1. Stage-based Behavioral Counseling for Persons Living with HIV/AIDS

2. CHBT Designed as - Behavioral & Social Intervention Center
of the New York State STD/HIV Prevention Training Centers
(PTC’s) by the CDC, part of the National Network of PTC’s
- Center of Expertise in Behavioral & Social
Science and HIV/AIDS Regional Training Center by the
AIDS Institute, NYS Dept. of Health

3. - Clinicians and case managers providing care to those living
Module: Using Stage-based Behavioral Counseling for Persons Living with HIV/AIDS
Target Audience:
- Clinicians and case managers providing care to those living
with HIV/AIDS
Rationale:
- Need for HIV primary transmission prevention
- Primary prevention depends on behavior change
- Presumption that patient education and knowing one’s
HIV status would result in risk behavior change
- Evidence shows education is not enough
- Behavioral counseling is more effective

4. Module Objectives
Increase knowledge of behavioral counseling intervention used in STD & HIV clinics
Increase awareness of SOC/TTM of Behavior Chance Theory and how it was adapted to develop Stage-based Behavioral Counseling
Increase Knowledge of the steps in using this intervention
Increase knowledge of training and resources

5. Patient Education vs Behavioral Counseling
Patient education is one-directional which increases knowledge levels, but is not effective for sustained behavior change
Behavioral counseling doesn’t require more time - but is a different approach
Short term, provider delivered, behavioral counseling in clinic settings - now proven effective
Group and community level interventions also work

6. Scientific Evidence Accumulating Over Past 10 Years
Has led to Changes in recommendations
about using behavioral counseling for STD/HIV prevention
- NIH Consensus Conference (1997)
- IOM Report: STD’s The Hidden Epidemic (1997)
- CDC’s Compendium of HIV Prevention Interventions
with Evidence of Effectiveness (1999)
- CDC’s Guidelines for HIV Counseling, Testing &
Referral (draft, 2000)

7. CDC Guidelines for HIV Prevention Counseling - 2000
Behavioral counseling is more effective than
patient/client
There are many models - Essential Elements:
- Science-based
- Must be interactive
- Focused on client’s personal risks and circumstances
- Help client to set and reach specific goals
Now a standard of care for STD clinics
Becoming standard of care of HIV clinics

8. Behavioral Counseling Intervention for STD/HIV Prevention used in STD Clinics
Project Respect - based on selected influencing factors of behavior change. Model for CDC’s HIV Prevention Counseling for Persons Living with HIV/AIDS
Others - eg. Shain Intervention, NIMH Multi -site,
VOICES/VOCES
Stage-based Behavioral Counseling - based on the stage of change/Transtheoretical Model of Behavior Change Theory used for integrated STD/HIV Prevention

9. Behavioral Counseling Interventions for STD/HIV Prevention in HIV Clinics
Not routinely used - new role for these
providers
CDC’s Project SAFE --
Serostatus Approach to Fighting the
Epidemic (SAFE): Prevention Strategies for
Infected Individuals*
*Janssen et al. (2001). American Journal of Public Health.

10. In Order to Be Used by Clinicians...
Behavioral Counseling Model must also be
- effective for “ difficult/problem” clients
- able to integrate STD and HIV prevention
- acceptable to the client population
- able to be used by a wide variety of providers
- able to fit into a busy, clinical setting - into existing clinic
flow
- efficient and practical -- able to be completed in 10-20
minutes
- able to be used for many health related behavior change
goals

11. Factors Influencing Behavior Change Identified by Social and Behavioral Science Research
A variety of factors are now known to influence
behavior change:
- Some are more internal within the individual self:
knowledge, attitudes & beliefs, skills, et al
- Other factors are more external: sexual relationship
dynamics, influence of peers, family and cultural norms,
and environment
Behavioral counseling strategies need to address
each client’s influencing factors in order to in
influence change

12. Stage of Change/Transtheoretical Model of Behavior Change Theory
SOC/TTM Theory states that people are in different
psychological stages of readiness to change any
given behavior at any given time, AND that
counseling strategies need to match the SOC in
order to be effective
SOC/TTM Theory addresses internal and external
factors influencing behavior change
SOC/TTM provides effective counseling strategies
for a subset of patients who see no need for change
or who have significant barriers

13. Stage of Change/Transtheoretical Model of Behavior Change Theory
SOC/TTM currently used to help health care providers be more effective in the behavior change for many health related behaviors eg, smoking cessation, alcohol abuse, dietary modifications, exercise, etc...
The Rochester program adapted SOC/TTM to
develop a behavioral counseling intervention that
integrates STD and HIV prevention counseling

14. Stage-based Behavioral Counseling
Named the intervention Stage-based Behavioral
Counseling
Established training curricula and QA program components, and implemented in 1995
Use it for
- HIV counseling & testing
- Primary transmission prevention for clients with
HIV/AIDS
- HIV/STD case management
- Accepting referrals
- Influencing behavior change - any primary or
secondary prevention goal

