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Prevention program aims to change patient behavior
STD and HIV prevention placed together
A Rochester, NY, program combines STD and HIV prevention and counseling to target some of the most difficult risk populations, including incarcerated people and HIV-infected people who have had reportable sexually transmitted diseases in the two years prior to or after their HIV diagnosis.
The philosophy driving the STD/HIV program is that suitable methods for behavioral change among HIV-positive people are precisely the same sorts of methods used to reduce risk behavior among high-risk HIV-negative populations.
"From an infectious disease standpoint and a behavioral standpoint, it makes a lot of sense," says Patricia Ann Coury-Doniger, FNP, director of the Center for Health and Behavioral Training and the STD/HIV Program, University of Rochester (NY). The Monroe County Health Department contracts with the university to provide its STD and HIV prevention services.
"If you have persons who are HIV-positive and who are having trouble because of new STDs, it only makes sense to do intense intervention for them," Coury-Doniger says. "The science says to do it, and I don’t think anyone would argue that the science of HIV/STD relationships strongly supports integrating services."
In fact, the strongest barrier to integrating the two is funding, she says.
"People are afraid of mixing the funding stream, and that’s a barrier," Coury-Doniger says.
However, that argument becomes less valid as the epidemic increasingly affects communities of color where public health officials traditionally have seen higher rates of STDs, Coury-Doniger says.
For instance, when STD and HIV services are not integrated, an HIV prevention educator may go out to speak to African-American teenagers about HIV, but will miss the opportunity to offer testing and treatment for the one in five teenage girls who might be infected with chlamydia, Coury-Doniger says.
"That’s the unscientific approach that happens when you don’t integrate services and interventions," Coury-Doniger adds.
The integrated prevention program operated by the University of Rochester in conjunction with the Monroe County Health Department has these features:
• Stage-based behavioral counseling.
Stage-based behavioral counseling is an adaptation of the Stages of Change/Transtheoretical Model of Behavior Change Theory.
"We implemented it for positives and negatives in 1996, and we stage each client according to their willingness to adopt specific sexual behaviors that would reduce their chances of transmitting or getting another STD," Coury-Doniger says.
"We have data on readiness for change and sexual risk behaviors for people with HIV," she adds. "And it’s not that different from people who are HIV-negative."
The philosophy behind the program is that it always is difficult for people to change their behavior, and obstacles to some behavior changes include cultural issues. For example, condom use may interfere with some HIV-positive gay men’s identity, so these men may decide they will only have unprotected sex with other HIV-positive men or they’ll have oral sex instead of anal sex, because oral sex is a lower risk for HIV transmission, Coury-Doniger says.
However such harm-reduction approaches ignore the problem of transmitting STDs such as gonorrhea, herpes, and syphilis, all of which can be transmitted through unprotected anal and oral sex, Coury-Doniger says.
"So if you only focus on HIV, that approach is not based on STD science, and we felt it was not the full picture," Coury-Doniger says.
Through the behavioral change program, counselors assess HIV-positive people for their readiness to disclose their serostatus to sexual partners and to use a condom with every partner every time, Coury-Doniger says.
Strategies selected based on circumstances
There are counseling strategies for each of the stages of readiness. For example, if someone is in the beginning or pre-contemplative stage, in which the person has not begun to think about changing his or her own behavior, there are three strategies: "One is storytelling, two is discussing the impact on others, and three is information-giving," Coury-Doniger says. "These are very specific, and for MSMs, we tell them what STDs have to do with it."
Counselors will select one of the three strategies based on the circumstances. For instance, if the HIV-infected person has not considered disclosing his HIV status to sexual partners, it may be because no one has discussed with him what the impact of that decision could be, Coury-Doniger says.
"The person may think, He’s an adult, so not using a condom is on his head,’" she explains.
The counselor would employ the impact-on-others strategy by showing the client a diagram of people who are linked together through sexual relationships. "We would show that the person is having sex with a person he doesn’t know, and it’s really a social network that is closed," Coury-Doniger says.
One person may transmit HIV to another, who will transmit it to others, and before long the same virus may be transmitted back to someone the original HIV-infected person knows and cares about, she says.
This behavioral change strategy works by influencing attitudinal change as a prerequisite to influencing behavioral change, Coury-Doniger adds.
• Masco program.
The health department’s STD/HIV program has started a pilot project called the Monroe County Safe (Masco) program. The program has identified 60 people living with HIV/AIDS who have had a reportable STD in the two years prior to or since their diagnosis, Coury-Doniger says.
"We picked people at the highest risk, including males and females who were having repeat STDs," Coury-Doniger says. "Then we developed a program where they receive a home visit every three months by a disease intervention specialist."
The specialist is someone trained to do partner notification in the public health department. For the Masco program, the specialist does urine screening for gonorrhea, chlamydia, and syphilis. The specialist also will offer an HIV test and counseling for anyone in the client’s household.
"And we use Stage-based Behavioral Counseling around the health care-seeking behaviors, such as whether they are accessing HIV medical care and adhering to prescribed treatments," Coury-Doniger says.
While many clients are enrolled in the program, Masco is now on hold because of funding cuts to the county, and alternative funding avenues are being sought, she adds.
• STD clinic and testing.
The center provides STD/HIV services to county juvenile and criminal justice facilities, Coury-Doniger says.
"There are disproportionately high numbers of HIV-positive men and women in these county criminal justice facilities, and many of them are not in care," Coury-Doniger says.
The center provides transitional planning for this population to link them to HIV care upon release. STD and HIV counseling and testing are also provided.
Again, stage-based behavioral counseling prevention services are provided to address the population’s risk behaviors, Coury-Doniger says.
An incarcerated population often is more receptive to receiving HIV/STD information than are clients seen in community settings, where there may be time constraints and competing interests, Coury-Doniger notes.
• Training in behavioral counseling.
The STD/HIV Prevention Training Center provides behavioral training and instruction in stage-based counseling. Most of the courses, which provide continuing education units, are offered free to anyone who would like to enroll. The coursework includes behavioral training specifically for HIV/STD prevention or for people living with HIV, and covers the following topics:
— community HIV educator training;
— domestic violence information;
— HIV/AIDS confidentiality law;
— HIV/AIDS treatment update;
— HIV disclosure;
— HIV treatment fraud;
— implementing HIV reporting and partner notification;
— HIV testing procedures;
— implementing rapid HIV testing;
— mental health services: ensuring appropriate referrals for HIV-positive clients;
— promoting adherence to HIV treatment;
— reducing perinatal HIV transmission;
— reducing the risk and harm of HIV infection;
— serving families from assessments to service plans;
— STD update for clinicians;
— tailoring HIV counseling and testing to the unique needs of adolescents;
— cultural diversity training for case managers;
— educational theatre for STD/HIV prevention;
— ABCs of hepatitis and HIV;
— behavioral interventions for incarcerated women and adolescents.
The course descriptions can be found on the Internet at www.urmc.rochester.edu/chbt.