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Contents: Address the Complexity of Individuals' Lives Profile 1: Positive Changes Profile 2: Supporting Positive Opportunities with Teens Conclusion

Human rights violations are not accidents; they are not random in distribution or effect. [Rather] rights violations are symptoms of deeper pathologies of power and are linked intimately to the social conditions that so often determine who will suffer abuse and who will be shielded from harm. Dr. Paul Farmer Addressing the Complexity of Individuals’ Lives In the July 2008 NASTAD Prevention Bulletin, we focused on the interplay between power and privilege and their contributions to inequity in accessing quality prevention and healthcare services. We discussed how these conditions facilitate a disproportionate impact of health disparity on gay men and other men who have sex with men (MSM) and racial and ethnic minorities, particularly African Americans and Latinos. As we emphatically argue in the NASTAD HIV Prevention Blueprint, the nation’s current prevention, care and treatment efforts cannot keep pace with the needs of these most-impacted communities, particularly in the context of their diverse and complex lives. The Centers for Disease Control and Prevention’s (CDC) recent estimates of national HIV incidence show that African Americans and Latinos accounted for 62 percent of new HIV infections in 2006, a respective rate of 83.7 and 29.3 per 100,000 persons.1 While race and ethnicity are not, in isolation, risk factors for health and social concerns like HIV/AIDS, research clearly demonstrates that members of racial and ethnic minority communities experience higher rates of the factors that contribute to HIV transmission, like sexually transmitted diseases (STD), drug use, poverty and stigmatization.2 When viewed by age and gender, the CDC’s recent incidence estimates reveal alarming differences in the rate of new HIV infections. With 53 percent of all new infections resulting from male-to-male sexual contact, men account for 73 percent of the total estimated new HIV infections.3 At the same time, 34 percent of new infections occurred in young people between ages 13 and 29. Where these data overlap has serious implications for young gay men and other young MSM. The CDC’s findings suggest that members of this group may be engaging in behaviors that contribute to HIV transmission, e.g., unprotected sex and substance use. In addition, Ibanez, et. al. reported that individuals use substances and engage in risky behaviors to cope with negative feelings.4 For example, childhood sexual abuse, partner violence and psychological distress (e.g., depression or anxiety) increase the likelihood of engaging in risky sexual behavior. Symptoms of depression are also associated with unprotected sex, multiple sex partners and increased exposure to STDs. As such, survivors of childhood sexual abuse were found to have higher rates of depression, self-destructive behaviors/attitudes, increased alcohol and/or substance use and to engage in more frequent sexual activity and promiscuity without attention to risks.5 The study also suggests that some gay men and other MSM use drugs, e.g., methamphetamine, to enhance their sexual desire, which also lowers their inhibitions for engaging in riskier sexual activities.6 Studies indicate that young persons who use injection drugs have higher levels of sharing contaminated needles due to their lack of access to youth friendly health services and adequate knowledge about HIV prevention and safe use.7 Our ability to understand the cumulative impact of co-occurring disorders has a significant bearing on our efforts to effectively address these concurrent crises. The harmful effect of multiple social conditions working in chorus with one another magnifies opportunities for exposure to and infection by certain diseases including HIV, viral hepatitis and STDs.8 As was discussed in the July 2007 NASTAD Prevention Bulletin, the term syndemics describes this negative, synergistic interaction of two or more social conditions or diseases that disproportionately burden a segment of the population.9 Because of the interactions of co-occurring conditions, young African American or Latino gay men and other young MSM face increased risk for HIV infection, as well as infection by other diseases. Creating and operationalizing programs and services that address transmission risk while honoring the realities of these young men’s lives can be challenging. Nevertheless, with one-third of all new HIV infections occurring in persons between ages 13 and 29 and nearly half of new STD infections occurring in persons 15 to 24, renewed commitment and efforts are needed to confront these “intersecting epidemics” that profoundly impact the lives our nation’s youth.10 Investment in substance abuse prevention and treatment and mental health services are a necessary means to preventing and/or reducing HIV and other disease transmission. In states where HIV prevention programs targeting youth are not given priority status, health departments and community-based organizations struggle to find the support necessary to adequately meet the needs of young people. Ironically, delaying the implementation of evidenced-based prevention interventions for youth forestalls the use of comprehensive, cost-effective strategies that offer a holistic response to meeting the needs of young people and families infected with and affected by HIV/AIDS. To illustrate successful programs that work to address the complex needs of individuals’ lives, this month’s Bulletin profiles two holistic programs that serve young people. References 1.Centers for Disease Control and Prevention. Estimates of new HIV infections in the United States : CDC HIV/AIDS Facts August 2008. 