Individual and Group Interventions
Health education and risk reduction activities are targeted to reach persons
at increased risk of becoming infected with HIV or, if already infected, of
transmitting the virus to others. The goal of health education and risk
reduction programs is to reduce the risk of these events occurring.
Activities should be directed to persons whose behaviors or personal
circumstances place them at risk. Street and community outreach, risk
reduction counseling, prevention case management, and community-level
intervention have been identified as successful health education and risk
Street and Community Outreach
Street and community outreach can be described as an activity conducted
outside a more traditional, institutional health care setting for the purposes
of providing direct health education and risk reduction services or referrals.
However, before conducting any outreach activity in a community, an agency must
define the specific population to be served and determine their general needs.
Based on this definition and determination, an agency can then decide
appropriately where to conduct intervention efforts. Street and community
outreach may be conducted anywhere from a street corner to a pool hall, from a
parish hall to a school room. To determine the setting, an agency need
only decide that the setting is easily, readily, and regularly accessed by the
designated client population.
Outreach demonstrates an agency's willingness to go to the community rather
than wait for the community to come to it. Often, agencies enlist and
train peer educators to conduct the outreach activities. It is recommended
that the content of the outreach activity be contingent upon the setting. The
nature of activity varies in scope and intensity; the activity is best
determined before an outreach team or individual educator goes out. Yet,
flexibility is also very important. Remember, everything is not
appropriate everywhere, all of the time. A street corner may be an appropriate
place to conduct a brief HIV risk assessment, but it is not an appropriate place
to conduct HIV counseling and testing.
While street and community outreach can be complementary service components
of a single agency, some agencies, based on needs assessment findings and staff
capacity, may choose to provide one service and not the other. Street outreach
and community outreach can also be "stand alone" pieces.
Street outreach commonly involves outreach specialists moving throughout a
particular neighborhood or community to deliver risk reduction information and
materials. The outreach specialist may set up an HIV/AIDS information
table on a street corner. They may supply bleach to injecting drug users
at shooting galleries and condoms to commercial sex workers and their customers
at the hotels or locations that they frequent. The fundamental principle
of street outreach is that the outreach specialist establishes face-to-face
contact with the client to provide HIV/AIDS risk reduction information and
Effective street outreach staff:
- Know the target group's language.
- Have basic training and experience in health education.
- Are sensitive to community norms, values, cultural beliefs, and
- Have a shared identity with the population served, stemming from shared
common personal experiences with the group.
- Are trusted by the group they serve.
- Act as role models to the clients they serve.
- Advocate for the population served.
- Act as liaisons between the community and the agency.
- Are informed about community resources and use them.
Street outreach is not simply moving standard agency operations out onto the
sidewalk. A number of specific issues are unique to the delivery of
services through this type of outreach and must be considered before instituting
a program of street outreach. These matters are usually addressed in an
agency's street outreach program plan and include the following:
- Regular contact among educators, outreach specialists, and supervisors.
- Observation of potential outreach areas to determine the locations, times of
day, and the day of the week that are most productive for reaching the
population to be served.
- A written and comprehensive field safety protocol that is regularly
updated. (See Figure 1.)
- Establishment of and adherence to regular and consistent schedules of
activities, including times and locations. (See Figure 2.)
- A mechanism for measuring the use of referral services.
- Creation and maintenance of a positive relationship between the agency and
the local law enforcement authorities.
- Identification and development of collaborative relationships with
gatekeepers (key informants) in the community.
- Activities for building and earning the trust and respect of the community.
- Descriptions of skills-building exercises relevant to stated program
- Establishment of mechanisms for maintaining client confidentiality.
Community Outreach: Workshops and Presentations
Workshops and presentations are typical activities of community outreach.
