AIDS and Behavior

, Volume 11, Supplement 1, pp 84–94

Designing and Delivering a Prevention Project within an HIV Treatment Setting: Lessons Learned from a Specialist Model

Authors

    • Center for Comprehensive CareSt. Luke’s Roosevelt Hospital Center
  • Mari-Lynn Drainoni
    • School of Public HealthBoston University
  • Victoria Sharp
    • Center for Comprehensive CareSt. Luke’s Roosevelt Hospital Center
Original Paper

DOI: 10.1007/s10461-007-9254-3

Cite this article as:
Nollen, C., Drainoni, M. & Sharp, V. AIDS Behav (2007) 11: 84. doi:10.1007/s10461-007-9254-3

Abstract

This paper presents lessons learned from an intervention designed to provide HIV prevention counseling within a hospital-based, multidisciplinary HIV clinic. The model, Positive Prevention, used Master’s-level social workers (MSWs) as intervention specialists to minimize burden on primary care providers and to offer a replicable way to provide prevention in a similar setting. The intervention goal was to reduce risk behaviors through Motivational Interviewing, a patient-centered counseling approach with proven success impacting behavioral change.

Implementation experiences offer insight into the challenges of using MSWs as prevention specialists. Particular challenges were related to patient engagement and retention. Experiences early in the implementation process were informative and allowed for adaptations to facilitate a more viable program; however even after executing new strategies, many of the program issues remained. Thus, the Positive Prevention model is not recommended as a best HIV prevention model for replication in similar high-volume, hospital-based, multidisciplinary HIV clinic settings.

Keywords

HIV preventionSpecialist interventionMotivational Interviewing

Background

Rates of the human immunodeficiency virus (HIV) infection remain high well into the third decade of the HIV epidemic (Morbidity and Mortality Weekly Report 2005). Over 70% of people who know their HIV-positive status are sexually active (Crepaz and Marks 2002), and approximately one in three HIV-positive men and women continue to practice risky sexual behaviors (Hankins et al. 2002; Kalichman 2000; Marks et al. 2002).

An estimated 350,000–528,000 individuals with HIV receive regular health care (Morin et al. 2004); therefore, clinical care settings are in a strategic position to improve on HIV prevention (Kalichman et al. 2001; Morin et al. 2004). Studies show that patients remember prevention messages and seek to change behaviors that their primary care providers discuss with them (Butler et al. 1998; Dodge et al. 2001; Eisenberg et al. 2005; Fisher et al. 2006; Kottke et al. 1988; Makadon and Silin 1995; Richardson et al. 2004). However, HIV prevention counseling is not routinely done in most clinics. The low frequency of such services represents missed opportunities for HIV prevention (Morin et al. 2004).

While it is desirable for primary care providers to incorporate prevention services within the primary care visit, it is not often feasible for physicians (and other primary care providers) to deliver all of the preventive services recommended to or required of them (Yarnall et al. 2003). Time is not the only impediment. Other barriers include lack of specialized training, lack of funding for sufficient staffing, and an understanding of their role that is at odds with incorporating prevention into treatment (Metsch et al. 2004; Morin et al. 2004; Yarnall et al. 2003).

In New York, HIV physicians face mounting responsibilities, including state-required screening of patients for domestic violence, psychiatric disorders, and substance abuse/dependence, while at the same time providing primary care, monitoring highly active anti-retroviral medication (HAART), and managing increasingly complex co-morbid conditions. Considerable current HIV prevalence, coupled with opportunities for prevention interventions in primary care settings, has prompted a look for new efforts to address prevention within HIV clinics that may be effective without overburdening primary care providers.

This paper presents a description and some initial lessons learned from an intervention designed to provide HIV prevention counseling within a busy urban, multidisciplinary HIV clinic and to minimize burden on primary care providers. The hope was that the model employed would prove effective within this clinic setting and would also be replicable in similar settings. The lessons learned from implementing the intervention offer some important insight into the challenges of using professionally trained master’s-level social workers (MSWs) as prevention specialists.

