1. Ask, Screen, Intervene 4 Cities Project FTCC Meeting April 25, 2012

2. ASI Session Outline Efficacy of HIV prevention in clinical care settings ASI Curriculum Overview ASI Project Overview Panel: Implementation Experience

3. National HIV/AIDS Strategy National HIV/AIDS Strategy. http://www.whitehouse.gov/administration/eop/onap/nhashttp://www.whitehouse.gov/administration/eop/onap/nhas Vision for the National HIV/AIDS Strategy “The United States will become a place where new HIV infections are rare and when they do occur, every person, regardless of age, gender, race/ethnicity, sexual orientation, gender identity or socio-economic circumstance, will have unfettered access to high quality, life-extending care, free from stigma and discrimination.”

4. New CDC High-Impact HIV Prevention Plan GOAL: to maximize impact of prevention efforts for persons at risk for HIV infection: gay and bisexual men, communities of color, women, injection drug users, transgender women and men, and youth. Use combinations of scientifically proven, cost- effective, and scalable interventions Target the right populations in the right geographic areas CDC, High-impact HIV prevention: CDC’s approach to reducing HIV infections in the United States, 2011. http://www.cdc.gov/hiv/strategy/hihp

5. Overview of High-Impact Prevention Strategies PREVENTION WITH POSITIVES HIV testing Linkage to care ART Retention in care Adherence STD screening and treatment Risk reduction interventions Partner services Perinatal transmission intervention PREVENTION WITH NEGATIVES Risk reduction interventions Condoms PrEP PEP Needle exchange Male circumcision Microbicdes STD screening and treatment SEROSTATUS NEUTRAL Social mobilization Condom availability Needle/syringe services Substance use, mental health and social support

6. Challenge of HIV Impact HIV Prevention Spectrum of Engagement in HIV Care in the U.S. Only 19% of HIV+ are adequately managed Gardner et al. 2011 Clinical Infect Dis

7. HIV/STD Prevention in Care Settings Prevention paradigm shift – Seronegative to seropositive Emerging evidence that provider-based prevention efforts are effective in reducing behaviors Opportunity for reinforced dialogue in the care setting

8. HIV/STD Prevention in Care Settings (cont.) Provider concerns about HIV transmission does not “translate into action” without specific messaging Prevention discussions in clinical settings require that providers adjust their clinical routine and philosophy

9. Ask, Screen, Intervene Developed in 2004-2005 as a collaboration between the NNPTC and AETC based on 2003 Consensus Recommendations Aim: Assist HIV care providers in learning new techniques to incorporate important intervention methods to help their patients reduce risk behaviors Target audience is HIV clinical providers

10. Curriculum Implementation 10/2007-12/2010 NNPTC delivered ASI at 137 sites to over 2,567 participants. To leverage resources and promote sustainability the NNPTC developed a collaborative model: – 96.4% trainings had at least 1 collaborative partner – 48% of trainings were collaborations with AETCs

11. ASI Curriculum Module 1: Risk Assessment & Screening for STDs – Rationale for HIV prevention as routine part of HIV care – Elements of brief risk assessment – Screening for STDs in HIV care Module 2: Prevention Interventions – Brief risk reduction counseling – Referrals for more intense prevention interventions and other support services Module 3: Partner Services – Importance of Partner Services (PS) in relation to HIV – Referrals to PS through state and local HD

12. Skills practice sessions Short demonstration videos Question and answer time with local PS representative for local reporting requirements & PS program guidelines Handouts and job aids Curriculum Includes Interactive Components

13. Effective Prevention In HIV care: A Replication of Ask, Screen, Intervene (ASI) (2011-2013)

14. Project Overview MAI-funded project through HRSA HAB – Supports National HIV/AIDS Strategy goals Began Fall 2011, 2 year project Collaborators – HRSA HAB, DSP and DTTA – CDC – 4 regional AETCs and 4 PTCs – National Resource Center for NNPTCs – AETC National Resource Center – AETC National Evaluation Center – 8 Ryan White Part C clinics/FQHCs in 4 cities

