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Overview
The Prevention Case Management (PCM) for Persons Living with HIV/AIDS Demonstration Project meets strategy three of the Advancing HIV Prevention (AHP) Initiative: preventing new infections by working with persons diagnosed with HIV and with their partners. PCM is a client-centered HIV prevention activity that combines HIV risk-reduction counseling and traditional case management to provide intensive, ongoing, individualized prevention counseling and support. Nine community-based organizations (CBOs) across the country are collaborating on and participating in this demonstration project. (See the program overviews below for names and locations of the collaborating CBOs.) These CBOs are funded to provide specialized assistance, through PCM, to HIV-positive persons with multiple and complex HIV risk-reduction needs. During the 2-year funding period (October 2003—September 2005), participating CBOs are required to provide PCM to 80–100 clients.
Eligibility criteria for client participation require the client to report “risk behavior” and be willing to address these risks with the prevention case manager. Risk behavior is defined for the AHP-PCM Demonstration Project to include reporting one of the following behaviors or diagnoses in the past 3 months: unprotected sex; sex with an HIV-negative or unknown status person; sex with an injection drug user; sex with someone before disclosing HIV status; sex while drunk or high; sharing injection drug use paraphernalia or syringes; diagnosis of a sexually transmitted disease (STD); exchanging sex for money, drugs, or shelter; and trouble adhering to prescribed HIV medication regimen. Because these eligibility criteria are so broad, the staff at some of the collaborating agencies thought that too many of their clients would be eligible for PCM. Thus, a few agencies are requiring that clients report two or three of these risk behaviors to be eligible for PCM.
CDC recognizes that local circumstances, needs, and mechanics of PCM activities may vary among the CBOs funded to participate in this demonstration project. However, when implementing activities, sites are expected to adhere to the core components and procedures outlined in the
HIV Prevention Case Management: Guidance (1997), the Advancing HIV
Prevention: Interim Technical Guidance for Selected Interventions
(2003), and the Procedural Guidance for Selected Strategies and
Interventions for Community-Based Organizations (2003). In addition, CDC staff members developed a procedures manual for this demonstration project to further assist sites in developing individualized implementation plans. All sites have agreed to submit client-level data to CDC in a CDC-developed Access database. Client-administered evaluation using a CDC-developed A-CASI (Audio-Computer Assisted Self Interviewing) program is conducted at baseline and every 3 months thereafter until the client is discharged from PCM.
Goals
The goals of this project are to
- provide specialized, individually tailored assistance to persons with multiple and complex HIV risk-reduction needs
- provide individualized, multiple-session HIV risk-reduction counseling to help initiate and maintain behavior change to prevent transmission or acquisition of HIV
- assess risks of other STDs and ensure appropriate diagnosis and adequate treatment
- facilitate referral services for clients' medical and psychosocial needs that affect their health and ability to change HIV-related risk-taking behavior.
Collaborator Projects
Philadelphia, Pennsylvania: Action AIDS will recruit 80–100 PCM clients from the existing pool of 3,500 persons with HIV/AIDS served by the agency, from social networks, and from referrals by the city health department and other AIDS service organizations. In 2003, 1,800 adults received HIV case management from Action AIDS. Of these 1,800 persons, 68% were African American, 9% were Latino, and 23% were white or other. Nearly 38% of clients served were women, and 18% were children and youth. Action AIDS has established consultative monthly meetings with Mazzoni Center, another Philadelphia CBO participating in the PCM demonstration project, to collaborate and share information about delivery of PCM.
Los Angeles, California: Bienestar will recruit PCM clients in-house by screening all of its current HIV-positive clients. All new HIV-positive clients will be screened as they enroll in counseling and testing, Ryan White case management, Self Help, and other prevention programs for HIV-positive clients. To be eligible for program participation, clients must meet at least three of the risk screening eligibility criteria described previously. Most of Bienestar’s clients are Hispanic and speak little or no English. Prevention counselors are proficient in Spanish. Incentives, including gift and movie certificates, will be offered for program participation. Because most of Bienestar’s clients are Hispanic, CDC has provided a Spanish-language version of the A-CASI survey.