Intervention Delivery

Setting for Program Implementation

The Center for Comprehensive Care (CCC) at St Luke’s Roosevelt Hospital Center is a New York City-based Designated AIDS Center. CCC is a full-service HIV/AIDS program serving communities in New York City having high rates of HIV infection. The CCC offers a complete range of multidisciplinary services including primary care, specialty medical services, mental health treatment, case management, dental care, nutrition planning, peer support, and complementary therapies. The CCC has two clinic sites: the Morningside Clinic and the Samuels Clinic. Approximately 2,600 patients access outpatient care at the CCC each year, resulting in over 40,000 visits annually. Data from adults receiving care at the CCC in 2004 indicate that the patient population is about two-thirds male, predominantly from communities of color, with the large majority having annual incomes below the federal poverty level. Almost two-thirds received case management services, and half received mental health treatment during that time.

Intervention Design

In 2003, the CCC was funded under a Health Resources and Services Administration (HRSA) Special Projects of National Significance (SPNS) initiative to develop and test a prevention model in an urban, multidisciplinary care setting. The CCC program, Positive Prevention, used staff social workers trained in motivational interviewing (MI) and considered “intervention specialists” to deliver the intervention.

A variety of approaches are employed by HIV primary care clinics to deliver prevention messages. In the Morin et al. (2004) study of 16 Ryan White-funded clinics in nine states, three approaches to prevention were employed: (a) physician-based, (b) specialist, or (c) multidisciplinary models. Clinics that used the specialist approach to conduct risk assessments and prevention counseling found that specialists, hired especially to address health education and prevention, had more time to spend with patients and were more expert than primary care providers in relevant skills (health education, motivational counseling, or case management). Given the myriad roles and responsibilities of primary care providers at the CCC, a version of the specialist model was chosen.

The Center for Comprehensive Care MSWs were selected to be trained as interventionists in Positive Prevention because they were already trained clinicians with a broad range of counseling and case management skills, and were therefore considered likely to be able to learn and apply MI with relative ease (Bhattacharya 2003). The Positive Prevention model was based on the potential for this group of clinicians to most seamlessly integrate prevention into HIV care within the clinic.

Before implementing the intervention, all social workers received 8 hours of comprehensive MI training, regardless of previous knowledge of or skill in MI. This initial training was followed by 15 additional hours of training during the first year of the intervention. All MI training was delivered by individuals considered expert in MI. The training incorporated a variety of teaching modalities and activities, including lectures, case studies, interactive games, and role-plays. Social workers were also given concrete MI tools and techniques for use with patients. For follow-up trainings, social workers were invited to bring questions and concerns as well as examples of particular challenges they experienced while implementing the intervention. The trainers provided feedback and demonstrated various methods of handling these challenges within the MI framework.

Conceptual Framework

The Positive Prevention program is a secondary HIV prevention intervention using the concepts and techniques of MI (Miller and Rollnick 1991a, b), which is grounded in the Transtheoretical Model of Change (TTM) (Prochaska and DiClemente 1984). MI is a directive, patient-centered style of counseling that elicits behavior change by helping patients explore and resolve ambivalence (Miller and Rollnick 1991a, b). The key tenet of MI is that by examining and resolving their ambivalence about a certain activity or behavior, patients will choose positive behavior change (Miller and Rollnick 2004). At the core of MI is raising awareness of the discrepancy between a person’s goal and his or her actual behavior (Britt et al. 2004). There is substantial evidence that behavioral motivational counseling, one tool of which is MI, works as a prevention strategy (Ehrhardt and Exner 2000; Kalichman et al. 2001; Schreibman and Friedland 2003; Shain et al. 2004). MI has been shown to be particularly effective in healthy behavior change with injecting drug users (Miller and Rollnick 1991a, b) and cigarette smokers (Britt et al. 2004).

One of the foundations of MI is TTM, also known as Stages of Change Theory. TTM is grounded in the belief that behavior change occurs in stages and that individuals work through a series of stages before behavior change is adopted and maintained. The five stages within the TTM model include pre-contemplation, contemplation, preparation for action, action, and maintenance. In TTM, change is a cyclical process, and individuals may move back and forth along the change continuum (Prochaska et al. 1992). Use of the MI approach assists people to become aware of the reasons for their decisions and raises their motivation to move along the change continuum, albeit rarely in a linear fashion. TTM has been applied successfully in many health interventions, such as interventions dedicated to weight control, mammography screening, and reduction of sexually transmitted infections including HIV/AIDS (Centers for Disease Control and Prevention 1993, 2005; Prochaska et al. 1994).

