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Positively Prevention
Feature article, Michigan HIV & STD News, Winter 2006 Issue
Prevention Options for Positives (POP) is an intervention
proven to change the risk behavior of persons living with HIV within a context
of peer support. It was researched and designed from the ground up starting with
input from a Michigan needs survey of persons living with HIV/AIDS (PLWH/As or
simply PWAs) initially conducted in 2001, with additional focus groups held
2001-2002. Rather than a top down approach this program was designed from the
beginning around the needs voiced by people in Michigan living with HIV/AIDS.
Working for the Midwest AIDS Prevention Project in close
collaboration with MDCH-HAPIS staff, Technical Assistance Coordinator/Program
Director Mark Peterson spent over a year developing the POP pilot program.
Peterson himself has been living with the virus for 14 years. Founder and
Director of MI-POZ, Michigan’s advocacy group for persons living with HIV/AIDS,
he has been an outspoken voice for PLWH/A’s at the Michigan HIV/AIDS Council
(and its prevention and care predecessor counsels) since 1995; and is a past
president of the former Michigan PLWH/A Task Force.
Peterson has worked on the streets with commercial sex
workers and in bath houses with men who have sex with men (MSM) doing front line
prevention work, so he’s in touch with those most at-risk. He researched and
co-created this science-based program with HAPIS staff, fully aware of its
intended audience and their needs.
The pilot program targeting HIV-positive MSM, was tested out
at four CBOs around the state in 2002: Lansing Area AIDS Network (LAAN);
HIV/AIDS Resource Center (HARC) in Ypsilanti; and Community Health Awareness
Group (CHAG) and the former Men of Color in Detroit. Since September 2003, four
agencies, LAAN, Wellness Flint, AIDS Partnership Michigan (APM) and HARC, have
POP programs supported by HAPIS prevention funding.
Program development
POP is an intense program – initially designed to
specifically target the most at-risk population, HIV positive MSM, with multiple
levels of intervention: individual level prevention counseling (ILPC) and group
level (GLI) skills building workshops.
“Based on the needs assessment we found that the social
component was going to be a critical part of this, and so we wanted to make this
intervention a social event for people as well as an opportunity to explore
their own risk reduction processes, etc.,” said the HAPIS consultant for
evaluation of POP Maria Lapinski-Lafaive.
“There was a social component to this as well as the notion
of the individual level behavior change issues and the group dynamic with other
members.” (See Facilitating POP)
The intervention covers communication, safer sex knowledge,
psycho-social issues, status disclosure, substance use – and then safer sex
skills. One of the things the PWAs asked for is that the program be peer-led, so
as much as possible these programs around the state are facilitated by PWAs who
are also MSM.
The individual level prevention counseling has a focus on the
needs of PWAs. It is not psychotherapy and not prevention case management.
“POP’s ILPC is targeted to specific things, that’s it,” said Peterson. “We’ll
make referrals for other issues.”
ILPC covers substance use and its connection to risk
behavior, disclosure of status and sexual risk reduction. This is to help build
the (personalized) risk reduction plan.
These counseling sessions also cover Partner Counseling and Referral Services (PCRS).
“We deal with PCRS in a new way that models a way for disclosure in the future,”
said Peterson. Referrals will be made for those who need professional mental
health counseling and other support services.
All of this has been generated by the PWA needs assessment
that gathered feedback from support groups and case management clients. Surveys
uncovered risk behavior and lack of disclosure of HIV status to their sex
partners: 43.6% reported protected sex without disclosing to partners their HIV
status; and 36% reported unprotected sex without disclosure.
“Those statistics, by themselves can be alarming and
enlightening,” said Peterson. “There are issues to disclosure – disclosure is a
huge issue because we have a felony law in Michigan.