Because they usually follow lecture formats, they can be highly structured
health education and risk reduction intervention efforts. While they supply
important opportunities to disseminate HIV/AIDS prevention information, their
impact on behavior change is limited because they are usually single-encounter
experiences. Although they provide crucial technical information that
raises awareness and increases knowledge and may be a critical first step in the
change process, the information alone is usually inadequate to sustain behavior
To maximize their benefit, workshops and presentations should be planned
carefully with knowledge goals and objectives specified before the individual
sessions. To the extent possible, presenters should be informed about the
setting where the workshop or presentation will take place, as well as the
composition and knowledge level of the anticipated audience. The following are
examples of issues the presenter might consider before conducting a presentation
- Where will the workshop or presentation be held?
- What is the age range of the participants/audience?
- What is the language(s) of the participants/audience?
- What audiovisual equipment is available?
A well-planned, detailed outline, which allows flexibility, can prove useful
and beneficial to the presenter and the participants/audience. Such an
outline helps keep the presentation on track and focused. If a pretest
evaluation is to be used, an outline can ensure that all relevant material will
be covered in the lecture.
In a workshop or presentation, audience participation is to be strongly
encouraged. Time must be allotted, usually at the end of the presentation, for a
question and answer session. However, some questions may be so pressing, or some
participants so persistent, that the presenter will have to address some
questions and concerns during the presentation. The presenter should answer the
questions succinctly and return to the original order of the presentation.
To increase the number of workshops and presentations they are able to
provide, some agencies will elect to develop speaker's bureaus to augment their
paid staff. Recruitment, training, and retention of volunteers present
complex programmatic questions and are not to be undertaken lightly.
Several references related to volunteers are provided at the end of this
document and should be reviewed carefully.
A more detailed list of important points to consider for workshops and
presentations is contained in Appendix C. The points below are relevant to
agencies providing workshops and presentations either by paid staff or by
volunteers in a speaker's bureaus. Effective presenters:
- Possess organizational and public speaking skills.
- Are well informed and comfortable talking about the subject.
- Ensure that the presentation is linguistically appropriate for the
- Elicit and encourage audience participation.
- Are adaptable to logistics and audience needs.
- Are non-judgmental.
- Assess the nature of questions to make appropriate responses, i.e.,
whether better answered in private.
- Seek accurate answers to difficult questions and provide information in
a timely manner.
A few items specifically needed in a Community Outreach Program Plan are
- A comprehensive workshop/presentation curriculum. (See
- Assurance that curricula provide for discussion of related issues.
- Detailed workshop/presentation outlines.
- Logistical guidance for workshops/presentations (e.g., time and
location, room arrangement, number of participants, number of facilitators).
- Methods to assure that the audience is informed about
workshop/presentation goals and objectives and that discussion of subject
matter is facilitated.
- Descriptions of skills-building exercises relevant to stated program
- Training in the operation of audiovisual equipment and the use of
diverse forms of audiovisual equipment.
- Recruitment of staff with organizational and public speaking skills.
Agencies that provide street and community outreach will frequently engage
peer educators to conduct intervention activities. Peer education implies a
role-model method of education in which trained, self-identified members of the
client population provide HIV/AIDS education to their behavioral peers. This
method provides an opportunity for individuals to perceive themselves as
empowered by helping persons in their communities and social networks, thus
supporting their own health enhancing practices. At the same time, the use of
peer educators sustains intervention efforts in the community long after the
professional service providers are gone.
Effective peer educators:
- Have a shared identity with the targeted community or group.
- Are within the same age range as the targeted community or group.
- Speak the same "language" as the community or group.
- Are familiar with the group's cultural nuances and are able to convey
these norms and values to the agency.
- Act as an advocate, serving as a liaison between the agency and the
targeted community or group.
Peer education can be very powerful, if it is applied appropriately.
The peer educator not only teaches a desired risk reduction practice but s/he
also models it. Peer educators demonstrate behaviors that can influence
the community norms in order to promote HIV/AIDS risk reduction within their
networks. They are better able to inspire and encourage their peers to
adopt health seeking behaviors because they are able to share common weaknesses,
strengths, and experiences.
