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Description
Core Elements, Key Characteristics, and Procedures
Adapting
Resource Requirements
Recruitment
Policies and Standards
Quality Assurance
Monitoring and Evaluation
Key Articles and Resources
References
Description
The Partnership for Health intervention offers an evidence-based approach to integrating a healthcare provider–delivered behavioral intervention to HIV-positive patients each time they attend the medical clinic. The intervention is short, usually taking only 4 minutes of time, and uses a technique called 'loss-framed' or 'consequence-framed' messages delivered to the HIV-positive patient by the healthcare provider.
How it Works
The Partnership for Health intervention uses the outpatient clinic and healthcare providers to provide brief behavioral prevention messages with each clinic visit. Partnership for Health uses message framing, repetition of the message, and reinforcement during patient visits to increase HIV-positive patients' knowledge, skills, and motivations to practice safer sex. The program is designed to improve patient–provider communication about safer sex, disclosure of HIV serostatus, and HIV prevention.
Research Findings
The Partnership for Health intervention was tested in a
quasi-experimental design in which clinics were randomized according to the
manner in which the prevention message was framed: 2 clinics used the
‘gain-frame message,’ 2 clinics used the ‘loss-frame message’ (also called the
consequence-framed message), and 2 clinics used standard patient education.
Patients in the clinics offering the ‘loss-frame message’ demonstrated
significantly fewer HIV risk behaviors than did patients in the clinics that
used the ‘gain frame messages’ or standard patient education. Further analysis
at the individual patient level indicated that patients who had 2 or more sex
partners or at least one casual partner and who received consequences-framed
messages were significantly less likely to engage in unprotected anal or vaginal
sex.1
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Core Elements, Key Characteristics, and Procedures
Core Elements
Core elements are those parts of an intervention that must be done and cannot be changed. They come from the behavioral theory upon which the intervention or strategy is based; they are thought to be responsible for the intervention's effectiveness. Core elements are essential and cannot be ignored, added to, or changed.
Partnership for Health has the following 9 core elements:
- Have providers deliver the intervention to HIV-positive patients in HIV outpatient clinics.
- Have the clinic adopt prevention as an essential component of patient care.
- Train all clinic staff to facilitate integration of the prevention counseling intervention into standard practice.
- Use waiting room posters and brochures to reinforce prevention messages delivered by the provider.
- Build on the ongoing supportive relationship between the patient and the provider.
- During routine visits, have the provider initiate at least a 3- to 5-minute discussion with the patient or client about safer sex that focuses on self-protection, partner protection, and disclosure.
- Have the provider incorporate good communication techniques and use of consequences-framed messages for patients or clients engaged in high-risk sexual behavior.
- Provide referrals for needs that require more extensive counseling and services.
- Integrate the prevention message into clinic visits so that every patient is counseled at every visit.
Procedures
Procedures are detailed descriptions of some of the above-listed elements. Procedures for Partnership for Health are as follows:
Preparation
Implementation of Partnership for Health includes development of clinic and staff “buy-in” and training. Incorporating prevention into a busy clinic can be difficult but can be facilitated with some modification of the clinic structure and flow. Any clinic that wishes to adopt Partnership for Health must engage in a 4-hour training on the intervention for all clinic staff who will help deliver the intervention. This 4-hour training can be delivered in the clinic setting.
Creating an atmosphere that endorses an integrated approach shows that HIV prevention is important to the medical care provider and staff. Posting prevention messages in the waiting and examination rooms and giving every patient printed material related to HIV prevention reminds the medical care provider and prepares the patient to discuss HIV prevention.
