1. Brief Counseling: Consolidating Our Skills for a Risk Reduction Session Linda Creegan, MS, FNP California STD/HIV Prevention Training Center Oakland, CA

2. STDs and HIV: Scope of the Problem/Burden in the U.S. An estimated 12 million cases of STDs occur annually Estimated 1 million Americans infected with HIV u One quarter of these do not know they are infected u Approximately 40,000 new cases of HIV infection each year Injection-drug use is practiced by 1-1.6 million Americans u Over 1 million cases of chronic Hepatitis B www.cdc.gov

3. Impact of STDs STDs disproportionately affect u adolescents u young adults u women u the poor u minorities Chlamydia is the most common reportable disease u 3-4 million cases/year About 1 in 5 adults has HSV-2 PID is a major cause of infertility in women www.cdc.gov

4. U.S. has highest rates of STDs of the industrialized nations Gonorrhea 1995 Syphilis 1995 Institute of Medicine, 1997

5. Working with Patients to Reduce Transmission of STD/HIV Biomedical interventions u Effective ART u Diagnosing and treating STDs u Circumcision Behavior change

6. What do we know about counseling for behavior change? Similar messages will help patients prevent HIV, STD, and unintended pregnancy Effective approaches share common elements Harm reduction provides a conceptual framework A client-centered approach is most effective

7. Research Limitations Limited research as to what methods are effective Translation from theory/research to practice is difficult and ill-defined u No established “tipping point” between fidelity to research design and simplification for everyday practice

8. Goals for this Workshop Learn a brief, simple counseling model that can be taught in your AETC trainings u As science-based as possible u As usable as possible u Adaptable to different counseling situations Get some practice

9. Applications STD clinics and primary care Family planning HIV testing and clinical care

10. Risk Reduction Interventions for HIV and STDs Community level Small group interventions Individual counseling u Published results from four studies of brief, individual approaches Outcome measures u Self-report behavior change u Biological outcomes

11. Client-Centered Counseling: Brief, Individual Approaches Stages of Change theory Project Respect (Kamb, 1998) and RESPECT-2 (Metcalf, 2005) Partnership for Health (Richardson, Jan 2004) OPTIONS Project - motivational interviewing (Fisher, Jan 2006)

12. Stages of Change Counseling Approaches 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 Source: Prochaska and DiClemente, 1983

13. Project Respect Almost 6000 patients attending large publicly-funded STD clinics (SF, LB, Denver, Baltimore, Newark) Patients randomized to receive client-centered counseling by trained (non-clinical) staff or education by clinician Outcome measures: –Self-report of risky sex behaviors, condom use –New STDs: GC,CT,Syphilis, HIV Outcome findings: two short counseling sessions (20 minutes each) increased condom use and prevented new STDs Kamb et al, JAMA Oct.7,1998

14. Effects of Risk Reduction Counseling: Results from Project Respect, 1993-1996 Kamb et al, JAMA 1998

15. Project Respect Protocol Components Introduce and orient client to the session 1-2 min Enhance the client’s sense of self-risk 2-3 min Explore the specifics of the most recent risk incident 2-3 min Review previous risk-reduction experiences 2-4 min Summarize the risk incident and risk patterns 3-4 min Negotiate a risk-reduction step 4-5 min Identify sources of support and provide referrals 1-2 min Close the session 3-5 min Total time: 18-28 min

16. Partnership for Health Almost 900 patients enrolled in California Six HIV clinics, randomized by clinic as gain-frame or loss-frame approaches, or as controls Counseling, 3-5 minutes, emphasized patient- provider team approach to staying healthy Outcome measures u self-report of unprotected anal or vaginal sex Outcome findings: brief, loss-framed counseling reduced unsafe sex in those with multiple or casual partners

17. Examples of Loss-Framed Prevention Messages “Unsafe sex may expose you to other STDs and other strains of HIV.” “If you don’t tell your partner that you have HIV before having sex, you cannot talk honestly with your partner about safer ways to have sex.”

18. OPTIONS Project 497 clients of two large HIV clinics in Connecticut Prospective trial comparing clinician-delivered risk reduction counseling to standard-of-care control Motivational interviewing technique, 5-10 minutes Outcome measures u Self-report of unprotected vaginal, anal and insertive oral sex Outcome findings: Counseling reduced unsafe sex

19. Common Elements of Effective Interventions Risk assessment Client and provider choose a behavior to modify u Explore readiness, willingness, barriers and supports Client and provider formulate a plan

20. Client-Centered Counseling: A Working Definition Counseling conducted in an interactive manner through the use of open-ended questions and active listening, which focuses on developing prevention objectives and strategies with the client rather than simply providing information. CDC HIV Prevention Case Management Guidelines, 1997

21. Factors that Affect Behavior Change Knowledge Perceived risk Perceived consequences Attitudes (beliefs) Skills Self -efficacy Actual consequences Access Intentions Perceived social norms Policy

22. Counseling vs. Information- Giving Dialog Individualized Takes feelings and beliefs into account Helps client understand themselves better Short and focused One-way Levels of detail but not tailored to an individual Sticks to the facts Helps client understand a subject better Short and focused

23. General Principles for Client- Centered Counseling Ask and listen more, talk less Approach each patient as an individual Focus first on issues and realities that the patient identifies Maintain a neutral, non-judgmental attitude Offer options, not directives Onus of action and responsibility remains with the patient