The Positive Prevention program was designed to reduce risk behaviors in a non-judgmental, culturally competent manner. An MI intervention grounded in the concepts of TTM was chosen because it is patient-centered and may be more engaging for a marginalized and highly complex patient population; furthermore, it has been proven successful in impacting behavioral change.

Implementation of the Positive Prevention Intervention

The Positive Prevention program was developed to seamlessly integrate prevention into routine clinical practice by using pre-existing staff commonly employed in comprehensive HIV clinical settings. Due to the myriad support needs of the population, upon enrollment at the CCC, each patient is assigned a social worker whose primary role is to offer case management services, but who also may provide short-term counseling if time permits. In the Positive Prevention program, the assigned social worker was also the interventionist, delivering the MI intervention in addition to responding to case management needs.

Patient recruitment into Positive Prevention was conducted by physician assistants (PAs) in clinic waiting rooms prior to primary care appointments. All HIV-infected primary care patients over age 18 were eligible to participate in Positive Prevention as long as the PA believed they had sufficient cognitive functioning to respond to the survey questions.

Depending on how well they knew the patient, the PA’s assessment of patient ability to participate was based on their long-term knowledge of the patient and/or clinical observation skills.

Each patient who agreed to participate in the program completed a written informed consent document. After giving informed consent, patients completed an Audio Computer Assisted Screening Instrument (ACASI) that focused on HIV risk behavior. Because the Positive Prevention program included a study to test the effectiveness of the intervention, after completing the ACASI survey, patients were randomized into either intervention or control groups (see Fig. 1). Patients randomized into the control group received the CCC’s standard of care, which includes case management by an assigned social worker.
https://static-content.springer.com/image/art%3A10.1007%2Fs10461-007-9254-3/MediaObjects/10461_2007_9254_Fig1_HTML.gif
Fig. 1

Intervention flow

Patients randomized into the intervention group received the MI intervention from their social worker in addition to standard case management services. Because patient engagement is important to encourage study participation, patients were assigned to their pre-existing CCC social worker, with whom they may have already had a relationship, to deliver the intervention. Each intervention patient had a brief social work encounter after completing the baseline ACASI survey. This initial encounter, called “meet and greet,” was intended to be an opportunity for the patient and social worker to discuss the planned intervention visits and address questions about the intervention as well as to process any feelings that may have arisen from taking the ACASI survey. During this brief encounter, the first intervention appointment was also scheduled. As much as possible, the first intervention session was timed to coincide with the patient’s next primary care appointment in order to minimize patient burden and to facilitate participation in both primary care and the Positive Prevention intervention.

The Positive Prevention intervention standard was at least four MI sessions within a 6-month period. This level of intervention was considered the minimum number of sessions required to allow time for patients to move through the stages of change. However, within a patient-centered model such as MI, both the content and number of sessions vary depending on the individual patient. (Sample intervention sessions are detailed in Table 1.)
Table 1

Sample content of intervention sessions

Session 1

Goal: motivate patient for high-risk behavior change

 Objectives

    Set expectations

    Explain motivational interviewing

    Assess risk

    Establish apparent areas of conflict from which to begin clinical work

  Activities

    Describe how patient and social worker relationships will work and what is expected

    Explain rationale of MI treatment

    Provide brief risk assessment

    Select areas of apparent conflict between values, beliefs, and risky sexual behaviors

Session 2

Goal: building commitment to change

  Objectives

    Elicit patient’s perceptions and belief of consequences

    Explore what feels good about risk behavior and what is not good

    Listen and summarize

  Activities

    Reflective listening and summarizing

    Weigh pros and cons; develop discrepancy; decisional balancing

    Explore reasons for wanting/not wanting to change

Session 3

Goal: develop discrepancy; weigh consequences of action and inaction

  Objectives

    Identify discrepancy between personal goals and how drug use interferes with achieving goals

