Prevention with Positives: Promoting Change While the Clock Ticks … Robert T. Carroll, PhC, RN,...

Prevention with Prevention with Positives:Positives:

Promoting Change Promoting Change While the Clock TicksWhile the Clock Ticks … …

Robert T. Carroll, PhC, RN, ACRNWashington State Education Coordinator,

Northwest AIDS Education and Training Center

U NIVERSITY OF WASHINGTON 2U NIVERSITY OF WASHINGTON 2

Today’s GoalsToday’s Goals• Describe the theoretical and

practical underpinnings of Prevention with Positives programs

• Provide a brief overview of the Motivational Interview process for promoting behavior change

• Describe the key elements of a brief motivational intervention focusing on prevention with PLWH/A


Why the Emphasis on Why the Emphasis on Prevention with Prevention with

Positives?Positives?Every person

infected with HIV was exposed by

a person who was HIV-Positive.


• New generation of prevention programs targeting individuals who

• Current emphasis arises from

What is Prevention What is Prevention with Positives (PwP)?with Positives (PwP)?

• Have already tested positive for HIV

• May be at risk of transmitting the disease

• CDC 5-year plan to reduce rates of infection by 1/2 over the next 5 years


Why the New Focus on Why the New Focus on Prevention with Prevention with

Positives?Positives?Advancing HIV Prevention (AHP)New Strategies for a Changing Epidemic

• September 2003

• CDC initiative to reduce barriers to early diagnosis of HIV and increase access to quality medical care, treatment, and ongoing prevention services for PLWH/A


Why a New Initiative Why a New Initiative for HIV Prevention?for HIV Prevention?

• 40,000 new HIV infections still occur in the United States each year

• One-quarter of the 850,000 - 950,000 PLWH/A in the U.S. do not yet know they are infected

• Recent increases in syphilis diagnoses among men who know they are HIV-infected suggests an increase in risk behaviors among PLWH/A and their partners


Local TrendsLocal Trends

Insert local/regional epidemiological charts and/or graphs which provide evidence of increases in new infections related to engagement in high risk activities (i.e., increase/spikes in other STI rates)


AHP Initiative AHP Initiative Strategies Strategies

Make HIV testing a routine part of medical care when and where patients receive care

• Use new models to diagnose HIV infection outside of traditional medical settings

• Prevent new infections by working with HIV positive people and their partners

• Continue to decrease mother-to-child HIV transmission


Prevent New Infections Prevent New Infections by Working with by Working with PLWH/APLWH/A

• Publish Recommendations for Incorporating HIV Prevention into the Medical Care of Persons with HIV Infection (CDC, HRSA, NIH, and IDSA)

• Fund demonstration projects to provide PCM for people with HIV who have ongoing high-risk behavior

• Fund demonstration projects of new models of PCRS

• In 2004, implement these services


Incorporating HIV Prevention Incorporating HIV Prevention into the Medical Care of into the Medical Care of

PLWH/APLWH/ARRecommendations of CDC, the Health Resources and Services Administration, the National

Institutes of Health, and the HIV Medicine Association of the

Infectious Diseases Society of America

MMWR 2003 July 18; 52


How Does it Work?How Does it Work?Individual-focused PwP interventionshelp PLWH/A reduce their transmission rates through theoretically-based interventions which--

• Help PLWH/A feel better about themselves

• Decrease the stigma associated with HIV

• Help PLWH/A take responsibility for their lives and for stopping the spread of HIV


How is this How is this Accomplished?Accomplished?

•Peer-based workshops and focus groups•One-on-one transmission risk counseling•Psycho-social assessment and supportive interventions•Case management•HIV status support groups

Prevention with Positives programs aim to build self-esteem and enrich coping skills through supportive services such as


PwP Programs in the PwP Programs in the U.S. U.S.

• CA office of AIDS EIP programPrevention integrated with care & treatment Prevention Case Management

• HIV Stops with me: LA, SF, BostonSocial marketing approach

• Prevention for HIV-Infected Person’s Project (PHIPP)

Multi-site CDCP demonstration project

• Positive Power (Seattle & WA State)

Targeting gay and bisexual men through individual and group work

• Partnership for Health (USC)2-day TOT program to implement4-hour individual intervention


I know there must be a I know there must be a theory in there theory in there somewhere…somewhere…

Yup.

