Brief Counseling: Consolidating Our Skills for a Risk Reduction Session

1. Brief Counseling: Consolidating Our Skills for a Risk Reduction Session Linda Creegan, MS, FNP California STD/HIV Prevention Training Center Oakland, CA

2. STDs and HIV:Scope of the Problem/Burden in the U.S. • An estimated 12 million cases of STDs occur annually • Estimated 1 million Americans infected with HIV • One quarter of these do not know they are infected • Approximately 40,000 new cases of HIV infection each year • Injection-drug use is practiced by 1-1.6 million Americans • Over 1 million cases of chronic Hepatitis B www.cdc.gov

3. Impact of STDs • STDs disproportionately affect • adolescents • young adults • women • the poor • minorities • Chlamydia is the most common reportable disease • 3-4 million cases/year • About 1 in 5 adults has HSV-2 • PID is a major cause of infertility in women www.cdc.gov

4. U.S. has highest rates of STDs of the industrialized nations Gonorrhea 1995 Syphilis 1995 Institute of Medicine, 1997

5. Working with Patients to Reduce Transmission of STD/HIV • Biomedical interventions • Effective ART • Diagnosing and treating STDs • Circumcision • Behavior change

6. What do we know about counseling for behavior change? • Similar messages will help patients prevent HIV, STD, and unintended pregnancy • Effective approaches share common elements • Harm reduction provides a conceptual framework A client-centered approach is most effective

7. Research Limitations • Limited research as to what methods are effective • Translation from theory/research to practice is difficult and ill-defined • No established “tipping point” between fidelity to research design and simplification for everyday practice

8. Goals for this Workshop • Learn a brief, simple counseling model that can be taught in your AETC trainings • As science-based as possible • As usable as possible • Adaptable to different counseling situations • Get some practice

9. Applications STD clinics and primary care HIV testing and clinical care Family planning

10. Community level Small group interventions Individual counseling Published results from four studies of brief, individual approaches Outcome measures Self-report behavior change Biological outcomes Risk Reduction Interventions for HIV and STDs

11. Client-Centered Counseling:Brief, Individual Approaches • Stages of Change theory • Project Respect (Kamb, 1998) and RESPECT-2 (Metcalf, 2005) • Partnership for Health (Richardson, Jan 2004) • OPTIONS Project - motivational interviewing (Fisher, Jan 2006)

12. Stages of ChangeCounseling Approaches Source: Prochaska and DiClemente, 1983

13. Project Respect • Almost 6000 patients attending large publicly-funded STD clinics (SF, LB, Denver, Baltimore, Newark) • Patients randomized to receive client-centered counseling by trained (non-clinical) staff or education by clinician • Outcome measures: • Self-report of risky sex behaviors, condom use • New STDs: GC,CT,Syphilis, HIV • Outcome findings: two short counseling sessions (20 minutes each) increased condom use and prevented new STDs Kamb et al, JAMA Oct.7,1998

14. Effects of Risk Reduction Counseling:Results from Project Respect, 1993-1996 Kamb et al, JAMA 1998

15. Project RespectProtocol Components • Introduce and orient client to the session1-2 min • Enhance the client’s sense of self-risk2-3 min • Explore the specifics of the most recent risk incident2-3 min • Review previous risk-reduction experiences2-4 min • Summarize the risk incident and risk patterns3-4 min • Negotiate a risk-reduction step4-5 min • Identify sources of support and provide referrals1-2 min • Close the session3-5 min Total time: 18-28 min

16. Partnership for Health • Almost 900 patients enrolled in California • Six HIV clinics, randomized by clinic as gain-frame or loss-frame approaches, or as controls • Counseling, 3-5 minutes, emphasized patient-provider team approach to staying healthy • Outcome measures • self-report of unprotected anal or vaginal sex • Outcome findings: brief, loss-framed counseling reduced unsafe sex in those with multiple or casual partners

17. Examples of Loss-Framed Prevention Messages • “Unsafe sex may expose you to other STDs and other strains of HIV.” • “If you don’t tell your partner that you have HIV before having sex, you cannot talk honestly with your partner about safer ways to have sex.”

18. OPTIONS Project • 497 clients of two large HIV clinics in Connecticut • Prospective trial comparing clinician-delivered risk reduction counseling to standard-of-care control • Motivational interviewing technique, 5-10 minutes • Outcome measures • Self-report of unprotected vaginal, anal and insertive oral sex • Outcome findings: Counseling reduced unsafe sex

19. Common Elements of Effective Interventions • Risk assessment • Client and provider choose a behavior to modify • Explore readiness, willingness, barriers and supports • Client and provider formulate a plan

20. Client-Centered Counseling:A Working Definition • Counseling conducted in an interactive manner through the use of open-ended questions and active listening, which focuses on developing prevention objectives and strategies with the client rather than simply providing information. CDC HIV Prevention Case Management Guidelines, 1997

21. Knowledge Perceived risk Perceived consequences Attitudes (beliefs) Skills Self -efficacy Actual consequences Access Intentions Perceived social norms Policy Factors that Affect Behavior Change

22. Dialog Individualized Takes feelings and beliefs into account Helps client understand themselves better Short and focused One-way Levels of detail but not tailored to an individual Sticks to the facts Helps client understand a subject better Short and focused Counseling vs. Information-Giving

