S P N S

Special Projects of National Significance
2005 Report to CARE Act Grantees

Prevention with Positives Initiative

Prevention with HIV-Infected Persons Seen in Primary Care Settings

Background

HIV prevention efforts to date have focused primarily on reducing the risk of infection among HIV-uninfected individuals, concentrating on those individuals who engage in high risk sexual and drug using activities. Less attention is devoted to prevention efforts targeting individuals already infected with HIV. However, recent reports suggest that HIV-positive individuals continue to engage in risky activities, and that their risk-taking may be becoming increasingly common, demonstrating a need for interventions targeting people who are HIV-positive who are in clinical care.

The HIV primary care setting may provide an opportunity to reduce new transmissions through clinic-based risk assessment, prevention counseling and behavioral interventions. Patients needing more intensive or ongoing behavioral interventions can be identified and referred for additional intervention services within the clinic setting or in the community.

To determine the efficacy of a clinic-based prevention approach, the feasibility of potential intervention models needs to be

 

assessed in terms of cost, time, and interventionist skill. The models should also describe the role of service providers and practitioners in clinical settings and their role in providing prevention messages and behavioral counseling as well as referring patients for additional prevention services when necessary. The Initiative on Prevention with HIV Infected Persons Seen in Primary Care Settings focuses on the evaluation of a behavioral prevention intervention program for HIV-positive clients.

The Prevention with positives Initiative

Prevention with HIV-Infected Persons Seen in Primary Care Settings, or Prevention with Positives Initiative, evaluates the effectiveness of a behavioral prevention intervention program for HIV-positive clients seen in clinical care settings. This initiative, funded by the Special Projects of National Significance (SPNS) in the HRSA HIV/AIDS Bureau (HAB), supports 15 demonstration sites and an Evaluation and Technical Support Center (Enhancing Prevention with Positives Evaluation Center, EPPEC).

 

 

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2005 REPORT prevention with positives initiative

During Year 1, EPPEC designed the multi-site evaluation to assess the effectiveness of behavioral interventions to be implemented by the 15 demonstration sites. The overarching questions to be examined by the initiative include:

· Can behavioral interventions in primary care clinical settings help HIV-positive clients reduce the risk of transmitting HIV to others?

· What models are most appropriate with different populations (e.g., men of color who have sex with men, heterosexual women, rural drug users)?

· What models are most appropriate for different primary care settings (e.g., rural, urban, high volume, community-based organization, large hospital)?

Working with 15 demonstration sites, EPPEC has been providing technical assistance to improve capacity for implementing prevention interventions and conducting evaluation and data collection to assess the impact of these interventions. As the technical support center for this initiative, EPPEC has conducted site visits and needs assessments in all 15 demonstration sites. EPPEC and these sites are engaging in collaborative communication networks to plan and conduct multi-level data collection and reporting. An overall assessment of initiative-wide outcomes is expected by the end of the funding period.

The primary audience of this initiative includes HIV-positive clients seen in clinical care settings.

 

The goal of the initiative is to evaluate the effectiveness of a behavioral prevention intervention program in improving behaviors and ultimately averting new HIV infections.

Contact Information

Evaluation and Support Center

AIDS Policy Research Center
74 New Montgomery Street, Suite 600
San Francisco, CA 94105

 

Stephen Morin, PhD, Principal Investigator
Phone: 415-597-9228

HRSA Project Officers

Special Projects of National Significance
5600 Fishers Lane, Rm 7C-07
Rockville, MD 20857

Faye Malitz, MS
Phone: 301-443-3259

Sandi Duggan, MA
Phone: 301-443-7874

Pamela Belton
Phone : 301-443-9481

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2005 REPORT prevention with positives initiative

Grantees

DeKalb County Board of Health (Decatur, GA)

Prevention with Positives in the Clinical Setting

Target Population: Urban African-American patients living with HIV infection

Goal: To initiate change in risky behaviors of HIV-infected individuals and to decrease the secondary transmission of HIV