Most PwP programs are based on one or many of the seven most popular theoretical models of (HIV) health promotion/risk behavior change


Seven Theoretical ModelsSeven Theoretical Models (HIV) Health Promotion & Risk Behavior (HIV) Health Promotion & Risk Behavior

ChangeChange

1. Health Belief model2. AIDS Risk Reduction Model3. Trans-theoretical model4. Social Cognitive Theory model5. Theory of Reasoned Action6. Theory of Planned Behavior7. Information-Motivation-Behavioral

Skills model


What do these What do these Theories have in Theories have in

Common?Common?KNOWLEDGE +

SKILLS +MOTIVATION +

RESOURCES +SUPPORT =

Behavior Change!


Transtheoretical ModelTranstheoretical Model (Prochaska & DiClemente, 1984)(Prochaska & DiClemente, 1984)

1. Precontemplation: Not even thinking about it

2. Contemplation: Thinking about it

3. Determination/Preparation: Taking steps to start behavior

4. Action: Person tries behavior

5. Maintenance: Person does behavior regularly

6. Relapse: Person slips up & needs to make adjustments

Six stages of behavior change


Transtheoretical Model Transtheoretical Model of Behavior Changeof Behavior Change


Transtheoretical Transtheoretical ModelModel

(Prochaska & DiClemente, 1984)(Prochaska & DiClemente, 1984)


Transtheoretical ModelTranstheoretical Model (Prochaska & DiClemente, 1984)(Prochaska & DiClemente, 1984)

• Change is an incremental process and not a discrete outcome

• Change takes time• Harm/risk reduction is a good goal• Relapse is the rule, not the exception• Two dimensions: stages and

processes

Key assumptions of the model


But it must have But it must have structure and structure and

purpose…purpose…

Brief Motivational Brief Motivational Interviewing Works!Interviewing Works!


First Things First!First Things First!

• Work with the patient to identify a behavior to be targeted for change

• Identify where the patient stands on the readiness-to-change continuum

• Establish with the patient incremental goals – appropriate to their readiness - to move toward the desired change


• Document, Document, Document!

• Ensure full staff understanding of, buy-in for, and consistency in delivery of the plan.

Remember…Remember…

Initial plan, subsequent encounters, outcomes, and changes to the plan


FRAMES:FRAMES: Active Ingredients of Active Ingredients of the Effective Brief Motivational the Effective Brief Motivational InterviewInterview

F : FeedbackR : ResponsibilityA : AdviceM : MenuE : EmpathyS : Self-Efficacy

(Miller & Rollnick, 1991)


Key ingredient which supports

the client’s ability to change.

MOTIVATIONMOTIVATION


General Principles of General Principles of Motivational Motivational InterviewingInterviewing

• Express empathy

• Develop discrepancy

• Avoid argumentation

• Roll with resistance

• Support self-efficacy


Phases of the Phases of the Motivational Interview Motivational Interview

Practice Practice I. Build motivation for change

Sensitive questioning and reflection encourage the person to articulate self-motivational statements and the arguments for change

II. Strengthen commitment to change

Motivation-building moves to key questions designed to evoke problem-solving and commitment to change


But What Can I Do in But What Can I Do in a Brief Period of a Brief Period of

Time?Time?If all you have is a short time in

which to make an impact-- seek at least

not to do any damagenot to do any damage

by entrenching resistance and discouraging change.

(Miller & Rollnick, 1991)


Five Key Five Key Communication SkillsCommunication Skills

1. Framing communication messages

2. Understanding the patient perspective

3. Active listening

4. Redirecting

5. Cocktail Party


Brief Intervention Brief Intervention Talking PointsTalking Points

(adapted from the Partnership for Health Program, PAETC, University of Southern

California)

• Compliment any protective behavior

• Ask a question/s about sexual behavior and disclosure

• Discuss sexual behavior and disclosure


PwP Internet PwP Internet ResourcesResources

• www.aidspartnershipca.org/pfp.html• www.paetc.com/partnershipforhealth.

htmlPAETC, Partnership for Health Program

• www.aegis.com/pubs/woalive/2001/WO2001-0607.htmlPrevention with Positives: What Is It?

Women Alive, Summer 2001. Cathy Olufs.

• www.hivstopswithme.org


PwP Internet ResourcesPwP Internet Resources

• www.omhrc.gov/OMH/aids/impact/HIV_march2002.pdfPrevention with Positives: Reducing

Further Transmission of HIV/AIDS.HIV Impact, March/April, 2002. Aimee Swartz.

• http://www.thebody.com/treat/prevpos.htmlArchived online articles


Contact InformationContact Information

Robert T. Carroll, PhD (c), RN, ACRN

WA State Education CoordinatorNW AIDS Education & Training

Center901 Boren Ave., Suite 1100

UW Box #359932Seattle, WA 98104-3508

[email protected]

Prevention with Positives: Promoting Change While the Clock Ticks … Robert T. Carroll, PhC, RN,...

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