    Consider benefits of change

    Process fear of change

    Review past history to elicit ideas for ways to improve future behavior

Activities

    Make a list of negative consequences of not changing and possible benefits of change

    Generate pros and cons of drug use in balance sheet format

    Conduct self-evaluation

Session 4

Goal: help to confirm and justify the decision to change

Objectives

    Summarize work to date

    Make plan to sustain positive momentum

Activities

    Determine patient’s readiness to consolidate commitment to change

    Review work done in previous sessions (to indicate progress and refresh patient on all of the hard work done already)

Each MI session was designed to address a target risk behavior identified by the patient and was expected to last approximately 30 min. The first MI session typically began with a behavioral risk assessment to elucidate risk behaviors that may not naturally emerge in conversation and to establish a baseline for the clinician. Once this was done, the social worker provided the patient with a menu of target behavior options to help focus the MI sessions. The target behavior options used in the Positive Prevention intervention included (a) sexual risk, (b) drug use risk, (c) difficulty taking HIV medications, (d) feelings about making changes, and (e) impact of relationships on drug use and/or sex life. By including the menu option of discussing feelings about making changes in one’s life, patients were given an opportunity to feel not forced to address HIV risk behaviors directly if they were not ready or willing to do so. Using a form specifically designed for the Positive Prevention intervention, social workers documented the presenting issue(s), previous stage of change, current stage of change, action(s) taken to address target behavior, MI tools and techniques used, and length of MI session.

Qualitative Research to Assess Social Worker Interventionists’ Experiences

The CCC was interested in learning how the Positive Prevention implementation process worked prior to learning about the effectiveness of the program (as indicated by patient outcomes) because a primary goal of the program was to develop a replicable prevention intervention for similarly busy urban HIV clinics; therefore, an external evaluator conducted semi-structured, in-person interviews with each social worker (interventionist) during November 2006. These interviews shed light on social workers’ experiences conducting the Positive Prevention intervention. Results from this qualitative evaluation, coupled with the process experiences of program staff, yield recommendations that follow in subsequent sections.

Using a semi-structured interview protocol, the following issues were addressed with CCC social workers:
  1. 1.

    Social worker background and experience, including reason for working in the HIV field;

     
  2. 2.

    Role in the Positive Prevention program and perceived changes in role and activities after Positive Prevention was implemented;

     
  3. 3.

    Frequency and manner of addressing prevention issues both before and during the Positive Prevention initiative;

     
  4. 4.

    How issues of sexual risk and drug use risk behaviors were addressed, and patient and social worker comfort addressing these issues;

     
  5. 5.

    Experience with the MI training program, examples of using the MI tools and techniques, and types of patients with whom the Positive Prevention intervention appeared successful and not successful;

     
  6. 6.

    Social worker and patient openness and resistance to participating in Positive Prevention and general experiences with the Positive Prevention program;

     
  7. 7.

    Plans for using the MI tools and techniques after the Positive Prevention demonstration is completed;

     
  8. 8.

    Perceptions of the challenges for CCC patients to complete the intervention sessions;

     
  9. 9.

    How serving as the MI interventionist impacted them within CCC; and

     
  10. 10.

    Social workers’ perspectives on the appropriate role of professional social workers in a multidisciplinary HIV clinic.

     
After the interviews were completed, the interview data were analyzed using the Constant Comparative Method (Glaser and Strauss 1967), a grounded theory approach. Using this method, results from the initial interview were coded into categories. Subsequent coding of remaining interviews was used to confirm the initial categories or refine, extend, and modify them to fit the new data from additional interviews. In addition, new categories emerged throughout the coding process. Important issues that emerged from the interviews are highlighted below.