23. General Principles for Client- Centered Counseling • Ask and listen more, talk less • Approach each patient as an individual • Focus first on issues and realities that the patient identifies • Maintain a neutral, non-judgmental attitude • Offer options, not directives • Onus of action and responsibility remains with the patient

24. Three Steps in a Synthesized CCRRC Approach 1. Focus on personal risk assessment • Identify patient’s personal perception of risk 2. Choose a safer goal behaviors • Identify patient’s level of readiness for change • Assess supports and obstacles for behavior change efforts 3. Develop a personalized action plan • Negotiate small, realistic risk-reduction steps • Refer to specialized services, if needed

25. Step 1 Assist Client in Assessing Risk Begin dialogue with patient to determine • number, gender of partners • sexual practices (anal, oral, vaginal sex) • patterns of condom use • prior STD testing history, and diagnoses • Identify factors affecting patient risk • current/past history of unprotected sex • intentions for becoming pregnant • history of domestic violence • history of injection drug use

26. Sample Risk AssessmentQuestions • What do you see as the riskiest things that you are doing? • What are you doing in your life that might be putting you at risk for STD/HIV? • What are the situations in which you are most likely to put yourself at risk for HIV or STD? • When was the last time that you put yourself at risk for STD/HIV? What was happening then? • How do drugs or alcohol influence your STD or HIV risk behaviors?

27. Step 2Set Safer Behavior Goal Risk Behavior “Unprotected vaginal sex with new partner” Safer Goal Behavior “Consistent condom use with this partner”

28. Sample Goal-SettingQuestions • How would you like to change that? • What would you like to do differently? • What might be better for you to do? • How could you make (sex/drug use) safer for yourself?

29. Reducing # of sexual partners Increase condom use with main/non-main partners Partner testing Monogamy Abstinence Enter drug treatment program Use needle exchange Stop sharing needles/works Possible Goal Behaviors for STD Risk Reduction Consideration of any of the above

30. Reaching a Goal Risk Behavior Safer Goal Behavior Factors that influence behavior Benefits, Supports Drawbacks, Obstacles

31. Circumstances of risk Analyze a recent risk occurrence Where does……occur? What makes it hard to…? When do you have sex without a condom? Obstacles and supports Power and control dynamics in relationships Cultural issues Access to care Significant others Identify Barriers/Sources of Support for Change

32. Step 3Formulate Realistic, Simple Plan Risk reduction plan must be… • patient-driven, • based on patient’s history, • readiness, and • ability to adopt safer behaviors Health care providers can… • support efforts previously attempted by patient • help the patient stay small and specific • offer options, not directives • remain non-judgmental

33. Making an Action Plan Safer Sex Goal Risk Behavior Drawbacks, Obstacles Benefits, Supports Factors that influence behavior Personalized Action Plan 1. 2. 3.

34. Sample Action Plan Questions • How will you go about that? • What is one thing you could do to begin? • What will you need to do first/next? • When will be a good time to try/begin this? • Who can you talk to about this for support?

35. Refer to Specialized Services, If Needed • Alcohol or drug treatment programs • Partner/domestic violence services • Partner counseling and referral services (PCRS) • Couples counseling • Benefits counseling to obtain access to services

36. Follow-up:Ongoing Dialog Ask about risk-reduction efforts at next meeting. • Review and repeat • Change or add to plan • Encourage patient to keep trying • Reinforce your support Remember: behavior takes time to change.

37. Encouraging Providers to Incorporate Brief Counseling into Routine Care • Emphasize importance “STDs and HIV are among the most common STDs in the US” • Emphasize results “Similar messages will help your patients prevent HIV, STD, and unintended pregnancy” • Emphasize research base “Counseling methods shown to be effective by research share common elements” • Emphasize do-ability • “These studies were done in HIV and STD clinics like yours” • Teach and practice skills • Ask trainees to identify their “first step”

38. Taking Personal Stock • Helping clients change behavior may begin with changing some of our own • Talk less, ask and listen more • Encourage and be satisfied with step-wise, incremental, realistic changes • Avoid “should/shouldn’t”, “I think you…..” “You need to…..” • Be willing to give it a try!

39. References • Johnson WD, et al. HIV intervention research for men who have sex with men: a 7-year update. AIDS Ed and Prev; 2005,17(6),568-589. • Kamb ML et al, Efficacy of Risk-Reduction Counseling to Prevent Human Immunodeficiency Virus and Sexually Transmitted Diseases, A Randomized Controlled Trial. JAMA 1998:280:1161-1167 • Richardson JL, et al. Effect of brief safer-sex counseling by medical providers to HIV-1 seropositive patients: a multi-clinic assessment. AIDS 2004, 18:1179-1186 • Fisher JD, et al. Clinician-delivered intervention during routine clinical care reduces unprotected sexual behavior among HIV-infected patients. J Acquir Immune Def Syndr Jan 2006:14(1): 44-52

40. Websites • HIV InSite, UCSFhttp://hivinsite.ucsf.edu/InSite?page=Prevention • RXisk Reduction Handout, Mountain States AETChttp://www.aids-ed.org/pdf/p02-et/et-05-00/risk_reduction_pad.pdf • Project Respecthttp://www.cdc.gov/HIV/projects/rep/RESPECT.htm • Partnership for Healthhttp://www.cdc.gov/HIV/projects/rep/partnershipforhealth.htm