Agencies often recruit and train peer educators from among their client
populations. However, not everyone is an educator. The model client
does not necessarily make the model teacher, no matter how consistently s/he
practices HIV/AIDS risk reduction or is liked by agency staff. Peer
educators should be instinctive communicators. They should be empathetic
and non-judgmental. They should also be committed to client
Peer educators will not replace an agency's professional health educators,
but they can complement the intervention team and enhance intervention efforts.
Peer educators may act as support group leaders or street outreach volunteers
who distribute materials to friends. They may be members of an agency's
speaker's bureau and give workshop presentations.
They may run shooting galleries, keeping bleach and clean water readily
available to other (IDUs). They may be at-risk adolescents who model
responsible sexual behaviors. The role of the peer educator is determined
by the intervention need of the client population and the skill of the peer
Although some agencies will hire peer educators as paid staff, others will
not. As in the case of speaker's bureaus, engaging volunteer peer
educators also involves issues of volunteer recruitment, training, and
retention. Several references in the list of publications included at the
end of this document provide more information on this issue. In addition
to the core elements identified for health education and risk reduction
activities, an effective peer education program plan contains the following:
- A written and comprehensive field safety protocol. (See
- Establishment of and adherence to regular and consistent schedules of
activities, including times and locations. (See
- A description of skills-building exercises relevant to the stated
Risk Reduction Counseling
The purpose of risk reduction
counseling is to provide counseling and health education interventions to
persons who are at high risk for HIV infection. The interventions promote and
reinforce safe behavior. The participants may range from a single individual to
couples, families, groups, or entire communities.
Risk reduction counseling is interactive. Such counseling assists clients in
building the skills and abilities to implement behavior change. These programs
offer training in the interpersonal skills needed to negotiate and sustain
appropriate behavior changes. For example, sessions could concentrate on
delaying the initiation of sexual activity, on methods for avoiding unsafe sex
and negotiating safer sex, and on techniques to avoid sharing injecting drug
paraphernalia. Risk reduction may be implemented in a variety of formats.
The interventions may take the form of role plays, safer sex games, small group
discussion, individual counseling, or group counseling.
Effective risk reduction counseling sessions:
- Emphasize confidentiality.
- Begin with an assessment of the specific HIV/STD prevention needs of the
- Identify, with the group or individual, the appropriate goals/objectives
(e.g., condom use negotiation skills for female sex partners of IDUs).
- Use skills-building exercises designed to meet the specific needs of the
- Include negotiations with the client(s) on suggestions and
recommendations for changing and sustaining behavior change as appropriate
to their situation.
- Enable/motivate participants to initiate/maintain behavior change
- Enhance abilities of the participant(s) to access appropriate services
(e.g., referrals to drug treatment).
Risk Reduction Program Plans
An effective risk reduction program plan includes the following:
- Protocols and procedures specific to each activity and logistical check
lists for implementation.
- Development of innovative behavior modification strategies.
- Provision for regular updates in techniques for skills building.
- Provisions for updates on client-focused approaches to risk reduction
- Provision for updates in techniques for increasing facilitators' skills
in managing group or one-on-one dynamics.
Groups can provide significant informational and therapeutic HIV risk
reduction interventions to individuals who are ready to initiate and/or maintain
specific health promoting behaviors. Groups are usually formed around common
issues or problems. Some groups, originally established to provide information
and skills training, may evolve into support groups, which encourage maintenance
of newly acquired behaviors. Utilizing groups suggests a systems approach to
intervention. Groups provide access to social networks that enable and reinforce
health enhancing behavior change through peer modeling and peer support.
Although open-ended groups (e.g., support groups) may have less structure
than the more close-ended kinds of groups (e.g., educational or
skills-building), both types should have clearly defined goals/objectives and
specifically defined processes. The structure of a group should be determined
based upon the needs of the members.
At times, the open-ended group with its open enrollment and extended life is
more suited to members' needs. By being open-ended, potential members are able
to drop in when they need to and thus avoid the wait for new groups to form.