Findings

Population Enrolled in the Intervention and Intervention Activities

As of October 31, 2006, 461 CCC patients had been enrolled in the Positive Prevention program. Of these patients, 231 were assigned to the intervention group and 230 to the control group. Similar to the total CCC patient population, patients in the Positive Prevention intervention group were primarily Black or Hispanic, almost two-thirds male, and mostly poor (on Medicaid). The majority were heterosexual and not married at intake. More than two-thirds had no education beyond the high school level. Most had been infected through sexual activity with an HIV-positive partner. Over 80% had been on HIV medications at some time, but less than two-thirds were currently taking HIV medications. The large majority said that they were sexually active, and although only 11% said that they had more than five sexual partners over the previous 6 months, almost a third had unprotected sex during that time. Almost a third binge drank (five or more drinks per occasion) during the 3 months before enrolling in Positive Prevention, although reports of other drug use were lower. Table 2 provides a demographic and health profile, and Table 3 offers a risk profile of the 231 patients in the intervention group. Data from the ACASI surveys upon enrollment into the Positive Prevention program indicated that the intervention and control groups were similar in terms of demographic, health status, and risk profiles.
Table 2

Demographic and health profile of intervention group patients (n = 231)

Characteristics

N

%

Race/ethnicity

    Black

151

65.4

    Hispanic

57

24.7

    White

17

7.4

    Other

6

2.6

Sex

    Male

140

60.6

    Female

91

39.4

    Transgender

0

0.0

Sexual orientation

    Heterosexual

176

76.2

    Homosexual

34

14.7

    Bisexual

16

6.9

    Other/not sure

5

2.2

Education

    <High school

88

38.1

    H.S. diploma/GED

71

30.7

    Some post-secondary education

53

22.9

    College degree or >

19

8.2

Income

    <$10,000

161

69.7

    $10,001–$20,000

45

19.5

    $20,001–$40,000

20

8.7

    $40,001+

5

2.2

Relationship status

    Single, never married

107

46.3

    Married/domestic partnership

48

19.8

    Committed relationship

18

7.8

    Separated/divorced

45

19.5

    Widowed

13

5.6

    Other

2

0.9

Currently on antiretroviral medications

152

65.8

Ever on antiretroviral medications

190

82.3

Rating of overall health status

    Poor

12

5.2

    Fair

62

26.8

    Good

88

38.1

    Very good

45

19.5

    Excellent

24

10.4

Table 3

Risk profile of positive prevention intervention group patients (n = 231)

Characteristics

N

%

How infected

    Sex with HIV+ man

121

52.4

    Sex with HIV+ woman

59

25.5

    Shared needles

40

17.3

    Blood transfusion

12

5.2

    Needle stick/work

5

2.2

    Sexually active

161

69.7

    Had 5 or more sex partners in past 6 months

18

11.2

    Had unprotected sex past 6 months

51

31.7

    Drank at least weekly during past 3 months

59

25.5

    Binge drank during past 3 months

67

29.0

Drug use past 3 months

    Marijuana

28

12.1

    Crack

22

6.9

    Cocaine

16

6.1

    Heroin

11

4.8

    Injection drug use in past 30 days

6

2.6

During the first 30 months of the intervention period, the eight social worker interventionists administered a total of 574 MI sessions to 186 of the 231 patients enrolled in the Positive Prevention program intervention group. Of the 186 patients receiving MI sessions, 110 completed four sessions, 15 completed three MI sessions, 28 completed only two, and 33 completed only one. The remaining 45 patients in the intervention group had received no MI sessions. The mean session length was 31.7 min (range = 15–60 min). Table 4 shows the frequency of each of the risk behaviors identified by patients and addressed in the intervention sessions. Drug use risk was the target behavior most often selected by patients, followed by feelings about making changes.
Table 4

Risk behavior selected during intervention sessions

Topic/Risk behavior chosen

Number of sessions topic selected (n = 577)a

N

%

Sexual risk behavior

63

10.9

Drug use risk behavior

193

33.4

Feelings about making changes

171

29.6

Impact of relationships on drug use

53

9.2

Medication adherence

91

15.8

Other/provide support to maintain

6

1.1

Total

577a

100

aThere were three sessions in which more than one topic was identified.

Challenges and Lessons Learned

There were several challenges for program staff in implementing the Positive Prevention program. Challenges were related both to some incorrect assumptions about how the intervention would function as an “add-on” to a busy hospital-based clinic and to the reality of carrying out a structured intervention with a highly complex patient population with multiple, competing demands.

