Presentation on theme: "The Options Project: A Clinician-Initiated Intervention for Reduction of HIV Risk Behavior Among HIV+ Patients in Clinical Care (NIMH grant 1R01 MH594378)"— Presentation transcript:
The Options Project: A Clinician-Initiated Intervention for Reduction of HIV Risk Behavior Among HIV+ Patients in Clinical Care (NIMH grant 1R01 MH594378) William A. Fisher, Ph.D. Center for HIV Intervention and Prevention University of Connecticut Departments of Psychology and Obstetrics and Gynaecology University of Western Ontario (email: email@example.com)
Project Staff Jeffrey D. Fisher, Ph.D, Principal Investigator University of Connecticut Gerald Friedland, M.D., Co-Principal Investigator Yale University Deborah H. Cornman, Ph.D., Project Manager University of Connecticut Rivet Amico, Ph.D., Assistant Research Professor University of Connecticut
The Problem HIV+ persons in clinical care may engage in risky behaviors that adversely affect their own and others’ health.
Exploring HIV Risk: The Options Project HIV+ Clinical Care Sample
Gender and Ethnicity (N=489) African American LatinoWhiteOtherTotal Male35% (100)36% (101)23% (64)6% (17) 58% (282) Female41% (85)34% (70)20% (41)5% (10) 42% (207) Total38% (185)35% (171)22% (105)5% (27)100% (489) Mean Age: 43.38 (7.69) Age Range: 22.93 to 70.06
Modes of HIV Transmission (N=489) Needle Sharing33% Sex: Male to Female27% Sex: Female to Male18% Sex: Male to Male10% Sex: Female to Female<1% Blood Transfusion2% Multiple modes9%
Three Month Risk Behavior Data: Options Project HIV+ Clinical Care Sample
Sexual Partners Potentially Exposed to HIV 52 HIV+ Patients Engaged in 1072 Risky Vaginal or Anal Sex With 197 HIV- or HIV Unknown Partners
Injection Drug Use Partners Potentially Exposed to HIV 29 HIV+ Patients Who Injected Drugs Last Month Borrowed or Lent Uncleaned Works or Needles With: 210 HIV- partners 200 HIV unknown partners 75 HIV+ partners
Substantial risk behavior among HIV+ patients in clinical care.
Towards a Solution: Clinician-Initiated Interventions in Clinical Care Settings
Clinical Care Setting: Outstanding Opportunity to Promote Safer Behaviors Among HIV+ Persons Efficient and most nearly universal access to HIV+ persons. Clinicians have repeated contacts with HIV+ persons over course of illness. Clinicians very often have strong and trusting relationships with patients.
HIV clinical care setting affords opportunity for clinician-initiated interventions that are brief, repeated, and potentially possess powerful cumulative effects.
A collaboration between HIV care clinicians, HIV+ patients, and researchers to assist address HIV risk behaviors The Options Project
Specific Aim of The Options Project: Design, implement, and evaluate a clinician-initiated HIV risk reduction intervention for HIV+ persons in clinical care settings. Craft intervention that is brief, delivered on multiple occasions over time, and in the course of routine care.
Options Intervention Theoretical Foundation: Information - Motivation - Behavioral Skills Model of HIV Prevention HIV Prevention Motivation HIV Prevention Information HIV Prevention Behavioral Skills HIV Preventive Behavior (J. Fisher & Fisher, 1992, 2000; W. Fisher & Fisher, 1993)
Options Project Protocol for Clinician-Patient Interactions
“There are a couple of things that I talk about with all of my patients – safer sex and safer drug use. I would like to spend a few minutes talking with you about these issues, if that is okay with you.” Step 1: Setting the agenda.
Step 2: Assessing risk “Many of my patients find it challenging to practice safer sex and safer needle use on a day to day basis. What works for you and what doesn’t, when it comes to safer sex?…clean needle use?”
Step 3: Ask patients to rate the “importance” of changing a risk behavior and their “confidence” that they could change it.
