Transcript HIV+ Youth: Development, Risk Behaviors & Issues Around

in+care Campaign
Meet the Author
July 11, 2012
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Agenda
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Welcome & Introductions, 5min
Meet the Author – Dr. Nikki Cockern, 30min
Q & A Session, 20min
Updates & Reminders, 5min
Retention of HIV+ Youth in Care:
Lessons Learned & New Directions
Nikki Cockern, PhD
Horizons Project
Wayne State University School of Medicine
July 11, 2012
**Funded by HRSA, MDCH, and United Way**
Defining Retention
Retention
Keeping or holding of something: the act of
retaining something or the condition of being
retained
Memory: the ability to remember things
The continued possession, use or control of
something
What Constitutes Retention?
Follow-up appointments at least every 3-6
months
Routine monitoring of CD4 counts and viral
loads
ART treatment and adherence counseling
Primary care services
Prevention for positives
Retention Strategies
“One-stop shopping” & multidisciplinary
approach to HIV care, that’s youth sensitive
Peer Advocacy
Transportation
Treatment Adherence Program
Lost to Follow-Up (L2FU) Program
Kids were still missing appointments!
What else could we do?
• Our outreach & prevention teams obtained
research dollars to implement & assess outreach
& behavioral interventions to improve testing
and care
• Results from their SPNS initiatives had a direct
impact on clinical services
• Interventions in other medical clinics that were
multi-systemic in nature were also proving to be
effective in positive behavior change
Shift How We Do Business
• Starts with a paradigm shift
• Examine how we (providers) think about the teens we serve
• What type of language do we use (assets vs. risk)
• Move from (implied) superiority
• Develop cultural competence
• Empowerment: Give youth an opportunity to be the
“expert”; demonstrate mutual respect & partnership
• Address stigma, assumptions, judgmental behavior
within the care delivery system
• Provide integrated peer driven medical and
psychological support models
• Address the ‘real affects’ of denial and depression
while increasing hopefulness and opportunities for
success
Using what we know to
foster supportive teen
interactions
THEORETICAL MODELS
Factors Associated with
Change
• Cognitive Processes
• Self-Efficacy – Confidence and Temptation
• Decisional Balance (importance & skill)
• Interference with Readiness to Change
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Drug Use
Emotional Distress
Lack of Social Support
Family/Marital/Partner Conflict
Motivational Interviewing (MI)
• Evidenced based intervention to promote health
behavior change
• MI is
• client-centered,
• goal-oriented approach
• focused on increasing intrinsic motivation for
change by:
• resolving ambivalence about different
potential courses of action
• and increasing self-efficacy about change
*Miller & Rollnick (2002, 2007)
What does this look like in a conversation?
• Empathic and warm
• Listening and understanding
• Expressing optimism and hope
• Reinforcing specific strengths
• Emphasizing personal choice and responsibility
• Offering menu of options
• Discussing value-behavior incongruence
Why MI?
•Client-centered and youth friendly
•Appropriate for those in earlier
stages of behavior change
•Validated with substance use,
condom use, and health behaviors
• at-risk youth and youth living with HIV
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Advantages of MI
•Client-centered intervention
•Can be performed by a variety of
staff members
•Occurs in a natural setting
•Ambivalence is addressed
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Horizons’Interventions Using MI
• Brothers Saving Brothers (BSB)
• MI for HIV Outreach to Encourage HIV testing among
young African American men who have sex with men
• MI for Youth Engagement in HIV Care
• MI for Medication Adherence and Secondary
Prevention
• Computer applications – Motivational
Enhancement System for adherence and sexual
risk (adapted from Ondersma et al.)