15. Stage-based Behavioral Counseling
Integrates STD and HIV prevention
10-20 minute sessions
Integrates easily into clinic flow
Can also be used in community-based, criminal
justice settings, street outreach
High levels of provider and client acceptability
Especially helpful for - “difficult” clients
Can be used for other behavior change goals

16. How is This Intervention Science-based?
SOC used to define stages of readiness
for change in relation to -- STD/HIV Prevention Target Behaviors:
Sexual , Substance Use, Health Care Seeking
TTM Processes of Change used to develop 11 counseling strategies that match the SOC

17. Steps in Using 1. Stage each client by identifying a target behavior
and assessing client’s readiness to adopt or adhere to
that behavior
2. Use a counseling strategy that matches the client’s
stage of readiness and is most likely to influence
behavior change for that client
3. Document the behavioral assessment, target
behavior and SOC, counseling strategy used,
immediate outcomes, and client’s first steps in order
to provide continuity of care and evaluate
effectiveness

18. Skills Rating Scale Stage-based Behavioral Counseling has been
A Rating Scale of skill items needed to perform
Stage-based Behavioral Counseling has been
developed and is used for training clinicians and
for program quality assurance
5 are general behavior change skills
6 are specific to stage-based behavioral counseling
This module will highlight two to these skill
items

19. Skill Item 3. Assess Client’s Stage of Readiness for Change
First -- Identify a target behavior -- what are
you trying to help the client to do?
- Sexual: use condoms, delay or avoid vaginal/rectal sex, disclose
HIV status to partner(s), get partner(s) STD/HIV tested
- Substance Use: use needle-exchange, enter a substance use
treatment program, accept a referral, use partner notification
services
- Health Care Seeking: get into HIV medical care, adhere to
prescribed treatment, get frequent screening/Rx for STDs, family
planning

20. Skill Item 3 (con). Assess Client’s Stage of Readiness for Change
Then - - Assess his/her readiness - attitudes
towards the target behavior
- Precontemplative: Doesn’t see the need to do it
- Contemplative: Sees the need to do it, but can’t because
of barriers
- Ready for Action: Ready to try or has already started to
try
- Action, Maintenance: Doing the target behavior
consistently for 3-6 months or more

21. Skill Item 3 (con). Assess Client’s Stage of Readiness for Change
First take a good sexual/substance use/HIV
care history to identify which target
behaviors would result in STD/HIV
prevention for the client
For example, staging for sexual behavior change:
R = nature and status of current sexual relationships
N = number of partners of both client and partner(s)
T = types of sexual contact

22. Skill Item 3 (con). Assess Client’s Stage of Readiness for Change
Then asses the client’s attitudes towards
doing the sexual target behavior
Staging for sexual behavior change (con):
A = history of, and attitude towards:
C = condom use
A = avoiding or delaying vaginal/rectal sex
D = disclosing HIV status to partners

23. When taking a sexual/substance use history, remember (con):
Use open-ended questions which paint a “big”
picture” to understand client’s influencing factors
such as
- Tell me about your current partner situation
- If steady, what’s that relationship like for you?
- When is the last time you had sex with that person? How
about with someone other than that person?
- What’s your experience been with condom use?
- With disclosing to sexual partner(s)?
- What’s your experience been with substance use? Etc..

24. When taking a sexual/substance use history, remember (con):
Use verbal prompts and minimal encouragers
to follow open ended questions to help the
client to say more, explain his/her personal
circumstances, e.g.:
- uh, huh
- tell me more about that
- so, then what happened...
- can you say more
- go on...

25. When taking a sexual/substance use history, remember (con):
Once you have gathered “big picture”
information, move to more closed-ended
questions to narrow and define the situation:
- Do you have vaginal, rectal, oral sex? With males, females,
both, or, with same sex partners?
- How many different partners have you had in the last 3
months? In the last year?
- Do your current partners know your HIV status?
- How often are you using? Have you ever been in
treatment?
- Have you ever been in a situation where you had sex in
order to use?

26. Skill Item 3 (con). Assess Client’s Stage of Readiness for Change
For example: Target behavior - using condoms
consistently with all partners
- Precontemplative: doesn’t see the need to use condoms
- Contemplative: sees the need to use condoms, but can’t because has barriers
- Ready for Action: ready to try using condoms, or has already started
- Action: using condoms for 3-6 months
- Maintenance: using condoms for 6 or more months

27. Skill Item 3 (con). Assess Client’s Stage of Readiness for Change
For example: Target behavior - disclosing HIV status to sexual partner(s)
- Precontemplative: doesn’t see the need to disclose
- Contemplative: sees the need to disclose, but can’t
because has barriers
- Ready for Action: ready to try to disclose, or has already started
- Action: has disclosed 3-6 months ago
- Maintenance: has disclosed more than 6 months ago