Detroit, Michigan: CHAG (Community Health Awareness Group)
clients who are already in Ryan White case management will be referred to PCM after initial screening by a case manager. Referral of clients to either Ryan White or PCM will be conducted by outreach workers when they deliver a positive HIV test result. All referrals for PCM will be drawn from existing CHAG programs. Main referral sources include the agency itself; support groups; needle exchange sites; current outreach sites for the state; CDC for outreach and counseling, testing, and referral (CTR); current sites for institutional outreach; and sites for all rapid testing initiatives. In addition to CDC eligibility screening (see above under “Overview” for details), CHAG implements a screening survey required by the state. The purpose of the survey is to assess readiness for
change. Individual counseling is done in the client’s home whenever possible. Group counseling occurs in the CHAG office.
Boston, Massachussetts: Health Services Partnership (HSP) of
Dorchester PCM clients will be primarily recruited from an existing pool of HIV/AIDS clients currently receiving Ryan White Title I case management. Recruitment will be conducted by both clinical and prevention case managers. In addition, HSP of Dorchester staff members can internally refer eligible clients for PCM from other departments. Further, social marketing of PCM services to community-based social services organizations will bring HSP of Dorchester referrals from external sources. PCM
services will be delivered from the HIV/AIDS Program offices at the
Dorchester House and Codman Square Health Centers. Dorchester House clients
are predominantly Hispanic and Vietnamese. On-site translators will be
available to aid prevention counselors in providing services to these
minority populations. Clients will be offered an incentive of $15 for
completing the ACASI assessments.
New York City, New York: Harlem United’s PCM program, called The Next Step, will provide PCM to 150 clients in year one and 200 clients in year two, with staff caseloads of 25 clients. Clients will be recruited through outreach to various venues; from social, sexual, or needle-sharing networks of PCM program clients; and from the existing pool of clients within the agency. The program will use incentives including Metrocards, t-shirts, hygiene kits, and food vouchers to encourage eligible clients to enroll in the program. Case management technicians (CMTs) will screen potential clients, and, if eligible, clients will be referred to the prevention counselor. Harlem United offers a broad variety of on-site medical, housing, prevention, and social services for people living with HIV, and program staff will be able to link clients to services within the agency. For services not available on site, the program will include referrals to qualified providers from the agency’s broad referral network.
Baltimore, Maryland: HERO’s Ryan White case managers and the prevention counselor will work together as a team to coordinate clients’ needs. Most referrals into PCM will come from in-house Ryan White case managers. Other referrals will come through new client intakes. When a new client comes into HERO, an intake worker will provide an intake assessment of all client needs. The intake worker will make referrals to PCM when appropriate. To incorporate the PCM program into this intake system, HERO integrated questions related to clients’ transmission risk behavior into the intake assessment. All clients who indicate risky behavior will be referred to the PCM project coordinator for an official eligibility screening and, if appropriate, referred to prevention counselors. (See “Overview” above for a list of eligibility criteria.)
Kansas City, Missouri: Kansas City Free Health Clinic (KCFC) will recruit 80–100 HIV-infected minority clients to participate in PCM over the 24-month project period. The primary source of recruitment will be KCFC’s existing pool of more than 400 HIV-infected clients as well as new clients entering services at the clinic. A team of clinical and nonclinical staff at KCFC conducts weekly case conferencing on all HIV-infected clients admitted to the agency. This will enable them to identify clients eligible for PCM. KCFC provides more than 25,000 patient encounters annually in general medicine, mental health, dental, HIV primary care, Ryan White case management, and diagnostic services and reaches more than 40,000 people annually with outreach/prevention services. Currently, one substance abuse case manager serves clients having substance abuse and HIV issues. To monitor the long-term impact of PCM, KCFC plans to continue to do A-CASI-based evaluation of clients for one year. This includes clients discharged from PCM as long as they remain in KCFC’s service.