2.Singer, M.C., Erickson, P.I., Badiane, L., Diaz, R., Ortiz, D., Abraham, R., & Nicolaysen, A.M. (2006). Syndemics, sex and the city: Understanding sexually transmitted diseases in social and cultural context. Social Science & Medicine, 63(2006), 2010-2021. 3.Centers for Disease Control and Prevention. Estimates of new HIV infections in the United States : CDC HIV/AIDS Facts August 2008. 4.Ibanez, G.E., Purcell, D.W., Stall, R., Parsons, J.T., & Gomez, C.A. (2005). Sexual risk, substance use, and psychological distress in HIV-positive gay and bisexual men who inject drugs. AIDS 2005, 19(supp 1), S49-S55. 5.National Alliance of State and Territorial AIDS Directors. HIV and mental health: The challenge of dual diagnosis: NASTAD Mental Health Issue Brief, July 2005. 6.Ibanez, G.E., Purcell, D.W., Stall, R., Parsons, J.T., & Gomez, C.A. (2005). Sexual risk, substance use, and psychological distress in HIV-positive gay and bisexual men who inject drugs. AIDS 2005, 19(supp 1), S49-S55. 7.World AIDS Campaign. Injection drug use, HIV/AIDS, young people: Recognising the linkages. 8.Singer, M.C., Erickson, P.I., Badiane, L., Diaz, R., Ortiz, D., Abraham, R., & Nicolaysen, A.M. (2006). Syndemics, sex and the city: Understanding sexually transmitted diseases in social and cultural context. Social Science & Medicine, 63(2006), 2010-2021. 9.Centers for Disease Control and Prevention. Introduction to the syndemics prevention network, January 2007. Retrieved from www.cdc.gov/syndemics/pdfs/network-intro.pdf. 10.Centers for Disease Control and Prevention. Trends in reportable sexually transmitted diseases in the United States , 2006. National surveillance data for Chlamydia, Gonorrhea, and Syphilis, November 2007. back to top > Profile 1: Positive Changes NASTAD spoke with Carol Crump, Behavioral Specialist with California’s Department of Public Health, Office of AIDS—Early Intervention Section, to better understand the role health departments can play in addressing the complex needs of young people living with HIV/AIDS. Positive Changes is a psychologically-focused approach grounded in harm reduction theory, motivational interviewing and short-term, solution-focused therapy. NASTAD: Please describe how your program addresses co-occurring factors of HIV prevention and treatment and care, e.g., mental illness, substance abuse and homelessness. What is the goal of the program? Crump: Positive Changes is an HIV transmission prevention intervention that takes place in 20 of California’s 36 Early Intervention Program ( EIP) sites. The goal of Positive Changes is to prevent transmission of HIV by providing an intensive, one-on-one counseling to HIV-positive EIP clients at high risk for transmitting HIV. Positive Changes focuses on HIV-positive EIP clients whose prevention needs are too complex to be addressed by the basic risk reduction counseling offered as part of EIP’s standard array of services. The intervention’s immediate emphasis is on establishing a working alliance with the client that will support long-term risk reduction work, identifying client strengths and life enhancement goals and identifying harm reduction steps that may be tied to these client-defined goals. Positive Changes counselors collaborate with clients to set goals for change that clients define as both desirable and achievable, then link clients’ life change goals to risk reduction in ways that help them achieve those goals while also reducing their risk of HIV transmission. The intervention is designed to build on incremental steps toward small, achievable goals in order to maximize client success and enhance motivation for further change. NASTAD: How was the program developed? How was the community involved, if at all, in the program’s development? Crump: Positive Changes is an enhancement and expansion of the basic goals of the Early Intervention Program, which are to prevent the further transmission of HIV and to improve health, quality of life and productivity for people living with HIV. EIP includes prevention for HIV-positive persons as part of its standard of care. All EIP clients receive regular risk reduction counseling and transmission prevention support. The EIP model is based on a team-centered approach in which client care is not parceled out into separate categories and referrals. Instead, client needs are addressed from a holistic perspective that directly links primary health care with psychosocial services, case management, health education and HIV risk reduction counseling. This integration of prevention counseling delivered within the care setting helps to ensure that not only do HIV-positive persons receive the services necessary to improve their health and quality of life, but that they are also supported in making the life or behavior changes necessary to prevent further transmission of HIV. Multiple factors led to the development of Positive Changes. First, while