Strategies: 1. Standard of care that includes prevention counseling and education conducted by existing clinical providers; 2. One-on-one counseling conducted by an HIV-prevention specialist; 3. Group interventions

Evaluation: The evaluation will examine and compare the impact of existing models versus those using a specialist with regard to development of individualized plans for behavior change, self reports of behavior change over time, and decreases in secondary transmission of HIV

Contact Information:

Kenneth Prince, Principal Investigator
445 Winn Way
PO Box 987
Decatur, GA 30031
Phone: 404-508-7940

Drexel University School of Public Health (Philadelphia, PA)

The Protect and Respect Project

Target Population: HIV-infected women receiving their primary medical care through the Partnership Comprehensive Care Practice

Goal: To reduce the sexual transmission of HIV by reducing high-risk behaviors

Strategies: 1. Training of clinical providers in the provision of consistent, science-driven, secondary prevention messages; 2. Group level intervention aimed at skills building; 3. Peer-led weekly discussion groups

Evaluation: The evaluation will focus on clinical outcomes, self reports regarding behavior, reports from providers, and a cost effectiveness analysis; the proposed model allows for comparison of outcomes among women receiving prevention messages with women who receive messages plus skill-building sessions and peer support

Contact Information:

Marla J. Gold, MD, Principal Investigator
1505 Race Street, 11th Floor, MS
660Philadelphia, PA 19102
Phone: 215-762-3940

El Rio Santa Cruz Community Health Center (Tucson, AZ)

Supporting Healthy Alternatives through Patient Education (SHAPE)

Target Population: HIV-infected persons currently being seen in clinical primary care services, many of whom are persons of Latino descent

Goal: 1. Reduce HIV transmission risks in HIV-positive patients; 2. Reduce HIV re-infection (including super-infection) risks in HIV positive participants; 3. Increase the comfort level of participants to disclose their HIV serostatus

Strategies: 1. Refine an already developed model based on input from local HIV-positive patients, in order to make the intervention culturally and linguistically appropriate; 2. Intervention to target high-risk sexual behaviors and increase protective behaviors

Evaluation: The evaluation will focus on data related to reducing HIV transmission and re-infection risks, and increasing efficacy for self-disclosure of serostatus. Process data regarding project reach and fidelity and client satisfaction will also be examined

Contact Information:

Stephen Trujillo, Project Coordinator
1701 West St. Mary's Rd., Suite 160
Tucson, AZ 85745
Phone: 520-628-8287

 

 

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2005 REPORT prevention with positives initiative

Fenway Community Health Center (Boston, MA)

HIV Prevention in Primary Care Settings

Target Population: HIV-infected men who are sexually active with other men who receive primary medical care at Fenway Community Health

Goal: To initiate positive sexual behaviors among HIV-infected men

Strategies: Individualized education and motivational and behavioral skills enhancement in addition to standard prevention case management (PCM)

Evaluation: Sexual risk taking behaviors will be tracked and compared between subjects randomized to receive PCM only and subjects receiving a combination of PCM and behavioral skills enhancement

Contact Information:

Kenneth H. Mayer, MD, Principal Investigator
7 Haviland Street
Boston, MA 02115
Phone: 617-927-6400

Johns Hopkins University
(Baltimore, MD)

Improving Provider Counseling Interventions in HIV Practice through Computer Assessments

Target Population: HIV-infected patients being seen in existing HIV clinics

Goal: To initiate positive sexual behaviors among HIV-infected men, improve health service counseling during clinical encounters, and improve patient interactions with clinical providers

Strategies: 1. Completion of an Audio-Computer Assisted Self Interview upon arrival at clinical appointments; 2. Prevention counseling; 3. Provider training

Evaluation: The evaluation focuses on comparing changes in self-reported transmission behavior at 12-month follow-up in the intervention group compared to a control group, patients' intent to change behavior, improvements in health service counseling, and patients' perceptions of the impact on patient-provider interactions