This type of group is likely to appeal to the individual whose commitment to the
group's process is initially limited. In the open-ended group, members determine
their own topic of discussion at each meeting. For this reason, an open-ended
model, that encourages drop-ins, is perhaps less amenable to instructional
sessions which usually need to build on information presented at earlier
meetings. The open model, because of its unpredictable structure and enrollment,
may be more amenable to process evaluation (i.e., percentage of agency's clients
attending a determined number of sessions).
The close-ended model will have a defined lifespan and is also likely to set
membership limits. The closed group allows for important continuity and
facilitating the development of trust among members, as they get to know each
other over time. Members can expect the same individuals to be present each
week, which can aid in building significant, supportive relationships. The
closed group model is more suitable to the establishment of client-specific
outcome objectives that can be monitored over time (i.e., self-reported
reduction in number of sex partners at the end of 8 weeks of group attendance).
There are significant advantages to both open and closed models, and
determination of which model to employ is based on the needs of an agency's
clients and on an agency's capacity to implement the model. Whatever the model
selected, the size of the group is an important consideration. Group
facilitation is not crowd control. Smaller groups can be more manageable and
result in enhanced group dynamics.
Group facilitators or instructors may
be peers or professionals; in some instances, they may be both. They should be
skilled at promoting effective group dynamics, encouraging reticent members to
speak up and guiding the dominant ones. Skilled facilitators and instructors are
astute observers. They not only listen to what is being said, but they also note
nonverbal cues. Good observation skills are especially critical for support or
therapeutic group facilitators. Skilled facilitators and instructors are able to
see changes in body language, hear sighs, and catch subtle changes in facial
Groups are a naturally occurring phenomenon. People come together for a
variety of reasons and left to themselves, they will develop informal but
powerful supportive networks. Proactive HIV risk reduction programs can tap into
this resource and enhance program effectiveness.
HIV Prevention Case Management
HIV Prevention Case Management (PCM) is a one-on-one client service designed
to assist both uninfected persons and those living with HIV. PCM provides
intensive, individualized support and prevention counseling to assist persons to
remain seronegative or to reduce the risk for HIV transmission to others by
those who are seropositive. PCM is intended for persons who are having or who
are likely to have difficulty initiating and sustaining safer behavior. The
client's participation is always voluntary, and services are provided with the
client's informed consent.
Prevention Case Management involves the assessment of HIV risk behavior and
the assessment of other psychosocial and health service needs in order to
provide risk reduction counseling and to assure psychosocial and medical
referrals, such as housing, drug treatment, and other health and social
services. PCM provides an ongoing, sustained relationship with the client in
order to assure multiple-session HIV risk reduction counseling and access to
service referrals. PCM should not duplicate Ryan White CARE Act case
management services for persons living with HIV.
Case managers work with clients to assess their HIV risk and psychosocial and
medical needs, develop a plan for meeting those needs, facilitate the
implementation of the PCM plan through referral and follow-up, provide ongoing
HIV risk-reduction counseling, and advocate on behalf of the client to obtain
services. HIV Prevention Case Management creates bridges to assist clients in
obtaining services with which they are unfamiliar or that pose special barriers
to access. Clients are active participants in developing their PCM plan for risk
reduction. Prevention Case Management may be carried out in a variety of
settings, including the client's home, a community-based organization's office
or storefront, clinics, or institutional settings.
Referral services may include HIV counseling and testing services (CT),
psychosocial assessment and care, other HIV health education and risk reduction
programs, medical evaluation and treatment, legal assistance, substance abuse
treatment, crisis intervention, and housing and food assistance. Additionally,
HIV PCM services should assist the client in obtaining STD prevention and
treatment services, women's health services, TB testing and treatment, and other
primary health care services. A strong relationship with STD clinics, TB testing
sites, HIV counseling and testing clinics, and other health service agencies may
be extremely beneficial to successfully recruiting persons at high risk who are
appropriate for this type of intervention. PCM services are not intended as
substitutes for medical case management, extended social services, or long-term
The case manager needs a thorough knowledge of available community social and
medical services as well as HIV prevention, treatment, and related services.