Providing Prevention Messages
The provider conducts a brief screening for risky behavior, and if the patient reports engaging in risky behaviors (unsafe sex or injection practices), the medical care provider should provide an appropriate brief prevention message. This message may include
- a general prevention message
- a tailored message that addresses behaviors or concerns specific for this patient
- correction of misconceptions about risk
- reinforcement of steps the patient has already taken to decrease risk for HIV transmission
Prevention messages should stress that the only ways to ensure that HIV is not transmitted are abstinence or sex with a partner of concordant HIV serostatus. However, patients should also know that sex with partners of concordant HIV serostatus does not protect against other sexually transmitted diseases or reinfection with HIV. For sexually active patients, condom use is the safest way to prevent transmission or acquisition of HIV and other sexually transmitted diseases. Patients should also be made aware of the importance of disclosing their HIV serostatus to potential sex partners.
Following Up
Finally, medical care providers should recognize that risk is not static. Patients' lives and circumstances change, and their risk of transmitting HIV may change from one medical encounter to another. Screening and providing risk-reduction messages should occur at every medical visit unless the client has other medical needs that take precedence.
The Partnership for Health model is diagrammed below.
| Patient is given a brochure or flyer (in patient's preferred language) by
front desk staff and asked to read it before seeing the medical care
provider. Patient reads it while waiting and also sees the prevention
posters in the waiting room. |
| Patient goes into examination room and sees a small poster on the wall that reinforces the same messages in the brochure |
| Medical care provider examines the patient. |
| After the examination, the medical care provider conducts a brief (3–5 minute) intervention. Medical care provider conducts a brief risk screening and gives a brief prevention message that fits the needs of the patient. |
| Medical care provider uses the brochure, poster, or other prevention materials to help with counseling. Medical care provider or patient places a check mark next to behaviors noted in the brochure and sets goals for behavior change. Medical care provider documents in the patient's chart that counseling was done. |
| If needed, the medical care provider refers the patient to other services. Medical care provider tells patient that he or she will be interested in hearing how the patient is doing at the next appointment. |
| Patient leaves feeling cared about, knowing more about safer sex and disclosure of HIV serostatus, and ready to practice safer behaviors. |
| At follow-up visits, medical care provider asks about progress on goals and referrals, if given at last visit. Medical care provider offers reinforcement for healthy behavior and helps patient find ways to overcome obstacles. Medical care provider and patient set goals for next time. |
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Resource Requirements
People
Partnership for Health uses existing providers and clinic staff, so no new staffing is required. Providers are asked to spend 3 to 5 minutes during each patient visit to discuss safer sexual behavior and disclosure of HIV serostatus. Providers and clinic staff will need to attend an orientation to the intervention, a half-day training, and another 2-hour booster training.
Each clinic should appoint a nurse or physician assistant to work half-time on this project as prevention coordinator. This person will
- set up training
- make sure that materials are on hand
- make sure that the intervention is being carried out
Clinics should have support and a commitment from all their staff to the following:
- training
- talking with patients about sex and drug use
- understanding prevention interventions and factors related to risk behavior
Space
Partnership for Health is done at HIV outpatient healthcare clinics. Clinics should have private examination rooms where medical care providers and patients can talk privately about the patient's sexual behaviors.
Supplies
Materials
The following materials are helpful for introducing the concept of integrated prevention and care services:
- Posters, in languages appropriate to the populations served, displaying the general prevention messages, to hang in clinic waiting areas and hallways
- Brochures, in languages appropriate to the populations served, given to patients when they register at the front desk. The brochures should emphasize the following:
- the role of sexually transmitted diseases in HIV transmission and the need to be tested and treated at the first sign or suspicion of symptoms of sexually transmitted diseases
- the potential role of drug use in increasing risky behaviors
- the risks of unsafe sex or injection practices for patients and their partners, even in the presence of a low or undetectable viral load
- the importance of disclosing HIV serostatus
- Posters to hang in examination rooms, in languages appropriate to the populations served, that contain the same messages as the brochure
- Documentation of patient counseling, which may be done with a chart sticker, a stamp, or a check box in the printed or electronic medical record. The purpose is to remind the provider to do the counseling regularly.
- Additional supportive materials, given out as supplements to the brochure at subsequent visits. Materials can address additional prevention topics of interest and may include helpful information and testimonials related to changing behavior.
Along with staff time for training, these supplies are the major expenses for Partnership for Health.
