Ask, Screen, Intervene
4 Cities Project
FTCC Meeting
April 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
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.”
National HIV/AIDS Strategy. http://www.whitehouse.gov/administration/eop/onap/nhas
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, costeffective, 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 POSITIVES
HIV testing
Linkage to care
ART
Retention in care
Adherence
STD screening and treatment
Risk reduction interventions
Partner services
Perinatal transmission
intervention
PREVENTION WITH
NEGATIVES
Risk reduction interventions
Condoms
PrEP
PEP
Needle exchange
Male circumcision
Microbicdes
STD screening and
treatment
SEROSTATUS NEUTRAL
Social mobilization
Condom availability
Needle/syringe services
Substance 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
Curriculum Includes Interactive
Components
• 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
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 Clinics
1. 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 Objectives
 Enhance 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
Qualitative Data:
In-depth Interviews with Staff
In-Depth Interviews with Trainers
Site visits/Observations
Secondary data analysis
Quantitative Data:
RSR Data Extraction
Evaluation Question Type
Process/
Outcome/
Impact
Feasibility
Fidelity
√
√
√
√
√
√ (Clinic)
√
Risk screening tool
√
Patient Exit Interviews
√
Myers, Malitz, & Maiorana, 2012
√ (Provider)
√ (Clinic &
Provider)
√ (Patient)
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,
FAAN
Implementation experience
Working with community health centers
Successes 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