Contact Information:

Emily Erbelding, MD, MPH, Principal Investigator
1830 E. Monument Street, Room 445
Baltimore, MD 21287
Phone: 410-614-3737

Los Angeles County Department of Health Services Office of AIDS Programs and Policy (Los Angeles, CA)

HIV Prevention in Primary Care Settings

Target Population: Sexually active HIV-infected patients being seen at HIV-oriented primary care settings

Goal: To improve patient-provider relationships, improve the ability of providers to implement intervention or counseling, and reduce high-risk sexual behaviors

Strategies: The intervention is a provider-based prevention service delivery model using prevention education and counseling methodology

Evaluation: Project evaluation will assess the extent to which the enhanced intervention meets project goals and will identify patient characteristics and behaviors that are covariates of outcomes or modifiers of intervention

Contact Information:

Charles L. Henry, Principal Investigator
600 S. Commonwealth Avenue, 6th Floor
Los Angeles, CA 90005
Phone: 213-351-8001

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THE SPNS MANDATE

The purpose of the Special Projects of National Significance (SPNS) program is to advance knowledge and skills through the support, development and evaluation of innovative models of HIV care for financially disadvantaged and medically underserved populations. The SPNS program, administered by the Health Resources and Services Administration (HRSA) HIV/AIDS Bureau (HAB), is part of the Ryan White Comprehensive AIDS Resources Emergency Act, also known as the CARE Act.

SPNS models of innovative care for HIV-positive patients have been designed to respond to the needs of the HIV epidemic. Currently, it is estimated that about 650,000 to 950,000 persons are infected with HIV and approximately 40,000 new infections occur every year in the United States. Only about one-third of HIV-infected adults are currently receiving regular or ongoing medical care for HIV infection. The most affected populations are traditionally underserved and hard-to-reach groups, particularly women, injection drug users and their heterosexual partners, gay and bisexual men of color and youth. HIV/AIDS is now most heavily impacting minority communities and individuals living in poverty.

SPNS response to the epidemic began in 1991 with some of the first Federal grants to target adolescents and women living with HIV. Today, a portfolio of 72 grants funded either solely by the HIV/AIDS Bureau or in partnership with other Federal agencies addresses the cutting-edge issues in HIV care.

The SPNS program is an integral link to all CARE Act programs. While it provides an opportunity to develop and evaluate new services, the program places great emphasis on the dissemination of these services. SPNS promotes the dissemination and replication of effective models of care relevant to the present challenges of the epidemic. These models include the integration of HIV primary care services to the needs of individuals who present with multiple diagnoses such as substance abuse, mental health, and other psycho-social burdens that complicate the effective delivery of health care.

As CARE Act grantees develop innovative services, the SPNS program will provide the funding and technical assistance for grantees to evaluate innovations and disseminate findings to the HIV community.

Within each multi-site SPNS initiative, grantees focus their interventions on a specific population or treatment issue, either by implementing components of existing interventions or designing new models. These models are evaluated for effectiveness, efficiency, and replicability. An important corollary is an examination of the contextual issues that contribute to the success or failure of an intervention in a particular setting or with a particular population.

Evaluation of Models

The structure of most of the multi-site initiatives is designed to collect data and evaluate interventions across sites. The projects are grouped by type of intervention or topic (e.g., outreach, prevention) with the guidance of an evaluation center, whose tasks include:

· facilitating cross-site evaluation, with technical assistance provided

· developing standardized data collection instruments

· assuring data quality

· disseminating findings

· and assessing policy implications of study findings.

Each grantee is required to participate in development of the evaluation plan for the overall initiative and most collect uniform data that can be analyzed and compared across programs. The SPNS initiatives have demonstrated that collaboration for multi-site evaluation of care programs is possible and rewarding, and that it requires time and effort on the part of all stakeholders: the evaluation centers, HRSA/SPNS, and the projects.

