2.3.1 Published Literature

PCM is a hybrid intervention, attempting to provide time-limited case management and HIV prevention services. PCM is based on the idea that people are unable to prioritize the threat posed by HIV when they face problems they perceive as more important and immediate (Falck et al., 1994). By addressing these acute needs through case management, high-risk persons who would not typically seek other risk-reduction programs might be reached for HIV prevention efforts. For example, a recent study found that poor mental health and drug dependence may undermine the ability and motivation of female sex traders in Harlem to adopt safer sex behavior (El-Bassel et al., 1997). A PCM intervention for this population would attempt to address the women's psychosocial and mental health needs and provide risk-reduction counseling so that they would be more likely to adopt safer sex practices. As discussed, however, one of the salient features of case management, including PCM, is that the core services provided by the case manager are not sought by every client. In other words, PCM clients may not come to an agency or a health department to seek prevention services, even though HIV prevention is the primary purpose of the program.

Only a few reports on PCM have been published or presented. Three reports focus exclusively on HIV-seropositive persons (CDC, 1993; Schwartz, Dilley, & Sorenson, 1994; Thurnherr, Moore, Bonk, & Strum, 1994), and one focuses mostly on HIV-seronegative individuals (Falck et al., 1994). Two of the studies provide very limited outcome evaluation data.

The CDC (1993) reported outcome data on PCM programs for HIV-seropositive persons in three community health centers. The goal of PCM at these three sites was to assist HIV-seropositive clients in obtaining services that would prevent or reduce behaviors that result in further spread of the virus, delay the onset of symptomatic HIV disease, and improve the client's health. Clients attended a follow-up visit after testing positive, during which the case manager collected data on risk behavior (five items), provided risk-reduction counseling, and developed a care plan for medical and psychosocial services (Time 1). Clients' next scheduled meeting with the case manager was 4 to 6 months after the first visit, and the risk questionnaire was readministered (Time 2). No other PCM activities took place between Time 1 and Time 2. Although 755 clients received PCM services at the three sites, because of changes in methodology, only 61 clients completed the same questionnaire at Time 1 and Time 2. At Time 2, significantly more of these clients had not had sex in the past 30 days and reported no current sex partner, than at the beginning of PCM. However, no differences were found in the number of new sex partners or the use of condoms with a regular sex partner.

Even though these findings are somewhat encouraging, they do not provide a very good test of the efficacy of PCM in decreasing high-risk behaviors. Problems include the small sample size, the lack of control for disease progression (which could have caused a decrease in sexual activity), and the failure to collect behavioral data in the time between HIV testing and the first case management appointment (a 2.4-month lag time on average, during which time changes could have occurred). In addition, interpretation of the findings on condom use is difficult because the serostatus of sex partners is not known. Furthermore, the intensity of the PCM services delivered at these program sites is unclear. The PCM intervention in this case seems to have consisted of two meetings with a case manager, although few details were provided.

In a randomized controlled trial of a PCM program in Ohio for injection drug users (most of whom were HIV-seronegative), no differences were found between three groups of participants (case management, health education, and control) with regard to drug use, risky sexual behaviors, or use of human services at 6-month follow-up (Falck et al., 1994). Participants in all three groups reported significantly less drug risk, but no change in high-risk sexual practices at follow-up. Although no evidence of behavioral change was found in this study, the difficulty in retaining participants suggests that it may not have been an adequate test of the PCM model. To try to increase the number of clients completing the intervention, the researchers changed their initial PCM plan (a minimum of six sessions with the prevention case manager) to one initial office visit and two sessions in the field. Even with this adjustment, retention was difficult. Of the 105 clients randomly assigned to the case management intervention, 66% agreed to further participation after the first office visit; 49% participated in at least one field visit; and only 37% participated in two or more field sessions. Thus, data were available only for the 38 participants who received at least two case management sessions.

These authors focused most of their commentary on the difficulty of getting clients to "engage" in the program (the first step in their six-step case management model) and to remain in the program. They were discouraged by the fact that, "the clients expressed a nearly uniform lack of interest in what the project offered" (Falck et al., 1994, p. 165). Given the intense effort that was needed to engage clients for the first session, Falck and his colleagues were disappointed in the retention rate. They concluded that the effects of drug use worked directly against the engagement and retention of clients in the case management process. Another possibility not mentioned by the authors is that because most clients were HIV-seronegative, they were less interested in primary prevention, and hence, in the HIV PCM program.

Schwartz and her colleagues (1994) reported on a case management model with HIV-seropositive substance-abusing persons that focused on decreasing drug usage, linking clients to services, and decreasing the risk of HIV transmission. Although no outcome data are available yet from this project, Schwartz and her colleagues did describe some difficulties with addressing prevention issues in the context of case management. She noted that AIDS issues were not primary for many clients and could not be addressed effectively until basic needs were met. They found, however, that meeting basic needs for this substance-abusing population was very difficult because of the number of obstacles faced by clients, including

• lack of money
• lack of child care
• lack of transportation
• lack of a telephone
• lack of necessary documentation (for example, identification or social security card, citizenship papers
• active substance abuse
• poor physical health
• mental illness
• eviction or criminal history
• long waiting lists or lines for services
• few services for people who were not HIV-seropositive and who were not disabled

To the extent that persons in PCM cannot become engaged in the process (and thereby get their basic needs met), implementing the prevention component of PCM becomes more difficult. Moreover, as seen from this list of obstacles, many of these barriers are significant. Clearly, long-standing individual or social issues may be difficult to overcome with any social program, let alone an HIV prevention intervention.

The final PCM-like program was a 60-day peer-based program in which clients who had recently tested seropositive were matched with seropositive agency veterans (Thurnherr et al., 1994). On the basis of focus groups with new and veteran clients, the agency determined that the biggest obstacles to services for new clients were the complexity of the service system and the clients' feelings of isolation. The clients with recent diagnoses also exhibited substantial confusion about safe sex practices. Thurnherr and his colleagues designed a 60-day, 6-session intervention in which the agency veterans led newcomers through training on safe sex alternatives, correct condom usage, personal responsibility and HIV, choices of early medical intervention, HIV basics, and STD education. The authors did not state whether or not traditional case management activities such as assessment, linking to services, and monitoring were provided. Although the authors called the intervention a peer PCM program, its seems to be more similar to risk-reduction programs and buddy programs for HIV-seropositive persons than to the usual PCM program. No outcome data were presented, and a phone call to the agency revealed that the program has been discontinued.

2.3.2 Conclusions

From the few publications on PCM, several points stand out. First, client engagement and retention are difficult with multiproblem, high-risk clients such as those who abuse substances. This difficulty is important because the goal of PCM is to reach such persons. Second, providing social services to high-need, multiproblem clients, let alone HIV prevention services, is difficult. Third, many PCM clients do not perceive a need for HIV prevention services, and this might be especially true for those who are HIV-seronegative. Finally, PCM programs have not been evaluated; thus, conclusions about the effectiveness of PCM are not warranted.

Go to section 3.0 Summary of PCM Practices in 1996