Transcript Enhancing Prevention with Postivies Evaluation Center

What Does It Take To Implement
HIV Prevention Interventions into
Care Settings?
Preliminary findings based on a qualitative evaluation
of the HRSA/SPNS Prevention with Positives Initiative
Kimberly Koester MA, Andre Maiorana MA, MPH, Karen Vernon
BA,
Center for AIDS Prevention Studies, University of California, San
Francisco, USA
Study Background
• CDC National HIV Prevention Plan identified
“prevention with positives” as top priority
• IOM recommended that prevention with positives be
integrated into clinical care settings
• NIH has funded a number of clinical trails to assess
potential prevention with positive interventions
• HRSA/SPNS developed an initiative HIV prevention in
clinical care settings
HRSA/SPNS Demonstration Sites
UCSF Evaluation & Support Center
Qualitative Evaluation Goals:
•
•
•
To assess feasibility & acceptability of
interventions
To provide context for the quantitative
results
To document the intervention
implementation process for replication
purposes
Methods
• Purposely selected sample (n=61) of research
team members & interventionists
• Conducted face to face in-depth interviews
• Audio-recorded interviews transcribed verbatim
& entered into Atlas.ti©,
• Framework Analysis (Ritchie & Spear) data were
coded, synthesized, themes compared and
contrasted
Intervention Models Differ By
‘Mode of Delivery’
• Provider (n=3)
• MDs, and/or NPs, and/or PAs
• Specialist (n=3)
• Health Educators or Social Workers
• Peer (n=3)
• People living with HIV/AIDS
• Provider + Specialist (n=6)
• Combination of MDs, and/or NPs, and/or PAs +
Health Educators or Social Workers
Intervention Models Differ in
Emphasis
• Emphasis on brief message (directive)
• Emphasis on education (directive)
• Emphasis on dialoguing, sharing, &
counseling (interactive)
How Sites Determined Who Should Deliver PwP
CDC promoted provider-delivered
prevention
Delivery Mode
Belief in the efficacy & efficiency
of provider-delivered messages
Provider
Provider willingness to participate
Provider + Specialist
Behavior change requires
in-depth counseling
Opportunity to enhance clinic services
by adding counseling staff
Specialist
Low provider willingness to participate
Peer
Special patient population requires
peer delivery:
stigma/prevention fatigue
Theories, Modes and Intervention Tools
Guiding Theories
Delivery Mode
Intervention Tools
Stages of Change
Provider
Computer-based
behavioral
Rx
Motivational
Interviewing
Provider +
Specialist
Computer-based
risk
assessment
Gender & Power
Theory
Specialist
Face to face
risk
assessment
Cognitive Behavior
Theory
Peer
Computer guided
counseling
sessions
Provider-Delivered
PwP Interventions
• Occurs during routine HIV care clinic visit
• Patient risk & stage of change is assessed via
computer (2) or face to face with provider (2)
• Risk assessment/stage generates prescriptive
behavioral counseling recommendation for
provider
• Provider delivers brief prevention message
tailored to patient risk profile & readiness for
change
Specialist-Delivered
PwP Interventions
• Typically occurs in conjunction with routine
clinical care visit over 4-5 sessions
• Social worker or health educator engages in
PwP counseling in individual or group setting
• Counseling topics typically include: safer sex,
drug use, relationships, taking medication,
disclosure, emotional well being, assertiveness
training, and patient priorities
Peer-Delivered
PwP Interventions
• Typically occurs separate from routine clinical
care during four - nine individual or group
counseling sessions
• Modular PwP counseling curriculum facilitated
by peer & tailored to patient priorities
• Counseling topics typically include: sexual
behavior, disclosure, adherence, stigma,
relationships, drug use, emotional well being
Specialist + Provider
PwP Interventions
• Provider: brief stage-based or prescribed
prevention message based on risk assessment
delivered during routine visit
• Specialist: 3-5 counseling sessions with health
educator or social worker covering topics such
as: safer sex, drug use, stigma, medications,
relationships, disclosure, emotional well being
Intervention Implementation Barriers & Facilitators
Barriers
Delivery Mode
Provider
resistance
Provider
Facilitators
Supportive clinic
leadership
Limited time
in clinic visit
Lack of experience
Disrupts
clinic flow
Provider +
Specialist
Developing
buy in
Specialist
Finding/developing
training
Requires
extra visits
Hiring &
Supervising
On-going
training
Attending to
clinic flow
issues
Peer
Highly
motivated
Overall
Implementation Challenges
• Integration most difficult in locations that
utilized providers
– Requires change in clinical practice
– Requires patient willingness to discuss risk
• Specialist & peer-delivered rely on patient
desire to participate
– Requires patient motivation to attend
additional sessions and engage in process
Overall
Integration Facilitators
•
•
•
Internal leadership to overcome resistance
and foster interest and motivation on the
part of medical providers and staff to
integrate prevention into medical care and
other services
Core belief among key stakeholders in
importance, need, viability, and
appropriateness of PwP in clinical setting
Securing high quality behavior change
training tailored to clinical environment
Easiest to Implement: Specialists
& Peers
Central Advantage
• Specialist/Peer as ‘Intervention Champion’
Considerations
• Requires extra effort to attract patients
• Training may be intensive and difficult to
access (e.g., M.I.)
• Hiring & supervising may be challenging
• New hires require funding & space
Unique Implementation Issues:
Mixed Models
Central Advantage
• Patient receives two doses of intervention
Considerations
• Time and resource intensive to set up two
different interventions
• Use of existing staff begged the question of
whether the interventions were even being
implemented at all
• Logistics associated with integrating two
components not easy
Implementation Requires Tenacity:
Providers
Central Advantage
Providers have a “captive audience”
Considerations
• Providers may ask “Why is this my
responsibility?”
• Providers need assistance to refine & improve
upon current practices
• Practical aspects of project can be unwieldy –
risk assessment, how, when, then what
• Trainings must be offered on a regular basis –
keep the fires burning…
Lessons Learned
Each intervention model is accompanied by
barriers & facilitators. Successful
integration depends on the complementary
fit between the intervention model and the
clinical setting.
Recommendations
• Invest time and effort in developing shared vision among key
stakeholders and methods for integrating PwP in clinic
• Conduct formative research/needs assessment to determine culturally
appropriate intervention models for clinic environment and patient
population
• Acknowledge provider and staff concerns, beliefs and existing practices
regarding HIV prevention
– Conduct a focus group or survey research to assess concerns, attitudes and
current practices
– Ask providers & staff to contribute ideas to program design
• Present evidence-based data to stress the importance of conducting
prevention in the context of a clinical setting
– Host meetings (led by clinicians) and provide food
• Provide adequate training that meets the expectations & objectives the
clinic is trying to achieve
– Secure the support of the medical director – they can facilitate the integration of
services into clinic and allow sufficient time for trainings
Resources
• NAPWA Principles of HIV Prevention with
Positives
http://www.napwa.org/publications/principles.htm
l
• EPPEC website:
http://ari.ucsf.edu/programs/policy_pwpresources.
aspx
• Forthcoming AIDS and Behavior supplement on
HRSA/SPNS PwP
Acknowledgements
This work is supported by grant number 5H97HA00261
from the Health Resources and Services Administration
(HRSA) Special Projects of National Significance (SPNS)
Program. The contents of this poster are solely the
responsibility of the authors and do not necessarily
represent the official view of HRSA or the SPNS program.
Special thanks to each and everyone of our participants
for taking time to tell us about their perspectives on the
intervention implementation process.