1. Prevention with HIV Positive Individuals in the Clinic Setting Janet Myers, PhD, MPH Carol Dawson Rose, PhD, RN

2. Goals of Session Present findings from research at CAPS on the prevention needs of positive individuals Discuss findings of key informant interviews with HIV Care Providers about integrating prevention into HIV clinic setting Present intervention/program models that are part of HRSA SPNS demonstration Discussion about how to integrate prevention into clinic setting. Implementation issues

3. CAPS Formative Research with HIV Positive Individuals Heterosexual Serodiscordant Couples Gay and Bisexual Men Heterosexual Injection Drug Users

4. Heterosexual Serodiscordant Couples The California Partners Study, II: A Risk Reduction Intervention for HIV Serodiscordant Opposite Sex Partners (1996-97) CDC; PI: Nancy Padian, PhD; Co-PI: Cynthia Gómez, PhD Prevention Needs Serodiscordant dynamics Negotiated safety and preservation of intimacy Commodification Calculated risk

5. Gay and Bisexual HIV+ Men Seropositive Urban Men’s Study (SUMS): Formative Behavioral Research on the Prevention of Sexual Transmission of HIV by Seropositive Men Who Have Sex With Men (1997-8) : CDC; PI: Cynthia Gómez, PhD Prevention Needs Relationship between drugs and unsafe sex Grey areas (oral sex, withdrawal, insertive/receptive) Relationship between HIV treatment, viral load, and infectivity Serostatus assumptions Power dynamics Need for communication and disclosure skills Mental health impact sexual behavior and health care Need to focus on STD’s

6. Heterosexual Injection Drug Users Seropositive Urban Drug Injectors Study (SUDIS): Formative Behavioral Research on the Prevention of Transmission of HIV by Seropositive Drug Injectors (1997-99),CDC; PI: Cynthia Gómez, PhD Prevention Needs Negotiated safety Context and partner type affect prevention decision-making Dynamics of drug-sex economy Gender and power dynamics Commodification of HIV Criminal justice system Need for skills building Drug use management

7. Overall Findings The responsibility for prevention HIV transmission is a key area of concern for HIV+ individuals HIV+ individuals would like to have prevention discussions with their medical providers

8. CAPS Formative work with HIV Medical Providers HIV Intervention for Providers (HIP): Behavioral Intervention Trial with HIV Primary Care Medical Providers (2000 - ongoing): CDC; PI: Carol Dawson Rose, PhD, RN; Grant Colfax, MD. Key Informant Interviews Interviewed HIV primary care medical providers MD, Infectious Disease (2); MD, Internal Medicine; MD, Family Practice; MD, HIV Specialist GP (2); RN, Education and Support, HIV Health Patients 2045 HIV+ patients MSM, MSM/IDU, heterosexual men and women, injection drug users

9. CAPS Study of RWCA Clinics  Aim: To assess the current practices of providers regarding prevention for HIV- infected patients in Ryan White funded clinics  Method: Interviews (N=618) with patients exiting regular HIV primary care visits  Sample: 16 Ryan White funded clinics in 9 states -- mix of high, medium & low volume providers

10. Research Sites

11. Barriers Barriers identified by providers were often practical –Time Constraints –Lack of training in counseling –Lack of dedicated funding Participants were significantly more likely to report prevention counseling if the office visit lasted more than half an hour (OR=1.55; p<.05)

12. Provider Role Conflicts Concept of “prevention with positives” is not well understood Many providers see role as “patient advocate.” This role seen as potentially conflicting with “public health” role. Not clear who at clinic would be responsible for providing prevention services.

13. Prevention Messages No consistent message Viewed current messages as “ineffective” “Use Condoms” -- to protect others “Protect Yourself” -- reinfection, STDs Moral -- being good v. being bad Medical advice v. motivational counseling

14. Fatalism Providers at 14 of 16 clinics expressed frustration about inability to counsel HIV-infected patients about preventing transmission. Providers in these clinics expressed fatalism; e.g. “How much of this can we change if it hasn’t changed already.” Patients in high fatalism clinics were significantly more likely to be gay men than heterosexual men (OR=11.96; p<.05) or women (OR=2.14; p,.05).

