Welcome to I-TECH HIV/AIDS Clinical Seminar Series October 9, 2008 HIV Prevention with Positives in Clinical Settings: A Powerful Tool Janet Myers, PhD

Overview Describe a 20-site clinical site demonstration project that evaluated the effectiveness of behavioral prevention intervention programs for HIV-infected patients seen in clinical settings in the US. Describe a 20-site clinical site demonstration project that evaluated the effectiveness of behavioral prevention intervention programs for HIV-infected patients seen in clinical settings in the US. State the features of successful behavioral interventions that were shown to reduce HIV transmission risks. State the features of successful behavioral interventions that were shown to reduce HIV transmission risks. Identify two examples of tools to help clinics integrate behavioral prevention activities into clinical services. Identify two examples of tools to help clinics integrate behavioral prevention activities into clinical services. Discuss ways to apply lessons from this project to international settings. Discuss ways to apply lessons from this project to international settings.

Ryan White HIV/AIDS Program Evolution of HAB Prevention Activities The Ryan White CARE Act Prevention Project ( ) The Ryan White CARE Act Prevention Project ( ) Incorporating HIV Prevention into the Medical Care of Persons living with HIV: Recommendations of CDC, HRSA, NIH, and HIVMA (2003) Incorporating HIV Prevention into the Medical Care of Persons living with HIV: Recommendations of CDC, HRSA, NIH, and HIVMA (2003) SPNS Initiative: Prevention with HIV-Infected Persons seen in Clinical Settings (Prevention with Positives Initiative, 2002 – 2008) SPNS Initiative: Prevention with HIV-Infected Persons seen in Clinical Settings (Prevention with Positives Initiative, 2002 – 2008) OPTIONS Project ( ) OPTIONS Project ( )

Findings: The Ryan White CARE Act Prevention Project * HIV prevention counseling was not routine in most clinics; patients reported receiving prevention counseling significantly less frequently than counseling related to diet, nutrition and adherence to ARVs. Lack of time, lack of specialized training and funding dedicated to the provision of prevention counseling were cited as barriers providing HIV prevention in the clinical setting. Some clinical providers did not understand their role in “prevention with positives”. The low frequency of HIV prevention services in these clinical settings represented “missed opportunities” for reducing HIV transmission. *Morin et al. (2004) Missed Opportunities: Prevention with HIV- infected Patients in Clinical Care Settings. JAIDS, 36(4):

Incorporating HIV Prevention into the Medical Care of Persons living with HIV: Recommendations of CDC, HRSA, NIH, and HIVMA/IDSA* Guidelines support the provision of HIV prevention in clinical settings Guidelines support the provision of HIV prevention in clinical settings Provide clinicians with the tools needed to conduct a behavioral assessment, screen for sexually transmitted diseases, and provide appropriate prevention messages Provide clinicians with the tools needed to conduct a behavioral assessment, screen for sexually transmitted diseases, and provide appropriate prevention messages * CDC. (2003) Incorporating HIV Prevention into the Medical Care of Persons Living with HIV. Recommendations of CDC, the Health Resources & Services Administration, the National Institutes of Health, and the HIV Medicine Association of the Infectious Diseases Society of America. MMWR Recommendations and Reports, 52 (RR-12), 1-24.

SPNS Initiative: Prevention with HIV-Infected Persons seen in Clinical Settings (Prevention with Positives Initiative) Goal: To evaluate the effectiveness of behavioral prevention intervention programs for HIV-positive clients seen in clinical care settings by examining the following questions: Goal: To evaluate the effectiveness of behavioral prevention intervention programs for HIV-positive clients seen in clinical care settings by examining the following questions: Can behavioral interventions in primary care clinical settings help HIV+ clients reduce the risk of transmitting HIV to others? Can behavioral interventions in primary care clinical settings help HIV+ clients reduce the risk of transmitting HIV to others? What models are most appropriate with different populations (e.g., MSM of color, heterosexual women, rural drug users)? What models are most appropriate with different populations (e.g., MSM of color, heterosexual women, rural drug users)? What models are most appropriate for different primary care settings (e.g., rural, urban, high volume, community-based organization, large hospital)? What models are most appropriate for different primary care settings (e.g., rural, urban, high volume, community-based organization, large hospital)?