Assessing Importance: “On a scale from 0 to 10, where 0 is ‘not at all important’ and 10 is ‘extremely important,’ how important is it to you to change this risk behavior? You said it was x important to change this risk behavior. Why did you say x and not less? What would it take to make it more important to you to change this risk behavior?”
Assessing Confidence: “On a scale from 0 to 10, where 0 is ‘not at all confident’ and 10 is ‘extremely confident,’ how confident are you that you could change this risk behavior? You said you were x confident that you could change this risk behavior. Why did you say x and not less? What would it take to make you more confident that you could change this risk behavior?”
Step 4: Negotiate goal or action plan and record on Options Prescription Pad. Allow the patient to choose a goal that is realistic and attainable in the context of his or her life.
STAR T HERE ARE RATINGS FOR BOTH IMPORTANCE AND CONFIDENCE 9 OR 10? (often true for maintenance) DISCUSS BARRIERS TO CHANGING BEHAVIOR (OR DO RELAPSE PREVENTION IF NOT ENAGING IN ANY RISKY BEHAVIORS) IS RATING FOR IMPORTANCE < 7 ? PROBLEM-SOLVE STRATEGIES FOR OVERCOMING BARRIERS (OR PREVENTING RELAPSE) ASK: (1) Why is importance that score and not lower? (elicits self-motivating statements) (2) What would need to happen to raise that score? (directs provider on how to proceed) WHICH RATING IS LOWER? IF SAME, CHOOSE IMPORTANCE ASK: (1) Why is confidence that score and not lower? (elicits self-motivating statements) (2) What would need to happen to raise that score? (directs provider on how to proceed)
Subsequent Options Meetings Explore what, if any, progress the patient made toward achieving the goal set on the last visit. Reassess Importance and Confidence concerning maintenance or new goal. Negotiate an attainable goal for the next visit. Give patient a new Options Prescription.
Training Providers in the Options Protocol Four-hour didactic and interactive training with substantial role-playing. (Feed Them and They Will Come)
Feasibility of the Options Project Intervention 22 HIV care clinicians have been trained to criterion. Options intervention is very consistently implemented, despite clinician time constraints. 70%-80% of all patient medical visits include the Options intervention.
Six Month Follow-Up Intervention Outcome Results A greater proportion of intervention vs control participants successfully maintained safer sexual behavior or reduced sexual risk behavior over a six-month interval, despite having had only one to two clinician-initiated intervention interactions, Chi Square 8.215, p =.004. Total High Risk Sexual Events at Follow-up Total Change in High Risk Sexual Events Intervention Group (N=150) Total of 32Decrease of 502 high risk events Control Group (N = 188) Total of 530Increase of 215 high risk events Rivet Amico: Chi Square of successful reduction in high risk events OR in maintaining safer behavior versus increases or maint of high risk behavior showed that 10% of control group increased high risk (vs 2% in exp arm) and 91% in control group maint safer beh or decreased risk (vs 98% in exp arm) Rivet Amico: Chi Square of successful reduction in high risk events OR in maintaining safer behavior versus increases or maint of high risk behavior showed that 10% of control group increased high risk (vs 2% in exp arm) and 91% in control group maint safer beh or decreased risk (vs 98% in exp arm)
Conclusion: Prevention can and should be linked to care for HIV+ patients.
Special Thanks to All Participating HIV+ Patients and HIV Care Clinicians Ken Abriola, MD; Frederick Altice, MD; Nancy Angoff, MD; Martha Buitrago, MD; Elizabeth Cooney, MD; Steve Farber, PA; Tim Hatcher, PA; Michael Kozal, MD; Michael Lawlor, MD; Neil Olson, MD; Phillip Pierce, MD; Tanya Schreibman, MD; Lynn Sullivan, MD; Jonathan Tress, MD; Holenarasipur Vikram, MD; Ann Williams, PhD; Madeline Wilson, MD; Hussein Zaioor, MD; Sandra Springer, MD; Lydia Aoun-Barakat, MD