Behavioral Interventions for STI Prevention in the Busy Practice Setting

1. Behavioral Interventions for STI Prevention in the Busy Practice Setting Cornelis A. Rietmeijer, MD, PhD Department of Community and Behavioral Health Colorado School of Public Health DCP HIV & Sexual Health Faculty Workshop Friday, 7th May 2010 London, UK

2. Rachel’s story D. What brings you in today? R. I’d like an STD check-up D. Just a check-up? R. Yes D. OK, sounds good. I first need to ask you a few questions, OK? R. OK D. How many sex partners have you had in the past 3 months? R. One

3. Rachel’s story D. Is your partner male or female? R. Male D. What types of sex do you have, oral, vaginal, anal? R. Oral and vaginal. D. You use condoms pretty much all the time? R. Yes D. OK, good. Doesn’t sound like you have a lot of risk, but you should always be using condoms, OK? Please feel free to take some when we’re done R. OK

4. What do you think?

5. Rachel’s story – Take 2 D. What brings you in today? R. I’d like an STD check-up D. What made you decide to get checked today? R. Well….eh….I’m a bit embarrassed… D. I understand. It is not easy to come to a clinic like this, but the more I know about the reason why you came today, the better I can help you. So, what’s up? R. Well, eh… it’s a bit of a story… D. That’s fine, please tell me what happened R. Well, I broke up with my boyfriend about 3 months ago and I haven’t had sex since then.

6. Rachel’s story – Take 2 D. I see R. But then about 10 days ago, I went to this bar with a friend. I really wasn’t looking for sex or anything, but I met this cute guy and we kind-of got into it. I guess I had a few glasses too many and we ended up at his place and before I knew it we had sex end… D. Yes? R. Well I’m always very careful, with using condoms I mean, but we didn’t have condoms and now I’m really worried I may have gotten something….

7. Rachel’s story – Take 2 D. So what do you think you might be able to avoid something like this from happening again? R. I don’t know. Probably avoid bars… You know, I have this friend who met a guy on the Internet and they’re hitting it off pretty well. What do you think about that? D. Well, I have actually read some interesting research about that recently; as it turns out the Internet may be a pretty safe place for women to meet partners because you have the time to get to know a guy a bit better before you actually meet him in person R. So, perhaps that’s what I’ll try… D. Sounds like a great plan.

8. What’s the difference? • The use of inquisitive (open-ended) questions can rapidly reveal the critical issues that formed the motive of the patient to seek care • This information in turn can be used to start the patient to reflect on his/her risk behaviors and forms the entry point in the patient formulating and taking responsibility of setting a first (small) step to reduce this risk

9. Steps in Client-Centered Counseling • Personalized risk assessment • Support patient-initiated behavior change • Help patient recognize barriers to risk reduction • Negotiate an acceptable and achievable risk reduction plan • Refer patient to other specialized services, if needed

10. Open-ended Questions • What do you think your risk is for STD? • What happened the last time you had sex? • What made you decide not to use a condom? • What made you decide to use a condom? • What do you think you can do to reduce your risk for STDs the next time you have sex?

11. Does it work? YES!

12. Kamb et al. JAMA 1998;280:1161

13. Project Respect (1993-1996)Overview • Purpose: to test the efficacy of client-centered pre- and post-test counseling in the context of two-session HIV testing • Method: Randomized, controlled trial • Setting: STI clinics in the U.S. • Outcome measures: • Self-reported behavior change • Incident STI during the follow-up period Kamb et al. JAMA 1998;280:1161

14. Project RespectInterventions • Arm 1: Enhanced counseling • 20-minute pre-test counseling followed by 3 1-hour theory-driven behavioral interventions in subsequent 4 week period • Arm 2: Brief counseling • Two, approximately 20-minute client-centered sessions at test and results dates (7-10 days apart) • Arm 3: Educational messages • Two, 5-minute educational sessions at test and results dates • Arm 4: Control • As Arm 3, but no active follow-up Kamb et al. JAMA 1998;280:1161

15. Project Respect • Patients in Arms 1 ,2 and 3 were interviewed at baseline, as well as 3, 6, and 12 months and received STI testing at all f/u visits. • Patients in Arm 4 were passively followed • Project ran from 1993 - 1996 • 5 clinics in the U.S. • 5,758 patients enrolled Kamb et al. JAMA 1998;280:1161

16. Project RespectMain Results • Compared to standard education messages, client-centered counseling resulted in overall STD reduction of 30% after 6 months and 20% after 12 months • 2-session prevention counseling was as effective as the 4-session enhanced counseling Kamb et al. JAMA 1998;280:1161

17. Kamb et al. JAMA 1998;280:1161

18. Kamb et al. JAMA 1998;280:1161

19. Project Respect Relative effectiveness was greatest among those at highest risk for STI # STI prevented per 100 persons counseled • 20 years and younger 9.1 • Exchange sex for money or drugs 5.9 • STD at baseline 5.3 • Lower education (<12th grade) 4.3 • Female 3.9 • African American 3.2 Bolu et al. Sex Transm Dis 2004;31:469.

