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Prevention with Positives: Promoting Change While the Clock Ticks …. Robert T. Carroll, PhC, RN, ACRN Washington State Education Coordinator , Northwest AIDS Education and Training Center. Today’s Goals.

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Prevention with Positives:Promoting Change While the Clock Ticks …

Robert T. Carroll, PhC, RN, ACRN

Washington State Education Coordinator,

Northwest AIDS Education and Training Center

Today’s Goals

  • Describe the theoretical and practical underpinnings of Prevention with Positives programs

  • Provide a brief overview of the Motivational Interview process for promoting behavior change

  • Describe the key elements of a brief motivational intervention focusing on prevention with PLWH/A

Why the Emphasis on Prevention with Positives?

  • Every person

  • infected with HIV

  • was exposed by

  • a person who was

  • HIV-Positive.

New generation of prevention programs targeting individuals who

Current emphasis arises from

What is Prevention with Positives (PwP)?

  • Have already tested positive for HIV

  • May be at risk of transmitting the disease

  • CDC 5-year plan to reduce rates of infection by 1/2 over the next 5 years

Why the New Focus on Prevention with Positives?

  • Advancing HIV Prevention (AHP)

  • New Strategies for a Changing Epidemic

  • September 2003

  • CDC initiative to reduce barriers to early diagnosis of HIV and increase access to quality medical care, treatment, and ongoing prevention services for PLWH/A

Why a New Initiative for HIV Prevention?

  • 40,000 new HIV infections still occur in the United States each year

  • One-quarter of the 850,000 - 950,000 PLWH/A in the U.S. do not yet know they are infected

  • Recent increases in syphilis diagnoses among men who know they are HIV-infected suggests an increase in risk behaviors among PLWH/A and their partners

Local Trends

  • Insert local/regional epidemiological charts and/or graphs which provide evidence of increases in new infections related to engagement in high risk activities (i.e., increase/spikes in other STI rates)

AHP Initiative Strategies

  • Make HIV testing a routine part of medical care when and where patients receive care

  • Use new models to diagnose HIV infection outside of traditional medical settings

  • Prevent new infections by working with HIV positive people and their partners

  • Continue to decrease mother-to-child HIV transmission

Prevent New Infections by Working with PLWH/A

  • Publish Recommendations for Incorporating HIV Prevention into the Medical Care of Persons with HIV Infection (CDC, HRSA, NIH, and IDSA)

  • Fund demonstration projects to provide PCM for people with HIV who have ongoing high-risk behavior

  • Fund demonstration projects of new models of PCRS

  • In 2004, implement these services

Incorporating HIV Prevention into the Medical Care of PLWH/A

Recommendations of CDC, the Health Resources and Services Administration, the National Institutes of Health, and the HIV Medicine Association of the Infectious Diseases Society of AmericaMMWR 2003 July 18; 52

How Does it Work?

  • Individual-focused PwP interventions

  • help PLWH/A reduce their transmission rates through theoretically-based interventions which--

  • Help PLWH/A feel better about themselves

  • Decrease the stigma associated with HIV

  • Help PLWH/A take responsibility for their lives and for stopping the spread of HIV

How is this Accomplished?

Prevention with Positives programs aim to build self-esteem and enrich coping skills through supportive services such as

  • Peer-based workshops and focus groups

  • One-on-one transmission risk counseling

  • Psycho-social assessment and supportive

  • interventions

  • Case management

  • HIV status support groups

PwP Programs in the U.S.

  • CA office of AIDS EIP program

    • Prevention integrated with care & treatment

    • Prevention Case Management

  • HIV Stops with me: LA, SF, Boston

    • Social marketing approach

  • Prevention for HIV-Infected Person’s Project (PHIPP)

    • Multi-site CDCP demonstration project

  • Positive Power (Seattle & WA State)

    • Targeting gay and bisexual men through individual and group work

  • Partnership for Health (USC)

    • 2-day TOT program to implement

    • 4-hour individual intervention

I know there must be a theory in there somewhere…

  • Yup.