EIP’s integration of prevention with care has been successful for many clients, there are some for whom basic risk reduction counseling did not lead to any significant change in risk behavior. Risk behavior patterns are complicated by factors such as substance abuse and other addictions, mental disorders, language or cultural barriers, chaotic or dangerous personal relationships, stigma and marginalized social status. The need to address these compelling factors, most of which can only be clearly identified and defined within the highly individualized context of each client’s life circumstances, pointed to the need for a new approach. Second, clients indicated via discussions with their EIP providers, as well as in client satisfaction surveys, that they wanted more support in dealing with substance abuse, addiction and mental health issues. Finally, while short-term counseling and psychosocial support is often available within HIV care settings, many EIP providers did not have the capacity (via funding or infrastructure) to deliver the longer-term counseling interventions often needed when dealing with complex risk dynamics and clients multiply diagnosed with HIV, addiction and mental disorders. NASTAD: Why is this program important? How does the program provide services that recognize the real life issues facing those being infected with HIV/AIDS? How is this program new or different from other programs/approaches, if at all? Crump: Positive Changes is important because it provides a means of intervening on both a short-term and long-term basis with the factors that contribute to HIV transmission risk behavior and because it is delivered within the overall context of HIV care. The intervention breaks change into small, achievable steps, thus taking providers out of the endless loop of trying to persuade clients to commit to behavior changes or treatment goals before they are ready. It gives providers the tools they need to help clients achieve desired life changes on both a short-term and long-term basis, thus opening the door to more substantial changes. It provides an environment that enables clients to feel, as one client said, “…like I’m a valuable person and not ‘just a case’.” It allows clients to have a place to identify their hopes for the future and to develop and practice the skills they need to make that future a reality. The stepwise approach to change allows clients to quickly experience success and thus strengthen motivation. Positive Changes is different because it goes beyond simply delivering “prevention messages” and helps clients create a foundation of strengths and skills that allows them to reduce their risk of HIV transmission while also improving the quality of their lives. It is based on research in the psychology of behavior change and health behavior, using approaches grounded in the principles of Short-term Therapy, Solution-focused Therapy and Harm Reduction. Its approach is tailored to fit the varied contextual factors influencing each client’s risks. Positive Changes operates within the HIV care setting. This placement recognizes the fact that for many clients, contact with medical providers is the most reliable basis for access to other essential services, including prevention. It decreases the number of referrals and intake processes that clients have to face in an effort to obtain services. It ensures that prevention interventions are delivered within the context of their care; helps keep all members of the care team informed and, therefore, better able to support the client’s prevention needs; and actively includes the client as a decision-maker in defining what changes they, themselves, are interested in making and how quickly or slowly they want to proceed. Once the client has achieved lower HIV transmission risk status, they are transitioned back into standard EIP services. Transition back to EIP case management can be seamless based on the fact that Positive Changes is implemented within the EIP care setting. Another advantage of implementing Positive Changes within the EIP model is that if the client lapses back into a very high risk behavior or faces a temporary setback that increases his or her vulnerability for risk, they can easily be referred back to Positive Changes without compromising continuity of care. Positive Changes recognizes the challenges clients face by framing interventions in such a way that clients will not be labeled as “resistant” or “failures” even if they struggle to achieve change. Lapses and difficulty achieving goals are not defined as “failures” but rather as an indication that client and counselor, together, need to revisit and scale down (not abandon) goals that may have been unrealistic within the client’s current circumstances. Any movement in the direction of positive change is deemed a success, and lessons learned through achieving success are built upon in order to set new goals for change. Once a working alliance has been established between client and Positive Changes counselor, they collaborate to define a risk reduction plan (this may be called a “positive changes plan” or a “life goals plan” or any other label that is acceptable to the client). Together, they produce a plan for improving the client’s health and quality of life, noting any factors that contribute to HIV transmission risk. They then define and agree upon a series of incremental steps toward goals defined by the client as desirable and achievable. The client and counselor meet regularly (the number of meetings is flexible, though at least once a week seems to be optimal), and review successes, identify barriers and decide whether any given step in the plan should move forward or be scaled down. NASTAD: What are the results of the program so far, if any? Crump:Formal evaluation of Positive Changes was concluded in 2006. (For a copy of the full evaluation report, contact Carol Crump at carol.crump@cdph.ca.gov.) Some program results that may be of interest within the context of this article include: Client characteristics at enrollment in Positive Changes: 49 percent had a history of mental disorders. 