The biggest challenge for the Positive Prevention program was engaging and retaining patients in the intervention. The “meet and greet” sessions between patients and social workers did not always occur as expected, either because patients did not remain after completing the ACASI or because social workers were unable to see unscheduled intervention patients immediately after the ACASI due to other pressing issues (commonly experienced by social workers concurrently managing caseloads of up to 250 patients). It is likely that when this engagement opportunity was lost there was a lower probability that patients would return to participate in intervention sessions. Not having had an initial engagement opportunity may be one reason that 19% of intervention patients had no MI sessions.

Even with achievement of the “meet and greet” session, intervention retention challenges remained. As of October 2006, only 59% of patients who had an initial MI session completed the four-session intervention.

Center for Comprehensive Care patients face considerable socioeconomic challenges, and working on HIV transmission risk behaviors was not always a priority for those in the intervention. As conveyed by one CCC social worker, “the CCC patient population is disenfranchised, and this [Positive Prevention program] was not a priority for them.” The ability of patients to adhere to additional appointments beyond those required to obtain their necessary medications and medical care is exacerbated by their co-morbidities such as mental illness, substance abuse, poverty, and complicated family issues, including domestic violence (Bing et al. 2001; Boyle and Goldenberg 2000; Leserman et al. 2000). One social worker aptly pointed out that even though the large majority of patients were open to participating in the intervention, “it was important to deal with the patients’ priorities first. Positive Prevention was a social worker priority, but the issues that we were dealing with in the MI sessions may not have been most important for the patient.”

Although some patients had competing priorities, others reported that they were at low risk for transmitting HIV; therefore, the intervention was not a current priority for them. As one social worker put it, “with Positive Prevention patients, it felt like I had to push [them] to come up with something to discuss and to identify an issue to address.”

Some patients, despite their interest and/or need for the intervention, simply did not understand what the Positive Prevention program was. For patients in the intervention group, Positive Prevention had two components: the ACASI survey and the MI sessions. Frequently social workers found that intervention patients did not understand that they would be asked to attend four MI sessions. Almost every social worker believed that the patients did not understand the behavioral aspect of the intervention even though participating patients signed an informed consent form. According to one social worker who was successful in retaining patients in the intervention, “Many patients did not understand the Positive Prevention program or know that [intervention sessions] were part of a study. They did not connect the surveys to the MI sessions.... It was clearly not well-explained to them in the beginning, and they needed it explained again—after that, most were okay with it.”

Another challenge with retaining patients in the intervention had to do with social workers’ competing demands. Social workers had limited time to conduct targeted outreach to intervention patients to come for follow-up sessions. The responsibility to deliver the intervention and conduct intensive outreach while maintaining a high-intensity caseload was more than some social workers could manage. According to one social worker, “Social workers have too many clients to add Positive Prevention to their caseloads. The workload was unmanageable.” (Social workers who resisted taking on a new responsibility were more vocal than those who embraced taking on a new challenge.) Compounded with social workers’ limited time was the challenge of succeeding in outreach efforts which have limited success with a highly transient and unstable population.

Employing pre-existing staff to carry out a specialized set of tasks and to adhere to an intervention design presumed a level of expertise in MI that proved challenging in practice. According to both the social workers and their supervisors, the social workers had variable skill levels in MI when the intervention began. One social worker had MI expertise and used it often in practice, while two others reported having had some MI training but not having used the method. The majority indicated having had little or no MI training or experience prior to the Positive Prevention program. These various skill levels may have impacted upon social workers’ motivation to implement the intervention with patients, as those with the least skill and experience in MI expressed some resistance to engaging with patients about sensitive issues of risk and prevention.

Social workers within hospital settings are usually viewed by patients primarily as case managers to help them in times of crisis. Social workers in this environment often have less influence over patients than primary care providers do. Despite a slow evolution in the culture of medicine toward the flattening of clinical hierarchy, the “white coat” maintains an influence that may not be emulated by clinical providers of non-medical disciplines (Brandt 2003; Wear 1998). Even when social work visits were coupled with primary care visits, they were scheduled after the primary care visit, and patients often failed to stay for the later appointment. This sequence of scheduling took into account the primary mission of the CCC, which is to provide medical treatment for HIV-positive patients. According to one social worker, “It is sometimes hard to catch [patients] around their medical appointments. They did not want to stay.”

