Ask, Screen, Intervene 4 Cities Project

FTCC MeetingApril 25, 2012

ASI Session Outline

• Efficacy of HIV prevention in clinical care settings

• ASI Curriculum Overview• ASI Project Overview• Panel: Implementation Experience

National HIV/AIDS Strategy

National HIV/AIDS Strategy. http://www.whitehouse.gov/administration/eop/onap/nhas

Vision for the National HIV/AIDS Strategy “The United States will become a place where new HIV infections are rare and when they do occur, every person, regardless of age, gender, race/ethnicity, sexual orientation, gender identity or socio-economic circumstance, will have unfettered access to high quality, life-extending care, free from stigma and discrimination.”

New CDC High-Impact HIV Prevention Plan

GOAL: to maximize impact of prevention efforts for persons at risk for HIV infection: gay and bisexual men, communities of color, women, injection drug users, transgender women and men, and youth. •Use combinations of scientifically proven, cost-effective, and scalable interventions•Target the right populations in the right geographic areas CDC, High-impact HIV prevention: CDC’s approach

to reducing HIV infections in the United States, 2011.http://www.cdc.gov/hiv/strategy/hihp

Overview of High-Impact Prevention Strategies

PREVENTION WITH POSITIVESHIV testing

Linkage to careART

Retention in careAdherence

STD screening and treatmentRisk reduction interventions

Partner servicesPerinatal transmission

intervention

PREVENTION WITH NEGATIVES

Risk reduction interventionsCondoms

PrEPPEP

Needle exchangeMale circumcision

Microbicdes STD screening and

treatment

SEROSTATUS NEUTRALSocial mobilizationCondom availability

Needle/syringe servicesSubstance use, mental health and

social support

Challenge of HIV Impact HIV Prevention

Spectrum of

Engagement

in HIV Care in

the U.S.

Only 19% of

HIV+ are

adequately

managed

Gardner et al. 2011 Clinical Infect Dis

HIV/STD Prevention in Care Settings

• Prevention paradigm shift– Seronegative to seropositive

• Emerging evidence that provider-based prevention efforts are effective in reducing behaviors

• Opportunity for reinforced dialogue in the care setting

HIV/STD Prevention in Care Settings (cont.)

• Provider concerns about HIV transmission does not “translate into action” without specific messaging

• Prevention discussions in clinical settings require that providers adjust their clinical routine and philosophy

Ask, Screen, Intervene

• Developed in 2004-2005 as a collaboration between the NNPTC and AETC based on 2003 Consensus Recommendations

• Aim: Assist HIV care providers in learning new techniques to incorporate important intervention methods to help their patients reduce risk behaviors

• Target audience is HIV clinical providers

Curriculum Implementation

• 10/2007-12/2010 NNPTC delivered ASI at 137 sites to over 2,567 participants.

• To leverage resources and promote sustainability the NNPTC developed a collaborative model:– 96.4% trainings had at least 1 collaborative

partner– 48% of trainings were collaborations with AETCs

ASI Curriculum• Module 1: Risk Assessment & Screening for

STDs– Rationale for HIV prevention as routine part of HIV care– Elements of brief risk assessment– Screening for STDs in HIV care

• Module 2: Prevention Interventions– Brief risk reduction counseling– Referrals for more intense prevention interventions and

other support services• Module 3: Partner Services– Importance of Partner Services (PS) in relation to HIV– Referrals to PS through state and local HD

• Skills practice sessions• Short demonstration videos• Question and answer time with local PS

representative for local reporting requirements & PS program guidelines

• Handouts and job aids

Curriculum Includes Interactive Components

Effective Prevention In HIV care:A Replication of

Ask, Screen, Intervene (ASI) (2011-2013)

Project Overview• MAI-funded project through HRSA HAB– Supports National HIV/AIDS Strategy goals

• Began Fall 2011, 2 year project• Collaborators– HRSA HAB, DSP and DTTA– CDC– 4 regional AETCs and 4 PTCs– National Resource Center for NNPTCs– AETC National Resource Center– AETC National Evaluation Center– 8 Ryan White Part C clinics/FQHCs in 4 cities