15. 4 Cities and Clinics 1.Baltimore – Chase Braxton Health Services – Total Health Care, Inc. (10 sites) 2.Chicago – Access Community Health Network – Erie Family Health Center, Inc. – Heartland Health Outreach, Inc. 3.Los Angeles – Alta Med Health Services Corporation 4.Miami – Jessie Trice Community Health Center, Inc. – Miami Beach Community Health Center Selected based on ECHPP designation and application review

16. Project Objectives Enhance clinician ability to conduct effective risk screening, conduct prevention counseling, and refer for services Increase the number of HIV-positive persons who receive information about transmission risks and regularly receive risk reduction counseling Increase the number of HIV-positive persons who are screened for STDs Assist in strengthening linkages to referral services

17. Project Activities Planning & Implementation (Fall 2011/Winter 2012) – Kick-off calls with all collaborators (facilitated by HRSA HAB) – TOT and planning meeting in Baltimore (January 2012) for AETCs/PTCs (planned and facilitated by NRCs) – Introductory meetings and needs assessments with clinics (initiated by TCs) Training & Ongoing Technical Assistance (Spring 2012 ) – Tailor to clinic needs – Use 2012 curriculum and related materials – Project coordinator in the clinic to help facilitate and monitor

18. Project Activities (cont.) Assessment & Evaluation (Spring 2012 ) – Training level NNPTCs and AETCs – Program level (feasibility, fidelity, impact) AETC National Evaluation Center

19. ASI Program Evaluation Goals for the program evaluation are to assess the: – Feasibility or process – Fidelity or outcomes – Impact of implementation of the project Mixed-methods evaluation (qualitative and quantitative) Methods will be tailored to each participating clinic Evaluation will be done collaboratively by HAB, the AETC NEC and participating clinics Note: Program evaluation is distinct from training evaluation for this project Myers, Malitz, & Maiorana, 2012

20. ASI Program Evaluation Aims Feasibility or Process Evaluation: – To assess the barriers and facilitators to implementation (lessons learned and also quality assurance during implementation) Fidelity or Outcome Evaluation: – To assess the extent to which ASI be successfully integrated into existing clinical settings Impact Evaluation: – To assess changes in patients’ reported transmission risk (patient impact) – To assess changes in STI screening (provider impact) – To assess clinic staff knowledge of ASI procedures (clinic impact) Myers, Malitz, & Maiorana, 2012

21. ASI Program Evaluation Methods Data Sources Evaluation Question Type Process/ Feasibility Outcome/ Fidelity Impact Qualitative Data: In-depth Interviews with Staff √√ (Clinic) In-Depth Interviews with Trainers √ Site visits/Observations √ Secondary data analysis √ Quantitative Data: RSR Data Extraction √√ √ (Provider) Risk screening tool √ √ (Clinic & Provider) Patient Exit Interviews √ √ (Patient) Myers, Malitz, & Maiorana, 2012

22. Panel: Implementation Experiences Los Angeles, CA: Mona Bernstein, MPH Chicago, IL: Dodie Rother, MPH Miami, FL: Jonathan Drewry, MPH, DrPH(c) Baltimore, MD: Linda Frank, PhD, MSN, ACRN, FAAN Implementation experience Working with community health centers Successes and barriers to date

23. Conclusions Research shows prevention counseling is more likely to occur if the provider feels more confident to initiate prevention discussions Continuous revisions are needed to keep the curriculum current and relevant to providers needs Project compliments and enhances partnerships between AETCs and PTCs Opportunity to assess feasibility of implementing federal guidelines in clinical settings

24. Questions Helen Burnside, NNPTC NRC: Helen.Burnside@dhha.org Helen.Burnside@dhha.org 303-602-3605 Jamie Steiger, AETC NRC: steigejl@umdnj.edu steigejl@umdnj.edu 973-972-9646