15. Patient Needs & Wants (Patients want …) To “Not transmit HIV to others” More understanding of complexity Information (re-infection) Support (learn how others cope) Leadership role -- prevention & reducing stigma (speaking to youth)

16. SPNS Clinic-based PwP Demonstration Project 15 Sites, four year funding Evaluation Center (UCSF) funded one year earlier Multiple Interventions Local and Cross-site Evaluation Components

17. SPNS Sites University of Washington, Seattle UC Davis UC San Diego Mt. Sinai Hospital, Chicago Dept. of Health Services, Los Angeles Drexel U, Philadelphia Johns Hopkins St. Luke’s, New York Whitman-Walker, Washington, D.C. El Rio CHC, Tucson, AZ UNC, Chapel Hill UA Birmingham Dekalb County, Decatur U of Miami Fenway CHC, Boston

18. Intervention Types Primary Care Provider delivered Intervention delivered by Prevention Specialist Intervention delivered by HIV+ Peers

19. Intervention Types SitePCPSpecialistPeerILIGLI Chicago  Miami   Philadelphia  Tucson  (Health Educator)  Seattle  (CSW)  New York  (Social Worker)  Boston  Chapel Hill  (Staff Specialist)  Baltimore   Los Angeles   Birmingham   San Diego  (Health Educator)  D.C.  (Health Educator)  De Kalb  (Specialist)  Davis  (Nurses & Social Workers) 

20. PCP Delivered Intervention Partnership for Health

22. Characteristics of the Program Integrates prevention into routine primary care Emphasize Self Protection, Partner Protection and Disclosure Every patient counseled at every visit Also can produce change in clinic norms

26. Peer Delivered Intervention Howard Brown’s Treatment Advocacy Program

27. The University of Illinois at Chicago Howard Brown Health Center Treatment Advocacy Program HIV medication skills 2: Men beginning HIV medications 4 / 24 / 03

28. Medication skills 2: Goals Cover “difficult doses” & adherence Talk about different coping areas …use your answers to develop a coping profile of your strengths and where we should focus more… Develop a treatment coping plan Welcome back to TAP This visit we will:

29. HIV Coping Check-in… ŽWhat questions do you have about HIV treatment? How are things going with.. Sexuality & intimacy? Sexuality & intimacy? Medications & treatment? Medications & treatment? Areas where things are going.. Difficult? Difficult? Particularly well? Particularly well? HIV Information HIV Information

30. Advocate’s notes & checklist Advocate: Visit Checklist  Coping interview form  Coping planning worksheet  Referral sheet (if used)  Next appointment hand card distributed Complete Counseling Notes Form and Visit Log for file.

31. Prevention Specialist Delivered Intervention University of Washington, Department of Psychiatry

32. Characteristics of the Program Individual Sessions delivered by Licensed Social Worker 4 – 50 minute individual sessions 6 – Group level sessions co-facilitated by –Peer and Social Worker (specialist)

33. Individual Sessions Counseling Model Assessment of Individuals Stage of Change Risk Assessment Motivational Interviewing approach –Client centered

34. Individual Sessions Documentation –Research Chart –Stage of Change Assessment –Progress notes –Specific issues addressed during session

35. Group Sessions Topics –Community Norms –Negative Self Talk –HIV Disclosure –Defining Safe Behavior –Negotiating Relationships

36. HIV Provider Needs for Integrating Prevention into the Clinic Setting External pressure to incorporate prevention into care Barriers (time, role, research) Support/Training for behavior change Public Health Vs. Individual’s Health

37. Questions

38. Prevention Message Provider delivered prevention message Harm Reduction Approach Provider / Patient Response Type

39. Implementation Clinic Policy Documentation of Risk Legal Issues Provider Fatigue

40. Contact Information Carol Dawson Rose Cdawson@psg.ucsf.edu 415 597 9338 Janet Myers Jmyers@psg.ucsf.edu 415 597-8168