Prevention with Positives Initiative Overview 15 sites (20 clinics) were funded to implement and evaluate HIV prevention interventions tailored to their individual clinics 15 sites (20 clinics) were funded to implement and evaluate HIV prevention interventions tailored to their individual clinics A TA & Evaluation Center received funds to conduct a multi-site evaluation and assist demonstration sites in designing their interventions and local evaluations A TA & Evaluation Center received funds to conduct a multi-site evaluation and assist demonstration sites in designing their interventions and local evaluations

SPNS Prevention with Positives Initiative Demonstration Sites

Intervention Modality Table 1: Intervention Modality and Type of Professional Delivering Intervention Site Intervention Modality Individual Level Group Level Johns Hopkins University, Baltimore  University of Alabama, Birmingham  County of Los Angeles  St. Luke’s Roosevelt Hospital, New York  El Rio/Special Immunology Health Ctr., Tucson  University of Washington, Seattle   Mt. Sinai Hospital, Chicago  Fenway Community Health Center  University of Miami  Drexel University, Philadelphia   DeKalb County Board of Health, Decatur, GA   University of North Carolina, Chapel Hill  Whitman Walker Clinic, Washington, DC  University of California, San Diego  University of California, Davis 

Target Populations All patients (3) All patients (3) Patients with sex or drug risk in last 6 months (2) Patients with sex or drug risk in last 6 months (2) MSM with sexual activity in last 6 months (1) MSM with sexual activity in last 6 months (1) All returning patients with sexual activity in last 3 months (1) All returning patients with sexual activity in last 3 months (1) All returning patients (1) All returning patients (1) All MSM (1) All MSM (1) Patients reporting sexual activity in last 3 months (1) Male patients (1) Female patients (1) Patients reporting risk in last 6 months (1) Patients diagnosed with HIV for at least 3 months (1) Patients age >45 reporting unprotected sex in last 12 months

Type of Professional Delivering Intervention Site Primary Care Provider Intervention Specialist Peer Johns Hopkins University, Baltimore  University of Alabama, Birmingham  County of Los Angeles  St. Luke’s Roosevelt Hospital, New York  (Social Worker) El Rio/Special Immunology Health Ctr., Tucson  (Health Educator) University of Washington, Seattle  (Social Worker)  Mt. Sinai Hospital, Chicago  Fenway Community Health Center  University of Miami  Drexel University, Philadelphia   (Health Educator)  DeKalb County Board of Health, Decatur   (Specialist) University of North Carolina, Chapel Hill   (Specialist) Whitman Walker Clinic, Washington, DC   (Health Educator) University of California, San Diego   (Health Educator) University of California, Davis   (Social Worker)

Study Assignment by Intervention Type Sites(N=14)N(N=3799)Percent% Provider388523% Health Educator (HE) % Mixed (Provider + HE) % Assessment only %

Sample Characteristics Gender Male Male Female Female71%28% Age Greater than 40 63% Education: High School or less 51% Sexual orientation MSMMSWWomen51%19%28% Race African American WhiteLatinoOther46%35%15%4%

Study Outcome Transmission Risk Behavior Transmission Risk Behavior ANY unprotected sex with HIV-uninfected or unknown status partner ANY unprotected sex with HIV-uninfected or unknown status partner

Sexual transmission risk behavior by intervention type

Summary and Conclusions Provider-led interventions led to significantly greater reduction in sexual risk at 12 months compared to the assessment only group. Provider-led interventions led to significantly greater reduction in sexual risk at 12 months compared to the assessment only group. Brief risk assessment and provider-led interventions appear to have the greatest effect on reduction in sexual risk among patients seen in clinical settings. Brief risk assessment and provider-led interventions appear to have the greatest effect on reduction in sexual risk among patients seen in clinical settings. More analysis is needed to explore whether and how professional and peer counselor-led interventions affect the lives of HIV-infected individuals in clinical settings. More analysis is needed to explore whether and how professional and peer counselor-led interventions affect the lives of HIV-infected individuals in clinical settings.

Qualitative Findings Risk assessment facilitated openness among some patients Risk assessment facilitated openness among some patients Interventions facilitated increased comfort in talking to providers about sex Interventions facilitated increased comfort in talking to providers about sex Interventions improved communication between patient and provider Interventions improved communication between patient and provider Interventions facilitated self- reflection Interventions facilitated self- reflection

Provider-Delivered Interventions “ The doctor in this program has really caused me to think more so than I used to about how I handle myself, especially when it comes to infecting other people.”

