2. Incorporating HIV Prevention into the Medical Care of Persons Living with HIV Ask ∙ Screen ∙ Intervene Developed by: The National Network of STD/HIV Prevention Training Centers, in conjunction with the AIDS Education Training Centers Module 2: Universal Prevention Messages and Addressing Misconceptions Tailored Behavioral Interventions

3. Learning Objectives: Module 2 Upon completion of training, providers who care for HIV-infected persons will be able to:  Deliver universal prevention messages  Address misconceptions  Provide tailored interventions o Brief behavioral interventions o Referrals for more intensive interventions & other prevention services

4. Effectiveness  Brief, clinician-delivered counseling interventions help patients change behaviors related to: o Depression o Smoking o Alcohol use o Weight and diet o Physical activity  Can also reduce HIV-transmission risk (Kamb 1998, Richardson 2004, Fischer 2004)

5. What are Prevention Messages? Statements that emphasize the need for safer behaviors to protect both the patient’s health and the health of their sexual- or needle-sharing partners

6. Case Example: TONY Summary from Module 1:  40 y/o man with girlfriend, but also has other male sex partners  HIV+, in care  Girlfriend also has HIV; Does not use condoms with her  Inconsistent condom use for anal and oral sex with male partners What prevention messages would apply?

7. Tony: Prevention Messages  Condoms could protect you from other STDs  STDs can be transmitted by oral sex  Unprotected sex with your girlfriend could expose her to STDs  Condoms could protect your other partners from HIV

8. Universal Prevention Messages  STDs facilitate transmission of HIV o Increase susceptibility to HIV o Increase transmissibility of HIV  Risk of superinfection remains unclear  Injection drug use  Can still transmit HIV despite o ART o Post-exposure prophylaxis

9. Learning Objectives: Module 2  Upon completion of training, providers who care for HIV-infected persons will be able to:  Deliver universal prevention messages  Address misconceptions

10. What are Misconceptions? Incorrect assumptions or beliefs that patients may have about HIV transmission.

11. Common Misconceptions Risk of HIV transmission associated with:  Specific sexual & drug using behaviors  Other cofactors o Stage of infection o Viral load o Co-existing STDs  Effectiveness of non-occupational post- exposure prophylaxis

12. Risk FactorRelative risk for a person without HIV infection of acquiring HIV infection Sex Act Insertive fellatio1 Receptive fellatio2 Insertive vaginal sex10 Receptive vaginal sex20 Insertive anal sex13 Receptive anal sex100 Condom Use Yes1 No20 Common Misconceptions: Risk of HIV transmission based on specific sexual behaviors MMWR, July 18, 2003

13. Common Misconceptions: Effect of ART on HIV transmission Serum viral load of HIV- infected partners (copies/mL) Risk for transmission to partners not infected with HIV (adjusted rate ratio; 95% CI) <3500Referent 3500-99995.80 (2.26-17.80) 10,000-49,9996.91 (2.96-20.15) >50,00011.87 (5.02-34.88) Per log increment viral load 2.45 (1.85-3.26) MMWR, July 18, 2003

14. Identifying Misconceptions  What do you know about how people get HIV?  What are your concerns about giving HIV to someone else?  What are your concerns about getting an STD or hepatitis?

15. What are Tailored Behavioral Interventions? Strategies designed to change a person’s behaviors or practices in order to reduce personal health risks or risk to others

16. Education vs. Behavioral Interventions Patient Education  Knowledge Behavioral Intervention  Knowledge  Attitudes/ Beliefs  Behaviors  Circumstances  Skills  Readiness NIH Consensus Conference: Brief, provider-delivered, tailored interventions in clinical setting have been shown more effective in behavior change than patient education… CDC (2001). Revised guidelines for HIV counseling, testing and referral. MMWR, 50 (RR-19), p 1 - 62

17. Tailored Interventions  Use with patients at high risk for transmitting HIV and acquiring STDs: o Current sexual and substance use practices indicate risk o Recent STD diagnosis  Core elements o Interactive o Based on individual circumstances o Leads to a first step

18. Individualized Concrete Incremental Realistic Behavioral Goal STEPS Find a First Step

19. Behavioral Goals: o Abstinence o Monogamy o Condom use o Reduce number of partners o Disclose to partners o Determine partners’ status o Refer partners for STD/HIV counseling & testing o Stop injection drug use o Use clean or new injecting equipment o Treatment adherence

20. Risk Screening focus on behaviors:  How often have you shared works in the last 3 months?  How often do you use condoms?  When was your partner last tested for HIV? Covered in Module 1 Tailored interventions focus on circumstances, attitudes & readiness:  When is it easier to use clean works?  What does your partner think about condoms?  Does your partner know that you’re HIV-positive? Provide responses tailored to patient circumstances

21. Assess Behaviors & Circumstances  What & With Whom? - relationship dynamics  Where? - bar, bathhouse, sex club, parks, chat rooms, home, etc.  When? - time frames  Triggers? - environmental or situational influences

22. Assess Patient’s Attitudes  Is a change needed? o Does the patient see a risk of transmission? o Is this risk serious enough?  Is change possible? o Can barriers be overcome? o Have skills to make change?

23. Assess Readiness for Change  Don’t see a need to change  See a need, but have barriers  Ready to try a behavior change

24. Case Example: TONY Behaviors from Risk Assessment  Doesn’t use condoms with his girlfriend  Using condoms sometimes for anal sex with male partners

25. Case Example: TONY Assess Circumstances  Meets partners in clubs  Uses condoms unless partner says he is also HIV+  Girlfriend of 3 years is HIV+, doesn’t know about male partners

26. Case Example: TONY Assess Attitudes  Doesn’t want to give HIV to others  Thinks bringing up condom use with girlfriend would make her suspicious about others

27. Case Example: TONY Assess Readiness  Syphilis diagnosis has influenced readiness - now sees a need to also use condoms with HIV+ partners  Sees a need to use condoms with girlfriend, but has barriers

28. Skills Practice DEVELOPING AN INTERVENTION Interact! Summarize risk Ask patient to set goal Discuss circumstances, barriers, readiness Ask patient if ideas are realistic and do- able Identify a first step

29. On-going Prevention at Next Visits Ask patient about progress  If patient is meeting the goal: o positive reinforcement o identify next steps o anticipate new problems or changes (Ask “what if.. ?” questions)  If patient is not meeting goal: o further assess circumstances, attitudes, readiness o revise steps o consider referrals

30. Referrals  HIV Case Management/ Prevention Case Management  Other behavioral interventions o Individual, group, community  Partner Counseling & Referral Services (PCRS)  Other services: substance use, mental health, social services, family planning

31. Training for Clinicians Where do I go to learn more about brief risk- reduction interventions?  Behavioral & Social Intervention Training Centers of National Network of STD/HIV Prevention Training Centers - New York, Denver, Texas, California www.stdhivpreventiontraining.org www.stdhivpreventiontraining.org  AIDS Education & Training Centers www.aidsetc.orgwww.aidsetc.org

32. Choosing an Intervention  Which of your patients need….. o Prevention messages/addressing misconceptions? o Tailored behavioral interventions? o Referrals for more intensive interventions and prevention services?

33. RISK SCREENING STD SCREENING PREVENTION MESSAGES ADDRESSING MISCONCEPTIONS BRIEF BEHAVIORAL INTERVENTIONS REFERRALS PARTNER MANAGEMENT What are your Next Steps?