While the provision of incentives may help to keep patients in the clinic for multiple appointments, no incentive was offered to patients to come for MI sessions in the first year of the program due to a concern with providing incentives for participation in clinical activities. (Coupling therapeutic sessions with financial incentives may be viewed by patients as coercive and could disrupt a clinical process grounded in a joint commitment to improve the patient’s health and well-being for its own sake.)

New Strategies Employed Based on Lessons Learned

Upon discovering challenges within the first year of program implementation, strategies to overcome them were put into place. Program managers began to meet at least monthly with the PAs and social workers to discuss their barriers to success, provide feedback on preliminary findings, and brainstorm about ways to improve the project. They also met independently with the social work managers to ask for their support for the project. Social work manager investment in the intervention was gained by incorporating them into the process of finding solutions to intervention challenges.

A number of strategies were put into place to enhance patient engagement and retention.
  1. 1.

    To increase rates of participation in the “meet and greet” sessions after the ACASI assessment, the PA sent a message to the assigned social worker through the electronic medical record system while an intervention patient was in the primary care appointment alerting the social worker that a patient had enrolled and would be ready for a “meet and greet” soon. The social worker then found the patient in the clinic after the primary care appointment and brought him or her to the social worker’s office. This strategy led to immediate and long-term improvement. During the first 10 months of Positive Prevention, less than half of the intervention patients had an MI session within the first month of enrollment. After implementing this procedure, more than 70% had their first session within 30 days of enrollment.

     
  2. 2.

    To encourage patients to stay beyond their primary care visit to attend an MI intervention session, patients were provided with a $4 metro card subsequent to the session. Although offering this incentive for participation in MI sessions was inconsistent with the desire to separate incentives from clinical intervention, the incentive is a small amount that makes a difference to patients and was thought to enhance the likelihood of their return. (Metro cards are routinely given to patients for attending medical appointments.)

     
  3. 3.

    To increase patient understanding of the project, information sheets were created that clearly described the intervention in simple, clear language. The PAs explained to patients what the information sheet said and provided them with a copy.

     
  4. 4.

    To reinforce the message to patients that the intervention was about reducing risk behaviors and was an important part of their health care, social workers provided patients with cards fashioned as “business cards” that included encouraging messages about the value of patient participation in the intervention and a reminder of their next scheduled MI session.

     
  5. 5.

    To assist the social workers with outreach in the hope of improving patient retention in the intervention, a research coordinator was hired. The research coordinator contacted patients in the intervention group to remind them of scheduled MI sessions. This hiring also led to a major change: prior to hiring the research coordinator, the four-session intervention completion rate among eligible intervention patients was approximately 30%; as of the end of October 2006, that rate had increased to 59%.

     
  6. 6.

    To address possible social worker resistance to the intervention related to lack of skills in MI and to increase social workers’ MI competence, ongoing MI training was offered quarterly by a variety of expert MI clinicians. Social workers were invited to bring in situations and examples from the Positive Prevention project to discuss during the training sessions. Several social workers shared success stories with MI since participating in periodic trainings, despite their initial reluctance. One social worker pointed out the benefits of MI in working with patients expressing ambivalence about taking medications: “With decisional balancing, people can see what will happen if they don’t take the meds.” Another reported, “MI helped deal with a ton of resistance that the patient put up. We used the MI tools of looking at pros and cons and at behavioral discrepancies.”

     

Discussion

As described throughout this paper, the Positive Prevention program model presented numerous implementation challenges. Experiences early in the implementation phase of the intervention were informative and allowed for adaptations to facilitate a stronger, more viable program. However, even after executing new strategies to improve the potential for success, many of the program issues remained. Thus, the Positive Prevention model is not recommended as a best HIV prevention model for replication in high-volume, multidisciplinary HIV clinics located within hospital settings.

Two key characteristics of interventionists in typical specialist prevention models are (1) they are hired specifically for the prevention intervention and (2) they are professionals or paraprofessionals with specialized training in delivering prevention interventions, such as health educators or prevention specialists. Positive Prevention diverged from these standard specialist models as it was designed for replicability and ongoing integration into the CCC without requiring additional funding; therefore, the CCC utilized pre-existing staff for this program. While MSWs have advanced clinical training and may be easily trained in MI, they are not, by virtue of their training, necessarily interested or skilled in MI, prevention counseling, or health education.

