Presentation on theme: "Stage-based Behavioral Counseling for Persons Living with HIV/AIDS."— Presentation transcript:
Stage-based Behavioral Counseling for Persons Living with HIV/AIDS
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 CHBT
Module: Using Stage-based Behavioral Counseling for Persons Living with HIV/AIDS 4Target Audience: - Clinicians and case managers providing care to those living with HIV/AIDS 4Rationale: - 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
Module Objectives 4Increase knowledge of behavioral counseling intervention used in STD & HIV clinics 4Increase awareness of SOC/TTM of Behavior Chance Theory and how it was adapted to develop Stage-based Behavioral Counseling 4Increase Knowledge of the steps in using this intervention 4Increase knowledge of training and resources
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
1.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) Scientific Evidence Accumulating Over Past 10 Years
CDC Guidelines for HIV Prevention Counseling 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
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
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.
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 minutes - able to be used for many health related behavior change goals
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
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
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 Stage of Change/Transtheoretical Model of Behavior Change Theory
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 Stage-based Behavioral Counseling
Integrates STD and HIV prevention 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 Stage-based Behavioral Counseling
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
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
Skills Rating Scale 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
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
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
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
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
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..
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...
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?
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
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
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 PC99 C RFA59 A17 M414 Total 4041
Distribution of SOC for consistent condom use for HIV/AIDS cases in STD Clinic TOTALS: Newly Diagnosed : 40 Previously Known: 41
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 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
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.
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”.
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
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.
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.
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.
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
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
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
For Training in Stage-based Behavioral Counseling CHBT St. Paul Street, 4th Floor Rochester, NY Training Provided on or off-site
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