4 Cities and Clinics1. Baltimore

– Chase Braxton Health Services– Total Health Care, Inc. (10 sites)

2. Chicago– Access Community Health Network– Erie Family Health Center, Inc.– Heartland Health Outreach, Inc.

3. Los Angeles– Alta Med Health Services Corporation

4. Miami– Jessie Trice Community Health Center, Inc.– Miami Beach Community Health Center

Selected based on ECHPP

designation and

application review

Project ObjectivesEnhance clinician ability to conduct effective risk

screening, conduct prevention counseling, and refer for services

Increase the number of HIV-positive persons who receive information about transmission risks and regularly receive risk reduction counseling

Increase the number of HIV-positive persons who are screened for STDs

Assist in strengthening linkages to referral services

Project Activities• Planning & Implementation (Fall 2011/Winter

2012)– Kick-off calls with all collaborators (facilitated by HRSA HAB)– TOT and planning meeting in Baltimore (January 2012) for

AETCs/PTCs (planned and facilitated by NRCs)– Introductory meetings and needs assessments with clinics

(initiated by TCs)• Training & Ongoing Technical Assistance

(Spring 2012 )– Tailor to clinic needs– Use 2012 curriculum and related materials– Project coordinator in the clinic to help facilitate and monitor

Project Activities (cont.)• Assessment & Evaluation (Spring 2012 )– Training level• NNPTCs and AETCs

– Program level (feasibility, fidelity, impact)• AETC National Evaluation Center

ASI Program Evaluation• Goals for the program evaluation are to assess the:– Feasibility or process– Fidelity or outcomes – Impact of implementation of the project

• Mixed-methods evaluation (qualitative and quantitative) • Methods will be tailored to each participating clinic• Evaluation will be done collaboratively by HAB, the AETC NEC

and participating clinics• Note: Program evaluation is distinct from training evaluation

for this project Myers, Malitz, & Maiorana, 2012

ASI Program Evaluation Aims• Feasibility or Process Evaluation:

– To assess the barriers and facilitators to implementation (lessons learned and also quality assurance during implementation)

• Fidelity or Outcome Evaluation: – To assess the extent to which ASI be successfully integrated into

existing clinical settings• Impact Evaluation:

– To assess changes in patients’ reported transmission risk (patient impact)

– To assess changes in STI screening (provider impact)– To assess clinic staff knowledge of ASI procedures (clinic impact)

Myers, Malitz, & Maiorana, 2012

ASI Program Evaluation Methods

Data Sources

Evaluation Question TypeProcess/

FeasibilityOutcome/

FidelityImpact

Qualitative Data: In-depth Interviews with Staff √ √ (Clinic) In-Depth Interviews with Trainers

√

Site visits/Observations √ Secondary data analysis √Quantitative Data: RSR Data Extraction √ √ √ (Provider)

Risk screening tool √ √ (Clinic & Provider)

Patient Exit Interviews √ √ (Patient)Myers, Malitz, & Maiorana, 2012

Panel: Implementation Experiences

• Los Angeles, CA: Mona Bernstein, MPH• Chicago, IL: Dodie Rother, MPH• Miami, FL: Jonathan Drewry, MPH, DrPH(c)• Baltimore, MD: Linda Frank, PhD, MSN, ACRN,

FAANImplementation experience

Working with community health centersSuccesses and barriers to date

Conclusions• Research shows prevention counseling is more likely

to occur if the provider feels more confident to initiate prevention discussions

• Continuous revisions are needed to keep the curriculum current and relevant to providers needs

• Project compliments and enhances partnerships between AETCs and PTCs

• Opportunity to assess feasibility of implementing federal guidelines in clinical settings

Questions

• Helen Burnside, NNPTC NRC: Helen.Burnside@dhha.org

303-602-3605• Jamie Steiger, AETC NRC:

steigejl@umdnj.edu 973-972-9646