“Skills are important and are part of the intervention, best taught repeatedly,”
said Peterson. But “the program is designed to look a little deeper than fear
and skills,” he said. “What the surveys and other PWA input showed us is there
are deep psycho-social issues around safer sex, intimacy, and how we express
ourselves sexually. Also all of the other co-factors, mental health, substance
abuse, etc. are all one big complex problem that when talking about prevention
for positives you have to address. It’s not as simple as just giving people
condoms.”
It was in 1999 that MHAC, the statewide community planning
group, identified PLW/As as the group with the highest priority population for
its prevention plan. Around the time that Michigan was looking at the need for
the PWA focused prevention program, the CDC was beginning to target this group
for prevention. There were several programs nationally at the time that were
adapted from older programs not originally designed for PWAs. In 2003 Peterson
was invited to the CDC to critique them, so he had a good opportunity to review
what was out there.
“The idea was to come up with the best model for Michigan,”
Peterson said. He didn’t see one designed elsewhere that he would feel
comfortable bringing to Michigan for use here.
Measuring Success
From the beginning this program has merged science
with street smarts, meeting the needs of the HIV+ community, while answering to
the outcome measurement needs of MDCH. HAPIS Community Partnerships Unit Manager
Liisa Randall and Lapinski-Lafaive have both been monitoring this program, with
Lapinski-Lafaive looking at evaluation from the beginning of the project. While
the public health outcome goals are behavior change aimed at reducing
transmission, as well as acquisition of new infections among the HIV+ community,
this program took a wider view.
For the participants the objectives are increased knowledge
regarding transmission and prevention, enhanced communication skills around
disclosure and negotiation for risk reduction, and behavioral risk reduction as
well as enhanced self-efficacy via social, normative support.
Theoretical Basis
“The main theories that are driving this model are
the Theory of Reasoned Action, and Social Cognitive Model” said Peterson. “The
Theory of Reasoned Action is kind of the big theory that we used for testing
some of the outcomes, and we tailored the messages more around this theory,”
said Lapinski-Lafaive. “The Social Cognitive Theory has a strong emphasis on the
idea of modeling behavior and how modeling is effective in changing behavior, so
we used the principles of Social Cognitive Theory in that way to help us design
curriculum.”
The ILPC sessions are an adaptation of the CDC’s HIV prevention counseling,
which is based on the AIDS Risk Reduction Model and Stages of Change Model.
Outcomes
The POP pilot demonstration project compared
outcomes from two different program models, one using just three Individual
Level Prevention Counseling (ILPC) sessions and another that got these plus
participation in six Group Level (GLI) sessions.
The big findings from the pilot study were “the people in the
combined interventions had greater changes in knowledge than just the ILPC and
were more likely to say they would avoid sexual activity with their main partner
when they were drunk or high, and they were more likely to talk about their main
partner’s HIV status than those in the ILPC alone,” said Lapinski-LaFaive.
“We also saw a trend for increased condom use among all
participants with both their main and their other partners and that trend was
stronger for the combined interventions group.” She added the caveat that a lot
of changes were not “statistitically significant,” but that was in part because
they had a small sample.
The findings clearly indicated that the combined ILPC with
the GLI intervention had the greatest impact on the participants. “After we
finished the data collection we went back and revised the curriculum based on
the evaluation and made some changes that we hoped would make it more
effective,” said Lapinski-LaFaive. Mark Peterson along with HAPIS Technical
Assistance Coordinator Amy Peterson, who has been a part of the program from the
beginning for quality assurance, met with the project leaders from each of this
fiscal year’s POP programs around the state to gather more input and make
further changes to the group level intervention curriculum in the fall.
By December they had preliminary data on 2005 program
participants. Knowledge increased again. “We saw a trend in decreased number of
sex partners, and we saw an increase in some risk reduction behavior – which is
what we saw with the original POP study,” said Lapinski-LaFaive.
The POP team has made several presentations around the
country and plan to package the program so that it can be replicated by others.
For more information on POP, contact Mark Peterson at MAPP (248) 545-1435.
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