Presentation on theme: "Stage-based Behavioral Counseling for Persons Living with HIV/AIDS"— Presentation transcript:
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 & SocialScience and HIV/AIDS Regional Training Center by theAIDS 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/AIDSTarget Audience:- Clinicians and case managers providing care to those livingwith HIV/AIDSRationale:- Need for HIV primary transmission prevention- Primary prevention depends on behavior change- Presumption that patient education and knowing one’sHIV status would result in risk behavior change- Evidence shows education is not enough- Behavioral counseling is more effective
4 Module ObjectivesIncrease knowledge of behavioral counseling intervention used in STD & HIV clinicsIncrease awareness of SOC/TTM of Behavior Chance Theory and how it was adapted to develop Stage-based Behavioral CounselingIncrease Knowledge of the steps in using this interventionIncrease 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 changeBehavioral counseling doesn’t require more time - but is a different approachShort term, provider delivered, behavioral counseling in clinic settings - now proven effectiveGroup and community level interventions also work
6 Scientific Evidence Accumulating Over Past 10 Years Has led to Changes in recommendationsabout 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 Interventionswith 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 thanpatient/clientThere 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 goalsNow a standard of care for STD clinicsBecoming 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/AIDSOthers - eg. Shain Intervention, NIMH Multi -site,VOICES/VOCESStage-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 theseprovidersCDC’s Project SAFE --Serostatus Approach to Fighting theEpidemic (SAFE): Prevention Strategies forInfected 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 clinicflow- efficient and practical -- able to be completed in 10-20minutes- able to be used for many health related behavior changegoals
11 Factors Influencing Behavior Change Identified by Social and Behavioral Science Research A variety of factors are now known to influencebehavior change:- Some are more internal within the individual self:knowledge, attitudes & beliefs, skills, et al- Other factors are more external: sexual relationshipdynamics, influence of peers, family and cultural norms,and environmentBehavioral counseling strategies need to addresseach client’s influencing factors in order to ininfluence change
12 Stage of Change/Transtheoretical Model of Behavior Change Theory SOC/TTM Theory states that people are in differentpsychological stages of readiness to change anygiven behavior at any given time, AND thatcounseling strategies need to match the SOC inorder to be effectiveSOC/TTM Theory addresses internal and externalfactors influencing behavior changeSOC/TTM provides effective counseling strategiesfor a subset of patients who see no need for changeor 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 todevelop a behavioral counseling intervention thatintegrates STD and HIV prevention counseling
14 Stage-based Behavioral Counseling Named the intervention Stage-based BehavioralCounselingEstablished training curricula and QA program components, and implemented in 1995Use it for- HIV counseling & testing- Primary transmission prevention for clients withHIV/AIDS- HIV/STD case management- Accepting referrals- Influencing behavior change - any primary orsecondary prevention goal
15 Stage-based Behavioral Counseling Integrates STD and HIV prevention10-20 minute sessionsIntegrates easily into clinic flowCan also be used in community-based, criminaljustice settings, street outreachHigh levels of provider and client acceptabilityEspecially helpful for - “difficult” clientsCan be used for other behavior change goals
16 How is This Intervention Science-based? SOC used to define stages of readinessfor change in relation to -- STD/HIV Prevention Target Behaviors:Sexual , Substance Use, Health Care SeekingTTM 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 tothat behavior2. Use a counseling strategy that matches the client’sstage of readiness and is most likely to influencebehavior change for that client3. Document the behavioral assessment, targetbehavior and SOC, counseling strategy used,immediate outcomes, and client’s first steps in orderto provide continuity of care and evaluateeffectiveness
18 Skills Rating Scale Stage-based Behavioral Counseling has been A Rating Scale of skill items needed to performStage-based Behavioral Counseling has beendeveloped and is used for training clinicians andfor program quality assurance5 are general behavior change skills6 are specific to stage-based behavioral counselingThis module will highlight two to these skillitems
19 Skill Item 3. Assess Client’s Stage of Readiness for Change First -- Identify a target behavior -- what areyou trying to help the client to do?- Sexual: use condoms, delay or avoid vaginal/rectal sex, discloseHIV status to partner(s), get partner(s) STD/HIV tested- Substance Use: use needle-exchange, enter a substance usetreatment program, accept a referral, use partner notificationservices- Health Care Seeking: get into HIV medical care, adhere toprescribed treatment, get frequent screening/Rx for STDs, familyplanning
20 Skill Item 3 (con). Assess Client’s Stage of Readiness for Change Then - - Assess his/her readiness - attitudestowards the target behavior- Precontemplative: Doesn’t see the need to do it- Contemplative: Sees the need to do it, but can’t becauseof barriers- Ready for Action: Ready to try or has already started totry- Action, Maintenance: Doing the target behaviorconsistently 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/HIVcare history to identify which targetbehaviors would result in STD/HIVprevention for the clientFor example, staging for sexual behavior change:R = nature and status of current sexual relationshipsN = 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 towardsdoing the sexual target behaviorStaging for sexual behavior change (con):A = history of, and attitude towards:C = condom useA = avoiding or delaying vaginal/rectal sexD = 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 factorssuch 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? Howabout 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 encouragersto follow open ended questions to help theclient to say more, explain his/her personalcircumstances, 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-endedquestions 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 3months? In the last year?- Do your current partners know your HIV status?- How often are you using? Have you ever been intreatment?- Have you ever been in a situation where you had sex inorder to use?
26 Skill Item 3 (con). Assess Client’s Stage of Readiness for Change For example: Target behavior - using condomsconsistently 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’tbecause 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 KnownPCCRFAAMTotal
29 Distribution of SOC for consistent condom use for HIV/AIDS cases in STD Clinic TOTALS:Newly Diagnosed: 40Previously Known: 41
30 Skill Item 4 (con). Use a Counseling Strategy that Matches SOC Eleven Counseling Strategies adaptedfrom TTM processes of changeMore effective because each is psychologically matched to client’s readinessLess likely to cause client resistanceNo more “difficult” clients
31 Skill Item 4 (con). Use a Counseling Strategy that Matches SOC Precontemplative (No Way. . .)- Information Giving: give informationspecific to client’s situation- Story Telling: tell client a “story” about acase similar to his/hers and outcome of thecase- Discuss Impact of Behavior on Others:help client to see how the behavior isnegatively impacting on persons the clientcares about
32 Skill Item 4 (con). Use a Counseling Strategy that Matches SOC Case Example of Info GivingA 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 transmissionThe 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 clientunderstand why he/she is on the fence; Discusspros and cons: exploring client’s cost/benefitto change; Offer Harm Reduction Substitutes- Discuss Behavior in a Relation to Self-Image: discuss patient’s self-image and howit conflicts with the behavior
35 Skill Item 4 (con). Use a Counseling Strategy that Matches SOC Case Example of Pros and ConsThe 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 detailinghow 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 andLiving it)- Identify Supports: help client find a supportsystem- Avoid Cues: assist client in recognizing andavoiding cues which led to risky behaviors- Identify Rewards: help client identify ameaningful reward for maintaining the change
40 Skill Item 4 (con). Use a Counseling Strategy that Matches SOC Action and Maintenance (Doing it andLiving it) (con)- Find Substitutes: assist the client to findsubstitutes for previous risky behavior- Become a role Model: help client become arole model of change for his/her peers
41 Training Provided on or off-site For Training in Stage-based Behavioral CounselingCHBT St. Paul Street, 4th FloorRochester, NYTraining Provided on or off-site
42 Other SBS Training Resources Dallas PTCDenver PTCCalifornia PTCEffective individual, group, community levelHIV and STD prevention interventions