1. What Does It Take To Implement HIV Prevention Interventions into Care Settings? Preliminary findings based on a qualitative evaluation of the HRSA/SPNS Prevention with Positives Initiative Kimberly Koester MA, Andre Maiorana MA, MPH, Karen Vernon BA, Center for AIDS Prevention Studies, University of California, San Francisco, USA

2. Study Background

3. HRSA/SPNS Demonstration Sites

4. UCSF Evaluation & Support Center Qualitative Evaluation Goals: To assess feasibility & acceptability of interventions To provide context for the quantitative results To document the intervention implementation process for replication purposes

5. Methods Purposely selected sample (n=61) of research team members & interventionists Conducted face to face in-depth interviews Audio-recorded interviews transcribed verbatim & entered into Atlas.ti ©, Framework Analysis (Ritchie & Spear) data were coded, synthesized, themes compared and contrasted

6. Intervention Models Differ By ‘Mode of Delivery’ Provider (n=3) MDs, and/or NPs, and/or PAs Specialist (n=3) Health Educators or Social Workers Peer (n=3) People living with HIV/AIDS Provider + Specialist (n=6) Combination of MDs, and/or NPs, and/or PAs + Health Educators or Social Workers

7. Intervention Models Differ in Emphasis Emphasis on brief message (directive) Emphasis on education (directive) Emphasis on dialoguing, sharing, & counseling (interactive)

8. Provider + Specialist Specialist Peer Provider CDC promoted provider-delivered prevention Belief in the efficacy & efficiency of provider-delivered messages Provider willingness to participate Behavior change requires in-depth counseling Opportunity to enhance clinic services by adding counseling staff Low provider willingness to participate How Sites Determined Who Should Deliver PwP Delivery Mode Special patient population requires peer delivery: stigma/prevention fatigue

9. Provider + Specialist Peer Provider Stages of Change Motivational Interviewing Gender & Power Theory Cognitive Behavior Theory Theories, Modes and Intervention Tools Delivery Mode Guiding Theories Computer-based risk assessment Face to face risk assessment Computer guided counseling sessions Computer-based behavioral Rx Intervention Tools

10. Provider-Delivered PwP Interventions Occurs during routine HIV care clinic visit Patient risk & stage of change is assessed via computer (2) or face to face with provider (2) Risk assessment/stage generates prescriptive behavioral counseling recommendation for provider Provider delivers brief prevention message tailored to patient risk profile & readiness for change

11. Specialist-Delivered PwP Interventions Typically occurs in conjunction with routine clinical care visit over 4-5 sessions Social worker or health educator engages in PwP counseling in individual or group setting Counseling topics typically include: safer sex, drug use, relationships, taking medication, disclosure, emotional well being, assertiveness training, and patient priorities

12. Peer-Delivered PwP Interventions Typically occurs separate from routine clinical care during four - nine individual or group counseling sessions Modular PwP counseling curriculum facilitated by peer & tailored to patient priorities Counseling topics typically include: sexual behavior, disclosure, adherence, stigma, relationships, drug use, emotional well being

13. Specialist + Provider PwP Interventions Provider: brief stage-based or prescribed prevention message based on risk assessment delivered during routine visit Specialist: 3-5 counseling sessions with health educator or social worker covering topics such as: safer sex, drug use, stigma, medications, relationships, disclosure, emotional well being

14. Provider + Specialist Peer Provider Disrupts clinic flow Lack of experience Requires extra visits Hiring & Supervising Intervention Implementation Barriers & Facilitators Delivery ModeBarriers On-going training Attending to clinic flow issues Highly motivated Supportive clinic leadership Facilitators Limited time in clinic visit Provider resistance Developing buy in Finding/developing training

15. Overall Implementation Challenges Integration most difficult in locations that utilized providers –Requires change in clinical practice –Requires patient willingness to discuss risk Specialist & peer-delivered rely on patient desire to participate –Requires patient motivation to attend additional sessions and engage in process

16. Overall Integration Facilitators Internal leadership to overcome resistance and foster interest and motivation on the part of medical providers and staff to integrate prevention into medical care and other services Core belief among key stakeholders in importance, need, viability, and appropriateness of PwP in clinical setting Securing high quality behavior change training tailored to clinical environment

17. Easiest to Implement: Specialists & Peers Central Advantage Specialist/Peer as ‘Intervention Champion’ Considerations Requires extra effort to attract patients Training may be intensive and difficult to access (e.g., M.I.) Hiring & supervising may be challenging New hires require funding & space

18. Unique Implementation Issues: Mixed Models Central Advantage Patient receives two doses of intervention Considerations Time and resource intensive to set up two different interventions Use of existing staff begged the question of whether the interventions were even being implemented at all Logistics associated with integrating two components not easy

19. Implementation Requires Tenacity: Providers Central Advantage Providers have a “captive audience” Considerations Providers may ask “Why is this my responsibility?” Providers need assistance to refine & improve upon current practices Practical aspects of project can be unwieldy – risk assessment, how, when, then what Trainings must be offered on a regular basis – keep the fires burning…

20. Lessons Learned Each intervention model is accompanied by barriers & facilitators. Successful integration depends on the complementary fit between the intervention model and the clinical setting.

21. Recommendations Invest time and effort in developing shared vision among key stakeholders and methods for integrating PwP in clinic Conduct formative research/needs assessment to determine culturally appropriate intervention models for clinic environment and patient population Acknowledge provider and staff concerns, beliefs and existing practices regarding HIV prevention –Conduct a focus group or survey research to assess concerns, attitudes and current practices –Ask providers & staff to contribute ideas to program design Present evidence-based data to stress the importance of conducting prevention in the context of a clinical setting –Host meetings (led by clinicians) and provide food Provide adequate training that meets the expectations & objectives the clinic is trying to achieve –Secure the support of the medical director – they can facilitate the integration of services into clinic and allow sufficient time for trainings

22. Resources NAPWA Principles of HIV Prevention with Positives http://www.napwa.org/publications/principles.ht ml http://www.napwa.org/publications/principles.ht ml EPPEC website: http://ari.ucsf.edu/programs/policy_pwpresources.aspx Forthcoming AIDS and Behavior supplement on HRSA/SPNS PwP

23. Acknowledgements This work is supported by grant number 5H97HA00261 from the Health Resources and Services Administration (HRSA) Special Projects of National Significance (SPNS) Program. The contents of this poster are solely the responsibility of the authors and do not necessarily represent the official view of HRSA or the SPNS program. Special thanks to each and everyone of our participants for taking time to tell us about their perspectives on the intervention implementation process.