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Current SPNS Initiatives

To date, SPNS sponsors a variety of demonstration programs, each with a set of unique, yet initiative specific goals and strategies designed to have the greatest impact on their respective targets. While SPNS has funded numerous innovative programs over the past decade, the table below summarizes eight initiatives that are currently funded through 2009.

Lessons learned from these and other initiatives are helping the HIV/AIDS Bureau develop effective strategies for addressing the demand for HIV services among underserved infected populations.

Current priorities include:

US-Mexico Border: Demonstrating and evaluating models that advance HIV service innovation along the US-Mexico Border

Outreach: Evaluating effective outreach strategies for bringing individuals into HIV primary care treatment

Information Technology: Assessing and evaluating the use of information technology to improve HIV medical care

American Indian/Alaska Native: Supporting the coordination and integration of existing services for Native Americans/Alaska Natives living with HIV and other co-morbidities

Caribbean: Improving care and treatment of HIV-infected persons of Caribbean descent through culturally appropriate strategies

Prevention with Positives: Assessing prevention strategies in primary care settings for HIV-positive persons

Buprenorphine: Developing, implementing and evaluating innovative methods for integrating Buprenorphine Opioid Abuse Treatment in HIV primary care settings

Young MSM of Color: Implementing and evaluating models of outreach, care and prevention targeted to young HIV seropositive men who have sex with men (YMSM) of color

Initiative Topic Grantees Funding Period
Demonstration and Evaluation Models that Advance HIV Service Innovation Along the US-Mexico Border US-Mexico Border 6 2000-2005
Targeted HIV Outreach and Intervention Model Development and Evaluation for Underserved HIV-Positive Populations Not in Care Outreach 11 2001-2006
Evaluating the Impact of Information Technology on Improving Delivery and Quality of Care for HIV-Seropositive Individuals Information Technology 6 2002-2006
American Indian/Alaska Native (AI/AN) Initiative AI/AN 7 2002-2007
Models of Peer Support for Caribbeans Living in the U.S. Caribbean 6 2003-2007
Prevention with HIV-Infected Persons Seen in Primary Care Settings Prevention
w/ Positives		 16 2003-2007
An Evaluation of Innovative Methods for Integrating Buprenorphine Opioid Abuse Treatment in HIV Primary Care Settings Buprenorphine 11 2004-2009
Outreach, Care, and Prevention to Engage HIV-Seropositive Young MSM of Color Young MSM of Color 9 2004-2009
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Mount Sinai Hospital (Chicago, IL)

HIV Prevention in Treatment Settings

Target Population: HIV-infected low-income persons of African-American or Mexican-American ethnicity

Goal: To improve coping ability, increase adherence to treatment regimens, promote safer sexual practices, and promote safer practices related to drugs

Strategies: A 12-month behavioral intervention consisting of multiple individualized educational sessions with a peer advocate using computer-assisted technology

Evaluation: Subjects who only receive prevention counseling will be compared to both newly diagnosed HIV subjects and those diagnosed for more than 18 months; evaluation will focus on assessing the variables stated in the above goals in addition to the extent to which participant impacts vary by HIV risk factor and demographic characteristics

Contact Information:

Nancy R. Glick, MD, Principal Investigator
California Avenue at 15th Street
Chicago, IL 60608
Phone: 773-257-5442

St. Luke's Roosevelt Hospital Center
(New York, NY)

Positive Prevention

Target Population: HIV-infected persons being seen at the Center for Comprehensive Care

Goal: To increase condom use, decrease high-risk needle use, decrease substance use, and improve treatment adherence

Strategies: Identify patients with high-risk behaviors using risk assessment, develop risk reduction plans and provide counseling, deliver health education, facilitate peer support networks, and facilitate referral for psychosocial services, substance abuse treatment, and other services

Evaluation: The evaluation will examine patient demographics, service utilization, and the impact of the intervention on risk behaviors and clinical outcomes

Contact Information:

Victoria Sharp, MD, Principal Investigator
The Center for Comprehensive Care
1111 Amsterdam Avenue
New York, NY 10025
Phone: 212-523-6050

University of Alabama
(Birmingham, AL)

HIV Prevention in the Primary Care Setting

Target Population: Male HIV primary care patients who have sex with men

Goal: 1. To increase motivation, facilitate positive decision making, and increase self-efficacy; 2. To increase condom use, decrease the number of sexual partners, and increase the frequency of HIV-serostatus disclosure to all sexual partners

Strategies: A provider-delivered, client-centered, theory-based intervention making use of computer-assisted self-interviewing technology

Evaluation: A randomized clinical trial to evaluate the impact of the intervention in achieving significant improvements in the outcomes listed above in addition to a comparison of STD rates among intervention and control groups

Contact Information:

Laura H. Bachmann, MD, MPH, Principal Investigator
Div. of Infectious Diseases, STD Program
ZRB 242, 1530 3rd Avenue
SouthBirmingham, AL 35294-0007
Phone: 205-975-5500

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2005 REPORT prevention with positives initiative

University of California, Davis (Sacramento, CA)

Prevention Intervention Strategies with HIV-Infected Persons Seen in Four Different Primary Care Settings

Target Population: HIV-infected persons seen in clinics that primarily serve low-income persons of color

Goal: To help providers and specialists assess patient's risk of HIV transmission, increase provider comfort and confidence in counseling about transmission risk, and ultimately to reduce the prevalence of high-risk behaviors among HIV patients

Strategies: 1. Development of a diagnostic questionnaire self-administered by patients; 2. Training of primary care providers and HIV Specialists to use Motivational Enhancement techniques to promote behavior change; 3. An intervention model to include a brief intervention from the PCP and another to include this brief intervention and a session with an HIV Specialist health educator

Evaluation: The project plans to demonstrate whether the combination intervention strategy is more effective in risk-behavior reduction than the provider-based model alone, in addition to establishing the cost-effectiveness of the intervention

Contact Information:

Neil M. Flynn, MD, MPH, Principal Investigator
4150 V Street PSSB 500
Sacramento, CA 95817
Phone: 916-734-3365

University of California, San Diego
(San Diego, CA)

Primary Prevention for Positives: An Evidence-Based Biomedical and Behavioral Intervention Strategy

Target Population: HIV-infected persons in the primary care setting

Goal: To reduce the risk of HIV transmission from patients receiving the intervention to their sexual and/or drug sharing partners

Strategies: Provide routine behavioral, symptom, and STD screening, making use of the Audio-CASI system, followed by triage to tiered treatment and prevention interventions; these interventions include integration of prevention for positives into routine medical care and/or a more intensive one-on-one prevention counseling with a specialist

Evaluation: Key variables examined in evaluation will include: 1. Percent change in self-reported HIV transmission risk behaviors; 2. Percent change in rates of substance use; 3. Percent change in STD rates; 4. Intervention cost-effectiveness and reproducibility

Contact Information:

Christopher Mathews, MD, Principal Investigator
200 W. Arbor Drive, MC 8681
San Diego, CA 92103-8681
Phone: 619-543-2415

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University of Miami (Miami, FL)

Project Road Map

Target Population: Older HIV-positive patients in a primary care setting recruited on referral from their primary care physician

Goal: To reduce sexual risk behaviors

Strategies: Group intervention consisting of four one and a half to two hour sessions addressing HIV education, problem solving and safer sex behaviors, disclosure, and relapse prevention

Evaluation: Intervention effects will be assessed comparing outcomes of subjects randomized into either the intervention or a comparison group

Contact Information:

Lourdes Illa-Sanchez, MD, Principal Investigator
Dept. of Psychiatry & Behavioral Sciences
1695 NW 9th Avenue
Miami, FL 33136
Phone: 305-355-7104

University of North Carolina
(Chapel Hill, NC)