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Recruitment
Agencies that choose to follow the recommendations will offer prevention services as the standard of care in their clinics; therefore, no specific recruitment strategy is endorsed for Partnership for Health. All clinic patients will receive the intervention with appropriate messages at each appointment. However, all patients should be informed that the clinic has adopted a model of integrated service so that they may make an informed choice regarding their attendance at the clinic.
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Policies and Standards
Before a clinic attempts to implement Partnership for Health, the following policies and procedures should be in place to protect clients and the clinic:
Clinic Support
Clinic management must demonstrate support for Partnership for Health by
- encouraging staff to attend 1 training related to providing prevention services (i.e., providing paid time off to attend)
- obtaining, distributing, and maintaining prevention materials
- committing to having primary care providers deliver patient counseling, and allowing providers the time to deliver prevention messages at every visit
Confidentiality
A system must be in place to ensure that the confidentiality is maintained for all clinic patients.
Cultural Competence
The Office of Minority Health of the Department of Health and Human Services has published the National Standards for Culturally and Linguistically Appropriate Services in Health Care,
which should be used as a guide for ensuring cultural competence in programs and
services. Please see Ensuring Cultural Competence in the Introduction of this document for standards for developing culturally and linguistically competent programs and services.)
Data Security
To ensure data security and client confidentiality, data must be collected and reported according to CDC requirements.
Informed Consent
All clinic patients should be informed that addressing issues of sexuality and HIV prevention is part of the standard of care at the clinic that incorporates HIV prevention into medical care. As with any patient care issues, they have the right to refuse treatment.
Legal and Ethical Policies
By virtue of participation in this intervention, clients will be disclosing their HIV serostatus. Clinics must know their state laws regarding disclosure of HIV serostatus to sex partners and needle-sharing partners; clinics are obligated to inform clients of the organization's responsibilities and the organization's potential duty to warn. Clinic also must inform clients about state laws regarding the reporting of domestic violence, child abuse, sexual abuse of minors, and elder abuse.
Referrals
For clients who need additional assistance in decreasing risk behavior, providers must know about referral sources for prevention interventions and counseling, such as prevention case management, partner counseling and referral services, and health department and CBO prevention programs for persons living with HIV.
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Quality Assurance
The following quality assurance activities should be in place for Partnership for Health.
Auditing
Charts should be audited to ensure that providers are delivering and noting the delivery of prevention messages.
Assessment of providers
The following attributes of providers should be assessed:
- skill in eliciting behavioral information and providing prevention messages
- attitudes and beliefs about their role in delivering prevention messages
- frequency of message delivery
- satisfaction with the intervention
Intervention process and materials
The clinic coordinator should ensure that materials are maintained in the waiting and examination rooms and ensure that patient brochures and informational flyers are handed out to all patients.
Patients
Patients' satisfaction with the services and their comfort should be assessed periodically.
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Monitoring and Evaluation
Specific guidance on the collection and reporting of program information, client-level data, and the program performance indicators will be distributed to agencies after notification of award.
General monitoring and evaluation reporting requirements for the programs listed in the procedural guidance will include the collection of standardized process and outcome measures. Specific data reporting requirements will be provided to agencies after notification of award. For their convenience, grantees may utilize PEMS software for data management and reporting. PEMS is a national data reporting system that includes a standardized set of HIV prevention data variables, web-based software for data entry and management. CDC will also provide data collection and evaluation guidance and training and PEMS implementation support services.
Funded agencies will be required to enter, manage, and submit data to CDC by using PEMS or other software that transmits data to CDC according to data requirements. Furthermore, agencies may be requested to collaborate with CDC in the implementation of special studies designed to assess the effect of HIV prevention activities on at-risk populations.
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Key Articles and Resources
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References
- Richardson JL, Milam J McCutchan A, et al. Effect of brief safer-sex counseling by medical providers to HIV-1 seropositive patients: a multi-clinic assessment. AIDS 2004;18:1179–1186.
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