54 percent presented with indicators of moderate to severe substance abuse. 85 percent showed significant symptoms of anxiety, depression and/or personality disorders. 58 percent had a history of physical abuse or neglect. 31 percent had a history of sexual abuse. Among clients who remained in the program 12 months past baseline, results showed: 53 percent increase in consistent condom use 41 percent decrease in methamphetamine use 58 percent decrease in amyl nitrate use 23 percent decrease in heroin use 31 percent decrease in STDs NASTAD: What were the keys to the program’s success? Crump: The keys to success included: Providing regular (quarterly) meetings and ongoing training and technical support for the Positive Changes counselors; Involving EIP program administrators from the beginning, in order to assist with integrating the program within EIP care sites and facilitating client referral when the program was new; and Requiring that the Positive Changes counselor be an active part of the EIP care team by participating in case conferences and reviewing cases with fellow providers. This helps ensure that clients are referred to Positive Changes, when necessary, and eases transition back into EIP case management when clients have achieved Positive Changes goals. NASTAD: Are there any barriers to implementation? Crump: Yes. It can be challenging to integrate a rather psychologically-minded intervention in settings that operate within the traditional medical model of care. Hiring and retaining qualified staff is a problem for some sites. Ongoing training and active support for staff in the form of regular case consultation and review is essential. It can be difficult to provide this if resources are slim. It is sometimes difficult to make the case for long-term cost savings when in an era of shrinking resources, but reducing HIV transmission does save future fiscal resources. Health outcomes are traditionally presented within the context of quantitative research. Sometimes, encouraging bureaucrats and bureaucratic institutions, as well as politicians and administrators, to invest in long-term goals framed in the sometimes-nebulous parameters of behavior change research rather than in concrete numerical terms can be a challenge. NASTAD: Are there any lessons learned or words of wisdom that would help other health departments that want to work on this issue? Crump: Some points to keep in mind: Risk behaviors take place within a web of individual, cultural and social influences. Risk behaviors are often highly pleasurable, addictive and complicated by psychological and cultural factors. For some clients, risk behaviors may have profound survival value and will not disappear with tactics that rely simply upon “education”, delivering “prevention messages”, or “breaking through denial”. Risk behavior is not just “a behavior”. It’s the endpoint of a series of cognitive and behavioral steps ultimately leading to the behavior. Change is incremental. If you focus only on the high risk behavior itself, your intervention will probably not change that behavior. Positive Changes is designed to intervene at any point in the series of steps that lead to high risk behavior. The earlier in the series an intervention “takes” or is internalized by the client, the more control the individual will have over his or her behavior. Keep the focus on solutions, not problems. We insist that clients are the experts about their own lives. At the same time, clients may initially fail to recognize their own strengths. Motivation for change is increased by building on strengths as defined by the client. Improved life quality leads to risk reduction. Usually, the factors that stand in the way of improving life circumstances are the same factors that contribute to high risk behaviors. Finally, remember that all clients, even those who seem most resistant to change, want better lives. That is the key to engagement with this intervention. Most people have little interest in seeing someone who “will help you reduce your risk behaviors”. The path to successful risk reduction begins by asking, “What do you want your life to look like, and how can you and I work together to get you there?” NASTAD: How would other health departments, with more or fewer resources or a different size, be able to implement this type of program? Crump: The basic principles of Solution-focused Therapy can be translated within primary care settings, can be well suited for brief encounters and can be learned and applied by staff members at almost any level of education and experience. While Positive