UNC HIV Prevention Demonstration Project

Target Population: Southern HIV-infected people living in non-urban areas

Goal: To improve behaviors and health outcomes and prevent HIV transmission

Strategies: 1. A provider-based HIV prevention brief counseling program in addition to a support system centered around the use of a client-centered web-based tool; 2. Some participants will also receive a motivational interviewing-based HIV prevention

Evaluation: The project plans to evaluate: 1. The effect of intervention type and dose on self-reported risk behaviors and STI infection; 2. The effect of training and prompting on provider counseling; 3. The cost of each intervention

Contact Information:

Evelyn Quinlivan, MD, Principal Investigator
Infectious Disease Clinic
130 Mason Farm Road CB# 7030
Chapel Hill, NC 27599
Phone: 919-966-2536

University of Washington (Seattle, WA)

Prevention with Positives

Target Population: HIV/AIDS patients in a primary care setting

Goal: To improve participant behaviors related to HIV transmission

Strategies: 1. Routine risk assessments performed by a prevention specialist during individual meetings; 2. Collaboration between the specialist, provider, case manager, and patient to identify barriers to risk prevention and solutions; 3. Motivational interviewing4. Weekly gender and behavior focused peer educational support groups with a specialist and peer educator

Evaluation: 1. Comparison of changes in risk-behaviors, determined through computer-assisted self-interview, among those randomized to the intervention or standard care; 2. Assessment of provider behavior change in terms of risk prevention activities, comparing standard care providers to intervention providers

Contact Information:

Karina K. Uldall, MD, MPH, Principal Investigator
HIV/AIDS Research Program
901 Boren Avenue, Suite 900
Seattle, WA 98104
Phone: 206-991-6224

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2005 REPORT prevention with positives initiative

  Whitman-Walker Clinic
(Washington, DC)

Prevention with HIV-Infected Persons Seen in Primary Care Settings

Target Population: HIV-infected persons seen in the primary care setting

Goal: To decrease risk behaviors associated with HIV transmission and ultimately reduce HIV transmission

Strategies: 1. Provider training in the acquisition and application of necessary knowledge and skills to conduct behavioral risk assessment and screening; 2. Focused behavioral interventions by health educators for those engaging in high-risk sexual behaviors; 3. Collaboration between health educators and primary care providers

Evaluation: A longitudinal evaluation will assess the duration and intensity of intervention in terms of client behavior change; differences and effectiveness will be compared between low and high-risk behavioral interventions using scores from a risk assessment tool

Contact Information:

Debra Dekker, PhD, Principal Investigator
1407 S Street NW
Washington, DC 20009

Phone: 202-797-3539

The University of California, San Francisco, AIDS Policy Research Center, Center for AIDS Prevention Studies (San Francisco, CA)

Enhancing Prevention with Positives Evaluation Center

Goal: Working with grantees of this initiative, the goals include: 1. To facilitate and conduct multi-site evaluation; 2. To determine the efficacy of the variety of interventions funded, appropriateness and feasibility of implementation, cost effectiveness, and provider and patient behavior change; 3. To stimulate innovative projects and ensure scientific excellence

Strategies: 1. Provide methodological research design and evaluation consultation and support, technical assistance in intervention development, design of data collection systems, and a central database for measurement of outcomes; 2. Use of a web-based data collection system; 3. Technical assistance and support to sites during collection of process, outcome, and impact indicators

Evaluation: The center plans to evaluate the initiative at the: 1. Organizational level (clinic size, client characteristics, etc.); 2. Intervention level (intervention type and dose, cost); 3. Provider level (attitudes, knowledge, intervention context, barriers to change); 4. Patient level (risk behavior and patient satisfaction), and; 5. Training level (pre and post knowledge, skills, and satisfaction)

Contact Information:

Stephen Morin, PhD, Principal Investigator
74 New Montgomery Street, Suite 600
San Francisco, CA 94105
Phone: 415-597-9228

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