This includes specific knowledge of the scope of services available, the
protocol for accessing these services, and contact persons working with local
agencies. Case managers are usually skilled in providing individual or couples'
HIV risk-reduction counseling on an ongoing basis. Case managers usually
have an academic background or special training in psychosocial assessment and
counseling (e.g., social work, drug and alcohol treatment counseling, nursing,
health education). Prevention Case Management supervisors need the academic
training and/or experience to adequately develop PCM protocols, case
documentation, and policies. The following provides further information on
counseling and testing issues: HIV Counseling, Testing, and Referral:
Standards and Guidelines, U.S. Department of Health and Human Services, Public
Health Service, Centers for Disease Control and Prevention, May 1994.
Staff Characteristics of the Prevention Case Manager
Effective case managers are:
- Non-judgmental in addressing the needs of the client.
- Empathetic and critical listeners.
- Skilled in dispute mediation.
- Skilled in individual and relationship counseling.
- Skilled in conducting a thorough behavioral risk assessment and
psychosocial assessment at client intake and skilled in developing an
individualized case plan.
- Comfortable working in the home environments of their clients as well as
in street settings, if necessary.
- Continually concerned about the protection of the client's rights,
including confidentiality, and always respectful of guidelines in the agency
- Sensitive to the client's ability to read literature and comprehend oral
- Responsive to the financial resources of clients in regard to case
planning and referrals.
Additionally, case managers:
- Maintain communication with case managers from other agencies working
with the client to assure a coordinated treatment plan.
- Identify resources and services for the client and assist them in accessing
- Take into account and provide for cognitive impairments that may be
related to the health status of the client.
- Reinforce behavioral change accomplished by the client at all opportunities.
- Troubleshoot episodes of client's unsafe behavior and relapse to
identify barriers to practicing safer behavior and provide support and
- Establish a rapport with clients and maintain open communication with them
and their partner(s).
- Act as an advocate in gaining access to services for clients.
Characteristics of the Prevention Case Management Program Plan:
- Includes specific, measurable, realistic, and time-phased program
- Assures that all services in the plan conform to agency policies and local,
state, and Federal laws (for example, confidentiality of information).
- Assures the development of a written, formal PCM protocol for service
- Provides for the development of specific, measurable, realistic, and
time-phased objectives in each client's case plan.
- Provides for regular meetings with each client to assess changing needs,
monitor progress, and revise the service plan accordingly.
- Assures that each case manager negotiates a risk reduction plan with the
client, referring to the plan at each session in order to assess progress.
- Assures the development and use of a comprehensive HIV risk assessment
instrument to assess the behavioral variables influencing the client's risk
- Assures the development and use of a comprehensive psychosocial assessment
instrument to assess psychosocial and medical service needs of the client as
well as financial resources, language preferences, barriers to accessing these
- Assures that prevention case managers and their supervisors meet
frequently for case presentations and supervision.
- Defines collaboration with other local service providers through memoranda
of agreement and regular meetings between agencies to facilitate access to other
social and health services as well as to discuss and coordinate treatment plans
for individual clients.
- Assures that the memoranda of understanding among agencies are
periodically updated, accurately reflecting collaborative activities.
- Assures that the assessment of progress in meeting the case plan is
communicated to the client for review and comment.
- Assures that case records include documentation that acknowledges
voluntary client participation and mutually satisfactory case plans.
- Assures that an updated written or computerized database of service
referrals and a system for documenting successful referrals are maintained.
- Assures that regularly scheduled staff meetings are held to discuss
challenges, successes, and barriers encountered by case managers; adequate time
must be allocated for staff to share concerns, frustrations, grief, and other
emotions experienced through the close work with persons at risk or with persons
living with HIV.
PCM staff training plans usually include the following:
- Staff training in established PCM protocols, agency policies, and
- Periodic training addressing the local services available for client
- Skills training to improve the HIV risk reduction counseling provided to
- Training that addresses how to effectively intervene with clients who
are in extreme states, such as persons who are combative, in emotional
crisis, mentally ill, or under the influence of drugs and/or alcohol.
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