer behaviors

Gain Framed Safer-Sex Messages If you use protection, it will help keep other people free of HIV infection If you and your partner use a condom while having sex, –you are more likely to stay free of STDs –you make it easier for your doctor to care for you Examples

Loss Framed Safer-Sex Messages (In print and verbalized by provider) Framing links a behavior with an outcome Loss frame emphasizes the consequences for high risk behaviors

Loss Framed Safer-Sex Messages If you engage in unprotected anal or vaginal sex, your partner could get infected If you and your partner dont use a condom while having sex, –you are more likely to get STDs –it is harder for your doctor to take care of you Examples

Summary of Study Results Loss (consequences) framed intervention effective among persons with multiple partners (38% reduction in UAV) Consequences framed intervention effective among persons with casual partners Neither frame was effective among those with only one partner (Richardson et al. AIDS May 21, 2004)

PfH Core Elements Core elements must be maintained to ensure program effectiveness

PfH Core Elements Continued… Having providers deliver the intervention to HIV+ patients in HIV outpatient clinics Having the clinic adopt prevention as an essential component of patient care Training of all clinic staff to facilitate integration of the prevention counseling intervention into standard practice

PfH Core Elements Continued … Using waiting room posters and brochures to reinforce prevention messages delivered by the provider Building on the ongoing supportive relationship between the patient and the provider

PfH Core Elements Continued… At routine visits, having the provider initiate a 3 to 5-minute safer sex discussion with patient focusing on self-protection, partner-protection, and disclosure Having the provider use good communication techniques and consequences-frame messages for patients engaged in high risk sexual behavior

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

Clinic Environment Brochure to read and bring to exam room PfH posters on walls Patient-Provider Interaction Provider communicates importance of partnership reviews brochure with patient states safer sex, disclosure messages discusses safer sex goals, risk reduction fills out goals sticker, places in chart Intervention Flow Chart

Intervention Flow Chart Continued… Patient-Provider Interaction Repetition and Reinforcement Patient returns for another visit Receives new information flyer Provider addresses barriers and reinforces message

Provider Counseling Outline Explain what the Partnership for Health is - Emphasize the relationship Ask questions about sexual behaviors & disclosure Discuss messages based on individual sexual behaviors and disclosure (i.e. abstinence v. sexually active)

Provider Counseling Outline Continued… Respond to questions & provide referrals Review behavioral goals Use good interpersonal communication skills Reinforce at every visit

Prevention Strategies: Clinic Visits 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 Initiate or increase discussions to explore:

PfH Core Health Education and Risk Reduction Messages Use consequences frame messages with higher risk HIV positive patients Use either frame with lower risk HIV positive patients Reinforce safer behaviors with all patients For the provider

Phases of an Intervention Pre-implementation Pre-implementation Training Training Implementation Implementation Maintenance Maintenance Evaluation Evaluation

PfH Intervention Materials PfH posters (waiting room, exam rooms) Brochures, prescription Provider pocket guide Videos (orientation and role models) Manuals: Technical Assistance Manual Train-the-Trainer Manual Participants Manual

Implementing the Safer Sex Intervention: Provider Concerns Too little timeLess than 5 minutes Not my responsibilityMay be the only person who regularly sees patient Dont know how to talk about safer sex and disclosure Training provides easy to use skills

Implementing the Safer Sex Intervention: Provider Concerns Fear of rejection by the patient Patients respect and want to cooperate with their health care provider Ethical concernsEthical responsibility to be aware of patient behaviors that affect their health.

Cost to the Clinic Resources to supplement the Coordinators time Provider and staff time during orientation, training, and booster. For PfH Involvement

Partnership for Health The Action of One, The Partnership of Two, The Power of Many