  • Most PwP programs are based on one or many of the seven most popular theoretical models of (HIV) health promotion/risk behavior change

Seven Theoretical Models (HIV) Health Promotion & Risk Behavior Change

  • Health Belief model

  • AIDS Risk Reduction Model

  • Trans-theoretical model

  • Social Cognitive Theory model

  • Theory of Reasoned Action

  • Theory of Planned Behavior

  • Information-Motivation-Behavioral Skills model

What do these Theories have in Common?


  • SKILLS +




  • Behavior Change!

Transtheoretical Model(Prochaska & DiClemente, 1984)

Six stages of behavior change

  • Precontemplation:Not even thinking about it

  • Contemplation:Thinking about it

  • Determination/Preparation:Taking steps to start behavior

  • Action: Person tries behavior

  • Maintenance: Person does behaviorregularly

  • Relapse: Person slips up & needs to make adjustments

Transtheoretical Model of Behavior Change

Transtheoretical Model(Prochaska & DiClemente, 1984)

Transtheoretical Model(Prochaska & DiClemente, 1984)

  • Change is an incremental process and not a discrete outcome

  • Change takes time

  • Harm/risk reduction is a good goal

  • Relapse is the rule, not the exception

  • Two dimensions: stages and processes

Key assumptions of the model

Brief Motivational Interviewing Works!

But it must have structure and purpose…

First Things First!

  • Work with the patient to identify a behavior to be targeted for change

  • Identify where the patient stands on the readiness-to-change continuum

  • Establish with the patient incremental goals – appropriate to their readiness - to move toward the desired change


  • Document, Document, Document!

  • Ensure full staff understanding of, buy-in for, and consistency in delivery of the plan.

Initial plan, subsequent encounters, outcomes, and changes to the plan

FRAMES:Active Ingredients of the Effective Brief Motivational Interview

  • F:Feedback

  • R:Responsibility

  • A:Advice

  • M:Menu

  • E:Empathy

  • S:Self-Efficacy

(Miller & Rollnick, 1991)


Key ingredient

which supports

the client’s

ability to change.

General Principles of Motivational Interviewing

  • Express empathy

  • Develop discrepancy

  • Avoid argumentation

  • Roll with resistance

  • Support self-efficacy

Phases of the Motivational Interview Practice

  • Build motivation for change

    • Sensitive questioning and reflection encourage the person to articulate self-motivational statements and the arguments for change

  • Strengthen commitment to change

    • Motivation-building moves to key questions designed to evoke problem-solving and commitment to change

But What Can I Do in a Brief Period of Time?

  • If all you have is a short time in which to make an impact--

  • seek at least

  • not to do any damage

  • by entrenching resistance and discouraging change.

  • (Miller & Rollnick, 1991)

Five Key Communication Skills

  • Framing communication messages

  • Understanding the patient perspective

  • Active listening

  • Redirecting

  • Cocktail Party

Brief Intervention Talking Points

  • Compliment any protective behavior

  • Ask a question/s about sexual behavior and disclosure

  • Discuss sexual behavior and disclosure

(adapted from the Partnership for Health Program, PAETC, University of Southern California)

PwP Internet Resources



    • PAETC, Partnership for Health Program


    • Prevention with Positives: What Is It? Women Alive, Summer 2001. Cathy Olufs.


PwP Internet Resources


    • Prevention with Positives: Reducing Further Transmission of HIV/AIDS.HIV Impact, March/April, 2002. Aimee Swartz.


    • Archived online articles

Contact Information

  • Robert T. Carroll, PhD (c), RN, ACRN

  • WA State Education Coordinator

  • NW AIDS Education & Training Center

  • 901 Boren Ave., Suite 1100

  • UW Box #359932

  • Seattle, WA 98104-3508

  • 206-685-0226


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