Philadelphia, Pennsylvania: Mazzoni Center is the main service provider to Lesbian, Gay, Bisexual, and Transgender (LGBT) communities in Philadelphia. The objective is to provide at least 4 sessions of comprehensive PCM to 50–80 clients during each contract year. Recruitment to PCM will initially be among those seeking services at the agency. Mazzoni Center offers a full array of services including HIV counseling and testing, prevention case management, HIV case management, primary medical care (including HIV care), food bank services, mental health services, and addiction services. Mazzoni Center serves the community through a staff of 60 professionals and provides services at 10 sites throughout Philadelphia. The agency reaches more than 30,000 persons per year. Mazzoni Center will use CDC-developed Access and A-CASI data collection instruments
Washington, District of Columbia: Whitman-Walker Clinic (WWC) will screen 138 high-risk clients and enroll 108 clients in PCM over the 2-year contract period. The main source of recruitment will be from an existing pool of more than 7,000 clients served by the agency. More than half of WWC’s total client base is Black/African American (53%), followed by 30% White (non-Latino), 8% Latino, 4% African, and 5% other. At WWC, 90% of clients are below the 2003 Department of Health and Human Services federal poverty level. Additional recruitment sources include the Social Networking Project and direct referrals from other AIDS service organizations. During its 30 years of development, WWC has evolved as a comprehensive HIV/AIDS care provider. Services provided include medical, behavioral health, social, and other supportive services. WWC has an information technology department and computer network system network in place that allows case workers to log on to client files while conducting outreach.
Project Milestones
- Research Funding Announcement developed: April 2003
- Interim Technical Guidance for Grantees published: July 2003
- Contractors selected: August 2003
- Investigator meetings held: November 2003
- Computerized data collection instruments developed: October 2003-May 2004
- Site visit to each collaborating CBO: December 2003
- Multi-site training on PCM for case managers: January 2004
Training on PCM data collection instruments: April 2004
- PCM implementation began: April 2004
PCM data collection tools implemented: June 2004
- Supplemental risk-reduction training for prevention case managers: October 2004
Data Collection
PCM begins with screening potential participants for eligibility, and data for all screened clients are retained. For those determined eligible who choose to participate in the program, the PCM case manager collects data on demographics, sexual and drug use risk behaviors, STDs, AIDS-related illness, mental health, treatment planning and outcome, and referral planning and outcome. These data are recorded as part of the initial assessment, and additional data are collected at each follow-up visit, as appropriate. This information is entered into an Access database. For program monitoring and evaluation, the client provides data using a self-interviewing computer-assisted system at baseline and at 3-month intervals for as long as he or she is enrolled in the program. To improve the reporting of potentially stigmatizing behaviors, the client enters these data in a private setting and does not share them with the PCM case manager. Participating sites submit both Access and A-CASI data to CDC at least monthly via a secured data network. Data collection for all 9 projects was completed by May 2006.
Results to Date
During the 2-year funding period of this project, a total of 900 people were screened for Prevention Case Management. Approximately 80% (n=720) of persons screened were eligible for PCM, and two thirds (n=475) of eligible clients decided to enroll. Clients who enrolled identified their racial/ethnic backgrounds as Black (64.0%), Hispanic (24.4%), White (7.8%) and Other (3.6%). Clients were primarily male (72.8%) and the average age was 39.7 years. Sexual orientation of enrolled clients was: 45.1% heterosexual, 38.3% homosexual, 11.6% bisexual, and 5.1% other. Sex with someone whose HIV status is negative or unknown, unprotected sex with men, and sex while high on drugs or alcohol were the most frequently identified-risks during the initial screening.
For more information . . .
Advancing HIV Prevention
http://www.cdc.gov/hiv/topics/prev_prog/AHP
Resources on the Advancing HIV Prevention initiative
CDC National Prevention Information
Network (NPIN)
1-800-4 58-523 1
http://www.cdcnpin.org
CDC resources, technical assistance, and publications
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