Changes was structured for use by mental health clinicians with clients at the greatest risk for HIV transmission, core program elements could be utilized by case managers, physicians or health educators in helping clients define and achieve behavior changes that support improved health and quality of life. back to top > Profile 2: Supporting Positive Opportunities with Teens NASTAD spoke with Regina Whittington, Director of the Washington University Youth Center in St. Louis, MO, Supporting Positive Opportunities with Teens (SPOT) program. SPOT is a new initiative set to launch on September 2, 2008. NASTAD: Please describe how your program addresses co-occurring factors of HIV prevention and treatment and care, e.g., mental illness, substance abuse and homelessness. Whittington: SPOT is a new Youth Center through Washington University that will focus on reducing HIV and STD in young people ages 13-24. SPOT will address co-occurring factors of HIV prevention and treatment by providing a psychiatrist, counselor and case manager as well as a drop-in area all within one space. This will assist in eliminating barriers to care. Community partners have had a dominant presence throughout the program’s development in order to assure that referrals for additional services, such as housing, can be addressed in a timely and sincere manner. NASTAD: What is the goal of the program? Whittington: SPOT goals include the following: Remove barriers that currently prevent youth from seeking or obtaining health and preventative services; Create a youth specific center; Combine health and social settings into a single setting; Engage youth in all aspects of program development; and Link youth into the existing healthcare systems by addressing and eliminating specific barriers. NASTAD: How was the program developed? How was the community involved, if at all, in the program’s development? Whittington: The base model for SPOT was the Howard Brown Health Center Broadway Youth Center located in Chicago, Illinois. The Broadway Youth Center played a significant part in assisting SPOT with its program development as well as technical assistance. SPOT was developed on a partnership model. Multiple organizations were intensely active throughout the development stages and will continue to be active participants as the program grows. The leading partner in the development of SPOT is Project ARK (AIDS Resources and Knowledge), which is founded on enhancing the lives of children, youth, women and families infected and affected by and at risk for HIV. Project ARK encompasses many programs that are specific to HIV infected, affected and at risk youth and families. NASTAD: Why is this program important? How does the program provide services that recognize the real life issues facing those being infected with HIV/AIDS? How is this program new or different from other programs/approaches, if at all? Whittington: This program is important in order to address a neglected population, youth ages 13-24. This age group represents one of the fastest populations affected by STDs and HIV. St. Louis ranks among the highest cities for rising cases of STDs. SPOT provides a one-stop style of service that is not currently available in the St. Louis region. SPOT is designed to be youth centered and youth specific. It offers a combination of services ranging from drop-in services, mental health, physical health and case management services. The staff includes physicians, nurses, a psychiatrist, counselor, case manager, development specialist and coordinator to ensure all aspects of a young person’s life can be addressed in a safe environment. Typically youth would have to obtain these services from multiple sources which create barriers. Another aspect that makes SPOT different from other programs includes the feedback and consideration from the Youth Advocacy Committee (YAC). YAC is a program sponsored by Project ARK. This program supports youth being equal partners in planning processes. The youth are included in a non-judgmental and supportive atmosphere. This fosters leadership and ownership for the youth. Members of YAC have been active in the entire development of SPOT. SPOT will be crucial to linking youth to appropriate services and identifying their areas of need. The program is conscious of youth specific needs relating to HIV/AIDS and other STD. Project ARK has played an instrumental part in ensuring that needs of HIV-infected youth are addressed. SPOT was founded on the philosophy of engaging youth in all aspects of the program development which allows for opportunities of leadership. These activities range from staff selection, marketing strategies, specific program availability, as well as additional areas of need. NASTAD: Are there any lessons learned or words of wisdom that would help other health departments that want to work on this issue? Whittington: Involving the community partners as well as the youth in all aspects of the program’s development proved extremely helpful in ensuring the development of a comprehensive model. back to top > Conclusion The profiles in this month’s Bulletin offer two examples of innovative programs that address the complexities of HIV prevention in the context of co-occurring health and social issues. The programs intentionally include the ongoing life circumstances that contribute to