Working with HIV-positive patients, who frequently have co-morbid medical conditions and a myriad of psychosocial issues, is time-intensive, and additional tasks are not easily added on to any existing job, particularly when the task (a prevention intervention) requires ongoing training and intensive outreach efforts to succeed. In addition to the time needed for service provision, the CCC learned extensive time must also be put into outreach efforts if a patient is to be retained in a prevention intervention conducted by social workers with whom hospital-based clinic patients typically interact only when faced with pressing case management issues. Ideas such as coupling intervention visits with primary care visits are often not effective due to the competing demands on patients’ time and the relatively low priority that prevention issues may have on patients’ hierarchy of copious needs.

For any intervention to succeed, the patients enrolled must understand why they are involved and must be suitable for participation. Despite intensive engagement efforts, including hiring extra staff to assist with outreach and creating informational material to clearly convey the importance and meaning of Positive Prevention, some patients were left with limited or no understanding of why they were participating in the intervention. This speaks to a limitation in the study recruitment procedure, as PAs identified patients by their familiarity with them as well as by using their clinical observation skills. Such ways of assessing individual’s cognitive capacity are incomplete and thereby flawed. Limited patient understanding of Positive Prevention underscores the need for recruitment staff not only to convey the importance of a prevention intervention, but also to use screening instruments to assess patients’ appropriateness, both in terms of risk behaviors and sufficient cognitive capacity for the intervention to be successful.

In spite of the challenges, patients, social workers, and program management staff gained valuable experience from participating in this HRSA SPNS demonstration project. MI is a valuable tool for addressing behavioral issues with patients and facilitating their progressive movement along the Stages of Change continuum. Even if not specifically geared toward prevention issues, periodic training of social work staff in MI was well-accepted and appreciated, and provided social workers with an important skill set for working with patients. As the program evolved and became recognized in the CCC clinics, social worker interventionists recognized that their clinical role in the intervention changed the perception of other clinic staff of their skills and abilities. As one social worker described the benefit of his role in Positive Prevention, “It was a way to do some therapeutic work and give legitimacy to our role as clinicians rather than just as case managers.”

Conclusion

The findings from this attempt to build a specialist-model prevention intervention using existing HIV clinic staff and resources has important implications for incorporating prevention into HIV primary care settings. The challenges faced within the Positive Prevention program are likely not unique to the CCC. While the concerns with using professional social workers in the health education/prevention role have been discussed, a question remains: would primary care providers be better suited to addressing prevention with their HIV-positive patients within a clinical setting like the CCC?

Brief, targeted prevention discussions are recommended to be part of every provider-patient relationship. Studies have shown that doctors have an impact on patients’ behavior change (Dodge et al. 2001; Eisenberg et al. 2005; Fisher et al. 2006; Kottke et al. 1988; Makadon and Silin 1995; Richardson et al. 2004). Moreover, primary care providers within an HIV medical treatment setting have considerably more contacts with patients than clinicians of other disciplines, thus they have more opportunities to provide messages to patients.

How can a “prevention add-on” be mandated to primary care providers’ lengthy list of current responsibilities, particularly given the limited time medical providers have per visit? If it is determined that these activities are the purview of medical staff in a busy, hospital-based HIV clinic setting, it will be critical to take a fresh look at medical providers’ tasks and consider delegating certain responsibilities. For example, nurses may complete medication logs, thus freeing up some time for primary care providers to routinely address prevention with patients. Finally, it is important to note that, even if not serving as interventionists, addressing prevention issues is part of the role and responsibility of all types of providers within an HIV clinic setting.

Acknowledgments

This publication is supported by grant number H97HA01297 from the Health Resources and Services Administration (HRSA) Special Projects of National Significance (SPNS) Program. The publication’s contents are solely the responsibility of the authors and do not necessarily represent the official view of HRSA or the SPNS program.

Copyright information

© Springer Science+Business Media, LLC 2007