20. Project Repect-2 • Single session counseling appeared to work as well as two sessions Metcalf et al. Sex Transm Dis 2005;32:130-8

21. The bad news is that the good news is old news…

22. Prevention Counseling the main Challenge • How to implement prevention counseling in the busy practice setting? • Competing needs • Resource constraints • Lack of provider buy-in • Lack of supervisory buy-in

23. Prevention Counselingin The Real WorldPotential Solutions • Use ancillary counseling staff • Use ancillary, easily implementable devices • Written materials • Video • CDROM-based products

24. Prevention Counselingin The Real WorldPotential Solutions • Move away from the concept of counseling as a stand-alone intervention

25. Prevention Counselingin The Real WorldPotential Solutions • Rather, incorporate the core elements of effective counseling into the standard provider-patient interaction

26. Prevention Counselingin The Real WorldPotential Solutions • This requires: • A shift from the interview process as solely a closed-ended form-filling exercise • Training of clinicians to develop/enhance client-centered counseling skills – an ongoing process

27. Effective behavior change at the patient level begins with behavior change at the provider level…

28. Enhancing Counseling at the Denver Metro Health (STI) ClinicA Step-Wise Approach • Series of sessions on motivational interviewing led by a local expert for all clinic staff • Identification of clinic champions who received more in-depth training • Ongoing peer-to-peer interactions to establish a “culture of counseling” in the clinic

29. Meanwhile in the Clinic Waiting Room….

30. Safe in the City(2003 – 2006)

32. Study Rationale • 19,000,000 incident STDs annually • STD clinics provide access to men and women likely to be infected and to acquire new infections over time • Yet behavioral interventions with counseling or multiple sessions are difficult to implement in busy medical settings • Recent interest in simple, easy to use, and low cost interventions for waiting rooms

33. Rationale continued • Previous research suggests benefits of video-based approaches, but subject to limitations: • Controlled research settings • Tailored videos • Single site • Inclusion of group counseling • Effectiveness of stand-alone video in ‘real-world’ setting is unknown

34. Safe in the City Project Overview • 5-year CDC-funded multi-site study • Develop a brief video-based STD clinic waiting room intervention to reduce (or eliminate) STI and risky sexual behavior • Evaluate effectiveness in 3 publicly funded STD clinics in Denver, San Francisco, and Long Beach, CA.

35. Denver Waiting Room 2nd TV

36. San Francisco Waiting Room

37. Long Beach Waiting Room

38. Intervention Development Considerations Waiting rooms in medical settings provide an underused opportunity to reach patients who are thinking about their health. Yet to be feasible and sustainable, interventions must: • Be easy and inexpensive to administer • Result in minimal interruption of patient flow • Require few clinic resources, especially staff time • Be acceptable to diverse clients

39. Formative Process • Identification of intervention medium, theoretical framework, and key messages by research team • Collaboration with award-winning film maker to integrate framework in an appealing product • Multi-step participatory process involving target audience, clinic staff, and community advisors • Intervention research study in 3 STD clinics

40. Intervention Development: Integrated Theoretical Framework Theory of Planned Behavior Information Motivation Behavior Model Social Cognitive Theory Core constructs grouped into interconnected elements → HIV/STD risk, knowledge, perception→ Positive attitudes toward condom use→ Self-efficacy/skills for condom negotiation, acquisition, use→ Modeling of appropriate behaviors

41. Focus Groups • 3 sites held 12 focus groups with 176 participants • 3 different stages of video development: • Story line development • Script development • Post-production editing

42. What Is the Intervention? • 23-minute video • 3 story lines • 2 cartoon animations • Condom variety and selection • Instructions for use • Posters in waiting and exam rooms

43. Things are getting more serious between Paul and Jasmine, but Paul “slips” and has a sexual encounter with Teresa. Teresa gets an STD and tells Paul. Now Paul has to tell Jasmine. Story Line – Paul and Jasmine

44. Story Line – Rubén, Tim and Christina Rubén’s girlfriend Christina doesn’t know about his interest in men. Rubén and Tim have a casual sex encounter after meeting in a bar. Days later, Christina suspects something is wrong. She insists on a visit to the STD clinic.

45. Story Line – Teresa and Luis Teresa has recently met Luis. After her STD scare with Paul, Teresa is serious about wanting to use condoms. Now she has to convince Luis.

47. Safe in the CityEvaluating Effectiveness of the Intervention

48. Maximizing Intervention Delivery • Identify environmental characteristics of waiting rooms • Observe waiting room flow • Determine appropriate playback frequency • Identify factors to assure viewership (goal: 80%) • Assess and adjust to clinic staff acceptance of video • Monitor viewership and audience response

49. Video Viewership Viewership as defined by watched most or all of the video + identified a main message

50. Overview of Study Design • Population: =~40,000 patients attending 3 STD clinics from December 2003 – August 2005 • Study design: 2 arm non-randomized controlled trial • Arm assignment: alternating 4-week control & intervention periods • Data collection: Passive review of clinic data & external surveillance records to ascertain new STI diagnoses* * gonorrhea, chlamydia, trichomoniasis, syphilis, and HIV