increased risk. While the programs strive to assist individuals with reducing the risks associated with HIV transmission, the ultimate impact is likely much more significant. By comprehensively addressing other health issues, like substance use and mental health concerns, these programs approach their clients holistically rather than with a focus on a specific disease. While these and many other programs are innovative in their approaches, many programs and services have great opportunity to expand attention into areas of additional health and social concern. Given the similarities in modes of transmission and among specific target populations, health department and community based HIV prevention programs seek to include STD, viral hepatitis, tuberculosis (TB), reproductive health issues, homelessness and unstable housing, substance use and mental health concerns as appropriate and where resources are available. With increased focus on program collaboration and service integration (PCSI) at the CDC National Center for HIV/AIDS, Viral Hepatitis, STD and TB Prevention, programs are encouraged to continue to build on existing relationships and creatively plan to enhance their client-level services by integrating additional services and by building collaborative partnerships. Our movement forward must attempt to deconstruct categorical philosophies, funding, guidance and structures to allow our programs to address the complex realities that lead to HIV infection in the populations we serve. Technical assistance and support to health departments about strategies for increasing integration and collaboration is available through NASTAD. Continuing our look into the principles featured in NASTAD’s HIV Prevention Blueprint, the October 2008 Bulletin will examine the use of structural-level interventions to effect change. Meeting and Planning Calendar Capacity Building Opportunities: For a searchable database of CDC-supported capacity building trainings and events, please visit: the Capacity Building Branch’s Group Events Management System site. September 18-21, 2008 United States Conference on AIDS (USCA), Ft. Lauderdale, FL. For more information, visit the conference website. September 29-October 1, 2008 National Hepatitis Technical Assistance Meeting, Washington, DC. For more information, contact Chris Taylor. October 3, 2008 2008 Summit on Oral Health Care and HIV/AIDS, New York City, NY. Focused on: oral lesions, implementing counseling and testing in the dental setting, post-exposure prophylaxis, infection control in the dental setting, HIV co-morbidities, as well as confidentiality and human rights, the summit is being sponsored by the New York State Dental Foundation and the New York State Dental Association in partnership with the NY/NJ AIDS Education and Training Center, Delta Dental, New York University College of Dentistry, and PennWell Publishing. For more information, visit the conference website. October 15, 2008 National Latino AIDS Awareness Day. October 20–22, 2008 Management of Hepatitis B: An NIH Consensus Development Conference December 1, 2008 World AIDS Day February 7, 2009 National Black HIV/AIDS Awareness Day March 10, 2009 National Women and Girls HIV/AIDS Awareness Day March 20, 2009 National Native HIV/AIDS Awareness Day April 5-7, 2009 4th International Conference on HIV Treatment Adherence, Miami, FL. Sponsored by the International Association of Physicians in AIDS Care (IAPAC). For more information, visit the conference website. May 18, 2009 HIV Vaccine Awareness Day May 19, 2009 National Asian and Pacific Islander HIV/AIDS Awareness Day June 8, 2009 Caribbean American HIV/AIDS Awareness Day June 27, 2009 National HIV Testing Day August 23-26, 2009 National HIV Prevention Conference, Atlanta, GA. Additional information, including a call for abstracts, forthcoming. Credits, Feedback and Input The NASTAD Prevention Bulletin is edited by NASTAD staff and is written by staff and prevention experts from around the country. This publication was supported by Cooperative Agreement Number 5U62PS323958-05 from the Centers for Disease Control and Prevention. Its contents are solely the responsibility of the authors and do not necessarily represent the official views of the Centers for Disease Control and Prevention. If you have an idea or program that you would like to include in the Bulletin, please contact Dave Kern or Lynne Greabell (202/434-8090). NASTAD welcomes feedback to issues presented in Bulletin. To submit commentary, please e-mail us at NASTAD@NASTAD.org.

	Credits, Feedback and Input The NASTAD Prevention Bulletin is edited by NASTAD staff and is written by staff and prevention experts from around the country. This publication was supported by Cooperative Agreement Number 5U62PS323958-05 from the Centers for Disease Control and Prevention. Its contents are solely the responsibility of the authors and do not necessarily represent the official views of the Centers for Disease Control and Prevention. If you have an idea or program that you would like to include in the Bulletin, please contact Dave Kern or Lynne Greabell (202/434-8090). NASTAD welcomes feedback to issues presented in Bulletin. To submit commentary, please e-mail us at NASTAD@NASTAD.org. Electronic versions of the Bulletin are available on our webpage.
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