Brothers Saving Brothers (BSB)
• Three session group level prevention intervention for YAAMSM
delivered to youth residing in DMA that addresses:
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Ethnic and gay identity
Partner negotiation
Sexual risk reduction
HIV risk and vulnerability
• N=37 (16-24 years of age; mean age=18)
• 100% completed 1 session
• 89% completed 2 sessions
• 86% completed 3 sessions
• 98% reported high satisfaction with intervention & staff
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Brothers Saving Brothers (BSB), Cont
• MI during outreach to encourage HIV C&T
• Single session (30 minutes) as part of field outreach for HIV C&T
(to get tested and return for results (OraSure testing)) (N=188
ages 16-24 (Mean=19.79)
• Random assignment to Outreach plus MI (N=96) or Traditional
Outreach (N=92)
• Baseline survey inquired about risk behaviors and readiness
to change risk behaviors
• Peer staff (high school degree or equivalent)
• Findings: More youth in MI condition tested immediately after
the session (49% vs. 20%) & returned for test results @
significantly higher rate than Outreach alone condition (98% vs.
72%)
MI for Engagement in Care
• Single session (30 minutes) delivered at baseline and
6 months focusing on engagement and retention in
care
• Randomized to Masters prepared staff vs. Peer staff
(high school degree or equivalent)
• Findings: Both groups improved regularity of
primary care appointments
• Effect size for peer staff was larger than Masters
prepared staff
MI for Medication Adherence
& Secondary Prevention
• 4 sessions (60 minutes) delivered over 6
weeks focusing on 2 of 3 behaviors (i.e.,
substance use, unprotected sex, and
medication adherence)
• Randomized to intervention (psychology
graduate students) vs. wait-list control
• Findings: Intervention group significantly
greater reduction in unprotected sex acts and
viral load at 3 month follow-up
MI Computer Applications
• Motivational Enhancement System for sexual risk
(adapted from Ondersma et al.) & adherence
• MISTI (Sexual Risk)(Feasibility study) (N=26)
• Youth randomized to a single session face-to-face (doctoral
staff member) or computer delivered intervention
• MISTI-II (Sexual Risk) (N=54)
• Youth receive single session computer delivered intervention
and 3 month follow-up (88% retention)
• MESA (Adherence)
• Youth randomized to a 2 session computer-delivered
intervention
Motivational
Enhancement System
• Intervention programmed with CIAS using principles
of Motivational Interviewing
• Evocation – elicit responses from participant including
desire, ability, reasons and need for change
• Collaboration – participant chooses goal while
interventionist (computer character) reflects choices,
gives affirmations, offers information and advice when
requested by participant
• Autonomy – interventionist emphasizes personal choice,
asks for permission to give information (participant can
say no!); participant may choose to change behavior,
not to change behavior, to think about change
• Tailored based on MOTIVATION (Readiness)
MISTI Feasibility
Results
•100% of patients in the computer condition (11/11)
completed their intervention session
•69% of patients in the in-person condition (9/13)
completed their intervention session
•Patient Evaluations (items rated on scale of 1-4):
•How helpful? M = 3.52 (SD = 0.75)
•How honest? M = 3.90 (SD = 0.30)
•Recommend Project MISTI? M = 3.52 (SD = 0.51)
MISTI Evaluation Results
- % of Sample
3 month post test
12 months post baseline
To Sum Up……
• MI interventions were helpful in reducing sexual
risk and substance use, and aided in increasing
attendance
• We decided to train our entire staff in MI to
enhance the conversations we had with youth
• Innovation is as essential to programming for
youth as nonjudgmental staff
Improvement Process-Missed Appointment Process
Youth who have missed a scheduled medical clinic appointment, without contacting team and scheduling another within 30 days.
List Prioritization
1. Clients who missed their clinic appointment within the first month (21-30) days and have not rescheduled
2. Clients who have not attended a clinic appointment in 2-6 months
3. Clients who have not attended a clinic appointment in 6-12 months
MI @ point of
contact & @
clinic appt.
1. Maintain List
Identify youth who
missed clinic
appt. & not
able
to reschedule
5.
Contact made w/
Client & clinic
visit scheduled
Or
Repeat
MI via
phone
MI @ HV if
contact
made
2.
month after
missed clinic
visit. Advocate
attempts
Contact via phone/text
1st
4.
month
Home Visit
3rd
3.