24. Three Steps in a Synthesized CCRRC Approach 1. Focus on personal risk assessment u Identify patient’s personal perception of risk 2. Choose a safer goal behaviors u Identify patient’s level of readiness for change u Assess supports and obstacles for behavior change efforts 3. Develop a personalized action plan u Negotiate small, realistic risk-reduction steps u Refer to specialized services, if needed

25. Step 1 Assist Client in Assessing Risk Begin dialogue with patient to determine u number, gender of partners u sexual practices (anal, oral, vaginal sex) u patterns of condom use u prior STD testing history, and diagnoses Identify factors affecting patient risk u current/past history of unprotected sex u intentions for becoming pregnant u history of domestic violence u history of injection drug use

26. Sample Risk Assessment Questions  What do you see as the riskiest things that you are doing?  What are you doing in your life that might be putting you at risk for STD/HIV?  What are the situations in which you are most likely to put yourself at risk for HIV or STD?  When was the last time that you put yourself at risk for STD/HIV? What was happening then?  How do drugs or alcohol influence your STD or HIV risk behaviors?

27. Step 2 Set Safer Behavior Goal Risk Behavior “Unprotected vaginal sex with new partner” Safer Goal Behavior “Consistent condom use with this partner”

28. Sample Goal-Setting Questions How would you like to change that? What would you like to do differently? What might be better for you to do? How could you make (sex/drug use) safer for yourself?

29. Possible Goal Behaviors for STD Risk Reduction Reducing # of sexual partners Increase condom use with main/non-main partners Partner testing Monogamy Abstinence Enter drug treatment program Use needle exchange Stop sharing needles/works Consideration of any of the above

30. Reaching a Goal Factors that influence behavior Drawbacks, Obstacles Benefits, Supports Risk Behavior Safer Goal Behavior

31. Identify Barriers/Sources of Support for Change Circumstances of risk Analyze a recent risk occurrence Where does……occur? What makes it hard to…? When do you have sex without a condom? Obstacles and supports Power and control dynamics in relationships Cultural issues Access to care Significant others

32. Step 3 Formulate Realistic, Simple Plan Risk reduction plan must be… patient-driven, based on patient’s history, readiness, and ability to adopt safer behaviors Health care providers can… u support efforts previously attempted by patient u help the patient stay small and specific u offer options, not directives u remain non-judgmental

33. Making an Action Plan Risk Behavior Safer Sex Goal Factors that influence behavior Personalized Action Plan 1. 2. 3. Drawbacks, Obstacles Benefits, Supports

34. Sample Action Plan Questions How will you go about that? What is one thing you could do to begin? What will you need to do first/next? When will be a good time to try/begin this? Who can you talk to about this for support?

35. Refer to Specialized Services, If Needed Alcohol or drug treatment programs Partner/domestic violence services Partner counseling and referral services (PCRS) Couples counseling Benefits counseling to obtain access to services

36. Follow-up: Ongoing Dialog Ask about risk-reduction efforts at next meeting. u Review and repeat u Change or add to plan u Encourage patient to keep trying u Reinforce your support Remember: behavior takes time to change.

37. Encouraging Providers to Incorporate Brief Counseling into Routine Care Emphasize importance “STDs and HIV are among the most common STDs in the US” Emphasize results “Similar messages will help your patients prevent HIV, STD, and unintended pregnancy” Emphasize research base “Counseling methods shown to be effective by research share common elements” Emphasize do-ability u “These studies were done in HIV and STD clinics like yours” Teach and practice skills u Ask trainees to identify their “first step”

38. Taking Personal Stock Helping clients change behavior may begin with changing some of our own u Talk less, ask and listen more u Encourage and be satisfied with step-wise, incremental, realistic changes u Avoid “should/shouldn’t”, “I think you…..” “You need to…..” u Be willing to give it a try!

39. References Johnson WD, et al. HIV intervention research for men who have sex with men: a 7-year update. AIDS Ed and Prev; 2005,17(6),568-589. Kamb ML et al, Efficacy of Risk-Reduction Counseling to Prevent Human Immunodeficiency Virus and Sexually Transmitted Diseases, A Randomized Controlled Trial. JAMA 1998:280:1161-1167 Richardson JL, et al. Effect of brief safer-sex counseling by medical providers to HIV-1 seropositive patients: a multi-clinic assessment. AIDS 2004, 18:1179-1186 Fisher JD, et al. Clinician-delivered intervention during routine clinical care reduces unprotected sexual behavior among HIV- infected patients. J Acquir Immune Def Syndr Jan 2006:14(1): 44-52

40. Websites HIV InSite, UCSF http://hivinsite.ucsf.edu/InSite?page=Prevention http://hivinsite.ucsf.edu/InSite?page=Prevention RXisk Reduction Handout, Mountain States AETC http://www.aids-ed.org/pdf/p02-et/et-05- 00/risk_reduction_pad.pdf http://www.aids-ed.org/pdf/p02-et/et-05- 00/risk_reduction_pad.pdf Project Respect http://www.cdc.gov/HIV/projects/rep/RESPECT.htm http://www.cdc.gov/HIV/projects/rep/RESPECT.htm Partnership for Health http://www.cdc.gov/HIV/projects/rep/partnershipforhe alth.htm http://www.cdc.gov/HIV/projects/rep/partnershipforhe alth.htm