28. Distribution of SOC for consistent condom use for HIV/AIDS cases in STD Clinic (98-00)
For clients with multiple partners:
Newly diagnosed Previously Known PC C
RFA A M
Total

29. Distribution of SOC for consistent condom use for HIV/AIDS cases in STD Clinic
TOTALS:
Newly Diagnosed: 40
Previously Known: 41

30. Skill Item 4 (con). Use a Counseling Strategy that Matches SOC
Eleven Counseling Strategies adapted
from TTM processes of change
More effective because each is psychologically matched to client’s readiness
Less likely to cause client resistance
No more “difficult” clients

31. Skill Item 4 (con). Use a Counseling Strategy that Matches SOC
Precontemplative (No Way. . .)
- Information Giving: give information
specific to client’s situation
- Story Telling: tell client a “story” about a
case similar to his/hers and outcome of the
case
- Discuss Impact of Behavior on Others:
help client to see how the behavior is
negatively impacting on persons the client
cares about

32. Skill Item 4 (con). Use a Counseling Strategy that Matches SOC
Case Example of Info Giving
A 28 year old HIV + female, presents to clinic for treatment after testing positive for cervical GC. The clinician discovers that the patient was infected by a new outside partner, and that her steady HIV - partner is coming in to be tested and treated today for the GC.
The patient does not see the need to consistently use condoms with her negative partner, because she is on antiretrovirals, with an undetectable viral load, and doesn’t think she can give him HIV.

33. Skill Item 4 (con). Use a Counseling Strategy that Matches SOC
The clinician identifies the clients need for further info regarding the connection between STD’s and HIV transmission
The clinician may say:
“Sounds like you know a lot about HIV. You are correct that you may be less likely to transmit HIV to your partner because you have a very low viral load on your HAART therapy. However, we also know now that if you have HIV and then get an STD, you are shedding high amounts of HIV from your cervical and vaginal fluids, which increases the chance your partner will get infected”.

34. Skill Item 4 (con). Use a Counseling Strategy that Matches SOC
Contemplative (Yes, but. . .)
- Focus on Ambivalence: help client
understand why he/she is on the fence; Discuss
pros and cons: exploring client’s cost/benefit
to change; Offer Harm Reduction Substitutes
- Discuss Behavior in a Relation to Self-
Image: discuss patient’s self-image and how
it conflicts with the behavior

35. Skill Item 4 (con). Use a Counseling Strategy that Matches SOC
Case Example of Pros and Cons
The same client presents with the same situation, but this time when asked about condom use and using them with her HIV negative partner on a consistent basis she replies, “I know I should be using them, but he doesn’t know I have it, and I don’t think he will stay with me if he finds out”.
The clinician is aware the client is ambivalent about the situation and decides to help the client explore the ambivalence more, by getting additional details about her situation.

36. Skill Item 4 (con). Use a Counseling Strategy that Matches SOC
The clinician, after discovering the patient is very financially and emotionally dependent on this partner, decides to use pros and cons for her strategy.
She says, “I understand you think he would leave you if he found out you had HIV, but tell me what you think might be good about using condoms with him?” She replies that he wouldn’t get HIV, she would have less guilt, and their sex life would be less stressful”
The counselor says, “those results do sound good, but what about the bad things that might happen?” She replies that he would think she was lying to him or cheating on him, and leave.

37. Skill Item 4 (con). Use a Counseling Strategy that Matches SOC
The clinician adds to the positives, tries to help the client to decide if her barrier is real or perceived and may recommend possible substitutes.
Harm reduction strategies are then discussed and might include making sure she is screened at treated for STD’s, having sex less frequently, or less risky sex with partner.

38. Skill Item 4 (con). Use a Counseling Strategy that Matches SOC
Ready for Action (Let’s do it. . .)
- Develop a plan: articulate plan detailing
how the client will accomplish the behavior;
Build Skills and Self-efficacy: build confidence,
practice skills and establish first step

39. Skill Item 4 (con). Use a Counseling Strategy that Matches SOC
Action and Maintenance (Doing it and
Living it)
- Identify Supports: help client find a support
system
- Avoid Cues: assist client in recognizing and
avoiding cues which led to risky behaviors
- Identify Rewards: help client identify a
meaningful reward for maintaining the change

40. Skill Item 4 (con). Use a Counseling Strategy that Matches SOC
Action and Maintenance (Doing it and
Living it) (con)
- Find Substitutes: assist the client to find
substitutes for previous risky behavior
- Become a role Model: help client become a
role model of change for his/her peers

41. Training Provided on or off-site
For Training in Stage-based Behavioral Counseling
CHBT St. Paul Street, 4th Floor
Rochester, NY
Training Provided on or off-site

42. Other SBS Training Resources
Dallas PTC
Denver PTC
California PTC
Effective individual, group, community level
HIV and STD prevention interventions