2nd month
Mail post
Card sent
Other Projects
• Interventions to increase medication adherence
among children youth, and young adults
• Healthy Choices
• A+ (Adolescent and Young Adult Positive Living
through Understanding and Support)
• This is framed as “a program for young adults that
want to make healthier choices as it relates to their
medical care and maintenance of a safe viral load”.
Healthy Choices PLUS
Pathway
Referral Criteria: VL>1000 on one active drug or self-report <80% adherence with
detectable viral load, ages 16-29 (will consider younger if no family for CHIP
program)
Failure
Healthy
Choices
PLUS
Healthy
Choices
PLUS
Support
Success
Clinic
Monitoring
Relapse
Failure
Healthy
Choices
PLUS
Booster
Success
If youth drops out of treatment after less than ¾ of sessions completed,
then return to beginning of planned intervention when they return
To retain Youth
• We continue doing what has worked
• Maintain Youth Tracking Log
• Contact youth to
• confirm before appointments,
• if missed then during appointments or as soon as possible after missed
appointment
• Continue use of
• Social media: texting and Facebook
• Motivational Interviewing integrated into calls, home visits, and clinical
appointments
•During HIV prevention & counseling sessions,
especially around safe sex; reducing sexual risk;
communicating w/partners
•On the phone w/clients who cancel or make
excuses about missing medical appointments
(during appointment reminder calls)
•With patients who are not adherent to medication
•During initial meeting (medical visit/intake) to
encourage engagement in treatment, identify
strengths
•Use MI to help youth realize their behavior doesn‘t
match their value
Next Steps
• Formally evaluate the effects of MI in clinic setting
(with new youth, those returning after extended
absence)
• Effective/Useful with increasing clinic attendance following MI
(short vs. long term effects)
• Examine timing of intervention (is there an impact)
• Venue of intervention (i.e. face-to-face, phone, text)
• Provide youth who continue to have greater difficulty
with more intensive interventions when feasible.
Staff Acknowledgement
Director of Medical Service and Research: Elizabeth Secord, MD
Director of Prevention Services: Angulique Outlaw, PhD
Consultant for Psychological Services and Research: Sylvie Naar-King, PhD
ATN Behavioral Research Coordinator: Monique Green Jones, MPH
ATN Clinical Research Coordinator: Charnell Cromer, MSN
Clinical Care Manager: Nikki Cockern, PhD
Clinical Nurse Practitioner: Debbie Richmond, NP
Clinical Social Worker: Tiffani Hollowell, CMSW
Care Coordinator/Case Manager: Keshaum Houston, BS
Health Systems Navigator: Tolia Mouzon, BS
Adolescent Consultant: Jessica Daniel, MPH
MSM Prevention Coordinator: Jeremy Toney
MSM Outreach Worker: Bre’ Campbell
ATN C2P Coordinator: Emily Halden Brown, MPP
ATN Research Assistant: Cindy Chidi, BS
Fisher HRH Prevention Coordinator: Angela Williams, MPH
Fisher Outreach Worker: Te’Neice Dobbins, BS
Thank you!—Questions/Comments?
Nikki Cockern, PhD; 313.745.4892; [email protected]
Monique Green-Jones, MPH; 313.966.9763 [email protected]
http://www.peds.med.wayne.edu/horizons
Time for Questions
and Answers
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Partners in+care
• Partners in+care Secret Facebook Group is live!
• Share tips, stories and strategies
• Join a community of PLWH and those who love them
• Email [email protected] for more details
• Partners in+care website is live!
• http://www.incarecampaign.net/index.cfm/77453
• Join our mailing list (a list-serv version of the FB Group)
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Upcoming Events and Deadlines
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Campaign Office Hours:
Mondays & Wednesdays 4-5pm ET
•
Improvement Update Submission Deadline:
July 16, 2012
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Data Collection Submission Deadline:
August 1, 2012
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Next Campaign Webinar: Substance Abuse and Retention
Tuesday, July 31, 2012 4pm ET
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Campaign Headquarters:
National Quality Center (NQC)
90 Church Street, 13th floor
New York, NY 10007
Phone 212-417-4730
[email protected]
incareCampaign.org
youtube.com/incareCampaign
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