Willingness + Risk Assessment = Dynamic Exchange Opportunities Interventions facilitated teaching/learning exchanges Interventions facilitated teaching/learning exchanges Providers counseled on re-infection, safer sex – condoms, disclosure Providers counseled on re-infection, safer sex – condoms, disclosure Patients discussed “lifestyle” and/or sexual behaviors, preferences Patients discussed “lifestyle” and/or sexual behaviors, preferences Patients appreciated doctor’s point of view Patients appreciated doctor’s point of view

Provider-Delivered Intervention Fit May work well: Privacy-sensitive patients Privacy-sensitive patients “Doctor knows best” patients “Doctor knows best” patients Low health literacy Low health literacy Willingness/openness to reveal sex practices/preferences Willingness/openness to reveal sex practices/preferences May not work well: High health literacy Sex positive patients Pre-existing discussions about sex practices Women ?

Provider Perspectives Feasible to deliver prevention during medical visit Feasible to deliver prevention during medical visit Increased comfort level to talk about prevention Increased comfort level to talk about prevention Risk assessment served as a reminder and vehicle to learn new information about patients Risk assessment served as a reminder and vehicle to learn new information about patients

Provider Perspectives “I thought the report of the risk factors was very helpful to me, particularly in pointing out things that I hadn't picked up with my interview with the patients….It was very helpful, as I would have these focused conversations …It led to a lot of discussions with the patients….it opened up this other area that we hadn't really talked about. It helped me get comfortable too…. So I think you have to get a level of comfort about that as a provider, and I think the -- having it in the folder there and having the patient already thinking about it …and saying "let's see what the [risk assessment] came up with for you today." “I thought the report of the risk factors was very helpful to me, particularly in pointing out things that I hadn't picked up with my interview with the patients….It was very helpful, as I would have these focused conversations …It led to a lot of discussions with the patients….it opened up this other area that we hadn't really talked about. It helped me get comfortable too…. So I think you have to get a level of comfort about that as a provider, and I think the -- having it in the folder there and having the patient already thinking about it …and saying "let's see what the [risk assessment] came up with for you today."

Conclusions Interventions targeted behavior change among patients and providers Interventions targeted behavior change among patients and providers Interventions directed providers to be more attentive to HIV prevention Interventions directed providers to be more attentive to HIV prevention Some patients enjoyed new opportunities to talk about HIV prevention and sexual practices with their provider and vice versa Some patients enjoyed new opportunities to talk about HIV prevention and sexual practices with their provider and vice versa Regularly assessing risk facilitated patient reflection on sex practices Regularly assessing risk facilitated patient reflection on sex practices Interventions were not universally accepted among patients or providers Interventions were not universally accepted among patients or providers

Methods and Tools: Provider-delivered Interventions

Computerized Risk Assessment to Support Risk Reduction Counseling Emily J. Erbelding, MD, MPH Johns Hopkins University School of Medicine

Computer Assisted Risk Assessment (CARA) Trained medical providers deliver counseling based upon Stage-of-Change theory Trained medical providers deliver counseling based upon Stage-of-Change theory Critical behaviors targeted: Critical behaviors targeted: Condom use Condom use Disclosure of HIV status to partners Disclosure of HIV status to partners Drug use Drug use Needle sharing Needle sharing

CARA printout content: example [Patient initials]9/18/2005 Completed the CARA today and identified: Stage for condom use Main partner C My main partner doesn’t want to Casual partner Patient states no casual partners Stage for disclosure of HIV status Main partner M Casual partner Patient states no casual partners Stage for drug use Stop Sharing Stop usingPatient states no drug use past 3 months Enter Drug treatment

PASHIN Peers Advocating for Sexual Health Initiative Laura Bachmann, MD, MPH Associate Professor of Medicine and Epidemiology UAB Schools of Medicine and Public Health Birmingham VA Medical Center Diane M. Grimley, PhD Professor of Public Health and Medicine Chair, Department of Health Behavior UAB School of Public Health and Medicine

Intervention Assessment based on stages of change construct for three target behaviors. Assessment based on stages of change construct for three target behaviors. Intervention messages are stage specific and were developed based on the decisional balance, self-efficacy, and process of change constructs. Intervention messages are stage specific and were developed based on the decisional balance, self-efficacy, and process of change constructs.

Acknowledgements Andre Maiorana Faye Malitz Karen Vernon Sandi Duggan Jennifer BiePam Belton Carol Dawson RoseKatherine McElroy Steve MorinMichelle Teti Starley ShadeCelina Kapoor Participating patients, providers & research collaborators across 15 sites

For more information: AIDS and Behavior Volume 11, Supplement 1 September, 2007

Contact Information Janet Myers, PhD, MPH National Evaluation Center AIDS Education and Training Centers University of California, San Francisco (415)

Thank you! Next session: October 23, 2008 Listserv: