Miguel Chion, MD, MPH Associate Director Education-CBA Programs

Presentación del tema: "Miguel Chion, MD, MPH Associate Director Education-CBA Programs"— Transcripción de la presentación:

1 Perspectivas de las Estrategias de Salud Pública para la Prevención del VIH.
Miguel Chion, MD, MPH Associate Director Education-CBA Programs Funded by the Centers for Disease Control and Prevention

2 Shared Action Es financiado por The Centers for Disease Control and Prevention (CDC) para proveer servicios GRATUITOS de consultoria y asistencia técnica a organizaciones de bases comunitarias que implementen programas de prevención del VIH : Infraestructura Organizacional y Sustentabilidad del Programa Intervenciones Basadas en Evidencia y la Estrategias de Salud Pública Evaluación y Monitoreo

3 Objetivos Familiarizarse con las diferentes estrategias de salud pública Identificar las estrategias de salud pública para la prevención del VIH. Nombrar los componentes centrales de las estrategias de salud pública

4 Estrategias de Salud Pública (ESP)
No son las intervenciones basadas en evidencia (DEBIs) Protocolos probados por proveedores de salud para la prevención, evaluación, diagnóstico, y el tratamiento Basados en principios pre-establecidos de salud pública Usadas en otras enfermedades (Ej. VIH, TB, y obesidad) What are public health strategies? Public health strategies are not the same thing as evidence-based behavioral interventions (e.g., Voices/Voces, Sista, Safety Counts) used in HIV prevention. Definition of public health strategies According to the CDC, public health strategies are time tested protocols used by public health practitioners in the prevention, screening, diagnostic, or treatment processes. They are based on established principles of public health; including primary, secondary, and tertiary prevention, and may include a range of activities. Public health strategies are used for a variety of diseases such as HIV, TB, obesity, chronic kidney disease and others.

5 Tipos de ESP Consejería y servicios integrales para la reducción de riesgo (CRCS) Examen del VIH, consejería, y referencias (CTR) Servicios de contactos/parejas (PS) What public health strategies are used in HIV prevention? Public Health Strategies Comprehensive Risk Counseling and Services (CRCS) HIV Counseling, Testing and Referral (CTR) Related Activities Partner Services

6 Consejería y servicios integrales para la reducción de riesgo (CRCS)
CRCS=Comprehensive Risk Counseling and Services por sus siglas en inglés Consejería y servicios integrales para la reducción de riesgo (CRCS)

7 CRCS Sesiones de consejería individual, intensiva y continua.
Reduce riesgos conductuales e identifica las necesidades psicosociales y médicas Promueve la adopción y mantenimiento de conductas de reducción de riesgo What is CRCS? CRCS is a client-centered HIV prevention activity that provides intensive, ongoing, individualized prevention counseling, support and service brokerage. The goal of Comprehensive Risk Counseling and Services (CRCS) is to help persons who are high risk for HIV transmission or acquisition to reduce risk behaviors and address the psychosocial and medical needs that contribute to risk behavior or poor health outcomes (CRCS implementation manual). The fundamental goal of CRCS is promoting the adoption and maintenance of HIV risk-reduction behaviors by clients who have multiple, complex problems and risk-reduction needs (CRCS procedural guidance)

8 CRCS (cont.) Usada con poblaciones VIH- de alto riesgo y con personas VIH+ Apunta a reducir el riesgo de transmisión del VIH Intervención compleja que necesita recursos múltiples CRCS is a public health strategy that can be used with high risk HIV-negative and HIV-positive persons. The primary focus of CRCS in on reducing risk of HIV transmission or acquisition CRCS is a complex intervention that requires multiple resources for implementation.

9 Elementos Centrales de CRCS
Estrategia de reclutamiento de clientes en alto riesgo Evaluar y seleccionar clientes para CRCS Registrar y evaluar riesgos y necesidades psicosociales Plan individualizado de prevención con metas y objetivos medibles What are the seven core elements of CRCS? Develop and implement a strategy to recruit and engage high risk clients Screen clients to identify those who are at highest risk and appropriate for CRCS, enroll t hem in CRCS, and assess enrolled clients to determine specific risk and psychosocial needs Develop an individualized prevention plan with goals and measurable objectives Provide ongoing, multi-session intensive HIV risk and behavior change counseling Coordinate client support with other case management programs and provide referrals as needed Conduct on-going monitoring and reassessment of client progress and needs Discharge clients when they attain and can maintain behavior change goals. In preparing discharge policies, agencies should establish protocols to classify clients as “active,” “inactive,” or “discharged.” Your agency should outline the minimum active effort required to retain clients. Finally, your CRCS program should be willing to readmit clients who need new or additional risk reduction support. (from implementation manual, p 9).

10 Elementos Centrales de CRCS (cont)
Sesiones múltiples de consejería de riesgo del VIH y de cambios conductuales Coordinar con otros proveedores de manejo de casos y referencias apropiadas Monitoreo y evaluación del progreso del cliente y sus necesidades Dar de alta a los clientes que hayan logrado y mantenido su metas de cambio conductual What are the seven core elements of CRCS? Develop and implement a strategy to recruit and engage high risk clients Screen clients to identify those who are at highest risk and appropriate for CRCS, enroll t hem in CRCS, and assess enrolled clients to determine specific risk and psychosocial needs Develop an individualized prevention plan with goals and measurable objectives Provide ongoing, multi-session intensive HIV risk and behavior change counseling Coordinate client support with other case management programs and provide referrals as needed Conduct on-going monitoring and reassessment of client progress and needs Discharge clients when they attain and can maintain behavior change goals. In preparing discharge policies, agencies should establish protocols to classify clients as “active,” “inactive,” or “discharged.” Your agency should outline the minimum active effort required to retain clients. Finally, your CRCS program should be willing to readmit clients who need new or additional risk reduction support. (from implementation manual, p 9).

11 ¿Cómo funciona? Sesiones múltiples de consejería centradas en el cliente Ayuda al cliente a iniciar y mantener cambios conductuales Abordar otros factores relacionados al VIH (uso de drogas, salud mental, etc) How does CRCS work? It provides several sessions of client-centered HIV risk reduction counseling. It helps clients initiate and maintain behavior change toward HIV prevention. It addresses the relationship between HIV risk and other issues such as substance abuse, mental health, social and cultural factors, and physical health.

12 ¿Cómo funciona? Se enfoca en los objetivos conductuales del cliente
Incorpora educación, desarrollo de destrezas, apoyo u otras técnicas Utiliza materiales basados en teoría o materiales de otras intervenciones (ej. CLEAR) How does CRCS work? (cont’d) Counseling sessions are aimed at meeting the identified behavioral objectives of each individual client. Counseling sessions may include education, skill buildings, role-playing, support or other techniques. Counselors may use their own theory-based materials or use materials from existing interventions focused on one-on-one prevention counseling such as the CLEAR intervention.

13 Componentes de CRCS Preparación (organizacional) Implementación
Control de calidad Evaluación de capacidad What are the components for implementing CRCS? Component 1: Organization Preparation Component 2: Implementation Component 3: Quality Assurance Component 4: Assessing Agency Readiness to Implement CRCS

14 A. Preparación (organización)
Integrar CRCS a otros servicios Entrenar el personal en consejería Coordinar con otras agencias para referencias y provisión de servicios Elementos estructurales y ambientales (ej. espacio privado, incentivos) What are the components for implementing CRCS? Component 1: Organization Preparation Integration: CRCS programs are more likely to be successful when they are fully integrated into a multi-service organization, although a single-service agency with strong collaborative relationships in the service community are also good CRCS service providers. Staffing: Well trained supervisors and counselors are essential to the success of any CRCS program. All CRCS counselors and supervisors should have, at a minimum, training in pre- and post-test counseling, which provides a standard client centered approach to HIV prevention. One model for this is Project RESPECT. In addition, agencies should provide clinical supervision for their CRCS counselors. A full time CRCS counselor should have between active clients at one time. The small caseload allows for more intensive counseling sessions. Caseloads will be larger for CRCS counselors who do not provide case management services. Coordination of service providers: Coordination between agencies requires planning, clear roles and a division of labor, and open channels of communication between participating organizations. An example of coordination would include referral agreements between HIV counseling and testing centers and HIV care clinics. An agency is able to enhance its services through collaborative sharing of resources with other agencies. Collaborating agencies focus on specific efforts or programs, and exchanging information to arrive at a mutually beneficial common purpose. Environmental and structural issues: The CRCS counselor should have access to a private room in which to meet with clients and where clients will feel comfortable talking about high-risk behaviors and other personal and sensitive issues. Alternatively, an agency should be open to providing services to clients where they are more comfortable receiving them, outside of your agency if need be. Incentives may encourage client participation – but your goal is that clients come to value reducing risk and living healthier lives. Your agency should decide If incentives will be useful for recruitment and retention If incentives are a good way to maximize existing resources; that is, if incentives result in better participation and lower no-show rates, and therefore better utilization of staff time

15 B. Implementación de CRCS
Reclutar y atraer clientes Seleccionar, registrar, y evaluar clientes Desarrollar un plan de prevención Consejería de reducción del VIH Referencias, coordinación de servicios y seguimientos Monitoreo del progreso y necesidades del cliente Dar de alta y mantenimiento Component 2: Implementation Part 1: Recruiting and Engaging Clients Part 2: Screening, Enrolling, and Assessing Clients Part 3: Developing an Prevention Plan Part 4: HIV Risk Reduction Counseling Part 5: Referrals and Active Coordination of Services with Follow-up Part 6: Monitoring Clients’ Progress and Ongoing Needs Part 7: Discharge and Maintenance

16 B. Implementación de CRCS
1) Reclutar y Atraer Clientes Derivaciones/Referencias Internas Derivaciones/Referencias Externas Alcance comunitario Compromiso What are the components for implementing CRCS? Component 2: Implementation Agencies should adapt CRCS to suit the organization and population served, but the seven core elements of CRCS should be present in all CRCS programs. Part 1: Recruiting and Engaging Clients Programs should use both active and passive recruitment methods Internal referrals: Referrals are a common source of CRCS clients and can come from inside and outside your agency. Many multi-service agencies find that most referrals to CRCS come from within the agency. External referrals: Another productive method of recruitment is referrals from outside your agency by case managers, medical staff, or others. This type of referral requires the cultivation of collaborative relationships between agencies and their respective staff to support clients who are particularly challenged by life circumstances. Outreach: One specific and active recruitment source can be through outreach workers at your agency or from other agencies. CRCS counselors or outreach workers can recruit clients through such venues as Support groups HIV counseling and testing sites Social marketing campaigns or handing out brochures to potential clients or displaying posters describing CRCS and the kinds of services that CRCS provides Medical providers Prevention activities at venues where high risk individuals are likely to be encountered: Crack houses and shooting galleries, bath houses and sex clubs, STD clinics, Commercial sex worker venues, 12-step programs The best recruitment strategy is using multiple approaches for recruitment & engagement. Engagement Engagement is an on-going process of working with clients and the community. Engagement involves helping clients to understand the value that CRCS may hold for them. Engagement takes time, energy, and commitment. To help engage clients, you or the outreach worker must be able to link things that clients value in their lives with the notion of risk-reduction. To make sure that the time spent on engaging potential clients is counted, some agencies define this time as another intervention within CRCS, such as ‘outreach’.

17 Implementación de CRCS
2) Selección, registración y evaluación Pre-Selección Selección Registración Evaluación What are the components for implementing CRCS? Component 2: Implementation Part 2: Screening, Enrolling, and Assessing Clients Potential CRCS clients should be screened to determine their eligibility. If they are eligible and want to participate in CRCS, clients are then enrolled. As soon as possible after a client enrolls, your agency should conduct a more thorough assessment of psychosocial needs and risk behaviors. Pre-screening Prescreening is a type of triage, meaning you talk with potential clients enough to get a good idea of the kinds of services they might need. If you think a client might need an intensive HIV prevention intervention, then refer that client for a full CRCS screening. Screening Your agency will screen potential clients for eligibility for CRCS. In general, eligibility criteria should be based on an informed understanding of the epidemic in your area and the resources available to your agency. Agencies may differ in their eligibility requirements. In addition, to eligibility criteria, potential high risk clients should be open to the idea of changing some of their risk behaviors. Enrollment Once you determine a client’s eligibility, you should once again make sure the client understands what the CRCS counselor will expect of them, as well as what they can expect from the counselor and the program. Enrollment is: Agreement to work together to make healthy choices and improve well-being Formal client consent to participate in the CRCS program Assessment In order to help the client reduce risk behaviors, you will need to assess your clients’ knowledge, attitudes, and beliefs about HIV and STD transmission. You will also need to determine which behaviors put your client at risk of acquiring or transmitting HIV and other STDs. In addition, it’s important to gather information about psychosocial factors that may affect risk. The assessment should not be a structured set of questions; rather, it should be a conversation that reduces anxiety and motivates confidence and disclosure, especially in the initial stages of the assessment.

18 Implementación de CRCS
3) Desarrollo de un plan de prevención Determine metas y objetivos Evalúe las barreras y otros factores influenciables Determine los pasos a seguir Incluya actividades de seguimiento Establezca acuerdos What are the components for implementing CRCS? Component 2: Implementation Part 3: Developing an Prevention Plan Based on the information gathered during the assessment, CRCS counselors should work with clients to develop a written prevention plan. This plan will define HIV risk-reduction priorities, strategies, and concrete steps for making behavioral changes. The plan may also track psychosocial and medical services needed. Setting goals and objectives Setting goals – Goals are risk reduction targets on the road to risk elimination and are usually longer term; for example, I want to reduce my sexual exposure to HIV. Setting objectives – These are tangible achievements that the client strives to accomplish on the way to meeting longer term goals. Assessing barriers and other influencing factors Assessing barriers and other influencing factors – You will want to help your clients recognize and talk about the primary barriers that might be in their way. You should also pay attention to other factors that may have an influence on risk behavior or risk reduction. Determining appropriate action steps This is how your client will know what to do and when. For example, a simple action step for a client would be taking a condom during your session, or picking up condoms this week. Follow-up Each session with your clients should include some time for you jointly to review progress and barriers in your clients’ implementation of their prevention plans. Agreement Having your client sign and date the prevention plan and its revisions is a signal to both of you that your client agrees that the plan is reasonable and otherwise acceptable. The act of signing the plan is a sign of commitment.

19 Implementación de CRCS
4) Consejería de reducción del VIH Sesiones de consejería individuales de reducción de riesgo Aborde temas no relacionados al riesgo del VIH Documente la sesiones What are the components for implementing CRCS? Component 2: Implementation Part 4: HIV Risk Reduction Counseling Individual risk counseling sessions This is the most important service provided by CRCS. It is based on development and ongoing revision of the client’s prevention plan. CRCS risk reduction counseling is interactive and client-centered, using education, skills-building, role plays, support, crisis management, and other strategies to help clients to reduce and eliminate risk behaviors and then maintain these changes over the long-term. Addressing issues not related to risk Discussions about issues that are not risk issues but related to risk in some way will help you understand more about your clients, their priority concerns, and the factors that influence risk behavior. Engagement as an on-going process It is through continuing to engage clients that they will continue to attend sessions and work on difficult issues. If you are nonjudgmental, your clients will grow to trust the CRCS intervention because of their own skills development and empowerment. Documenting client sessions Documenting your sessions as so soon as possible after a session is extremely important – Keeps track of the content of your sessions Helps you and your clients identify successes and barriers Tracks the development of and changes in your clients’ prevention planning Tracks the referrals you make for your clients and the outcomes of those referrals

20 Implementación de CRCS
5) Referencias, coordinaciones y seguimientos Coordine los servicios para apoyar al cliente De seguimiento a las referencias Documente las referencias What are the components for implementing CRCS? Component 2: Implementation Part 5: Referrals and Active Coordination of Services with Follow-up CRCS clients have multiple, complex issues and are likely to need referrals to a number of services, such as mental health, substance use treatment, or housing, to name a few. Coordination of services Because many of the issues for which clients need referrals actually influence risk behavior, you should - Work with your clients’ other service providers to address needs – especially those that influence risk – and assure services are being provided Discuss with your client the ways in which need for services and service provision (e.g., housing or substance use treatment) influences their risk behavior; for example, substance use can interfere with the ability to use protective measures such as condoms. Coordination of services is important in order to provide the most effective and comprehensive support to your clients. Follow-up on referrals Always follow-up on a referral you’ve made for a client. If the referral is unsuccessful in some way, find out why. Help clients to address any barriers they may have encountered. Documenting referrals Referrals and their outcomes should be documented. One model is the use of a referral form that can be duplicated – one for your client, one for your client’s file in the agency.

21 Implementación de CRCS
6) Monitoree el progreso del cliente Aliente la participación activa del cliente Documente los contactos y los temas tratados para monitorear el proceso What are the components for implementing CRCS? Component 2: Implementation Part 6: Monitoring Clients’ Progress and Ongoing Needs Regular meetings between the CRCS counselor and the client allow for assessing clients’ changing needs, monitoring progress on goals and action steps, and revising the prevention plan as needed. Ongoing engagement You should continually encourage your clients’ active participation and engagement in CRCS and attempt to address the most pressing risk reduction needs at that time. By addressing these critical risk reduction needs, clients will be more engaged in the process. Documenting contact and topics for monitoring progress Remember to document contact: The date, time, how the contact was made – phone, , personal visit – and the result or outcomes of the contact. In addition, you and your client will need to periodically review risk issues and progress in addressing them.

22 Implementación de CRCS
7) Dar de alta y mantenimiento Determinar posible graduación No existe número específico se sesiones Finalización de CRCS basado en completar las metas Importante: hablar en las primeras sesiones el proceso de dar de alta What are the components for implementing CRCS? Component 2: Implementation Part 7: Discharge and Maintenance Successful completion or graduation Once your clients accomplish their goals, you and your clients, in consultation with your supervisor, should decide if the next step is graduation from the program or if some additional CRCS support is needed to maintain safer behaviors. There is no fixed number of sessions that CRCS clients must attend before graduation, unless your State or local regulations require them to do so. Successful completion of CRCS results from accomplishing risk reduction goals, and this could require any number of sessions. Early on in sessions with clients, it’s often a good idea to introduce the notion of discharge and why this is a goal of the program.

23 C. Control de calidad Consejeros certificados en CRCS
Número de clientes: 12-20 Manual de implementación específico Métodos de control de calidad (e.g. supervisión, repaso de expedientes, cuestionarios de satisfacción Component 3: Quality Assurance QA activities should include at minimum the following: Compliance with local and state standards for certification of CRCS counselors Small caseload 12-20 Tailored agency specific implementation manual QA methods include the following: Written protocols Training Supervision Chart review Case conferencing and presentations Client satisfaction surveys

24 D. Evaluación de capacidad
¿Capacidad de la agencia para implementar CRCS (personal, experiencia, fondos, etc)? ¿Habilidad de reclutar y retener a clientes? ¿Habilidad de implementar y mantener CRCS con fidelidad? Component 4: Assessing Agency Capacity to Implement CRCS Assess the Agency’s ability to plan and implement CRCS using all available resources/tools. Does the Agency have the capacity to implement CRCS (staff, expertise in HIV risk reduction counseling, funding, access to multiple services either internally or externally, materials, etc.) Does the Agency have the ability to recruit and retain high risk populations targeted by CRCS? Does the Agency have the ability to implement and maintain CRCS with fidelity to its seven core elements?

25 Examen de VIH, consejeria y referencias (CTR)
CTR=Counseling, Testing and Referral Services por sus siglas en ingles Examen de VIH, consejeria y referencias (CTR)

26 CTR Aumentar el conocimiento del cliente sobre su estatus del HIV
Alentar y apoyar la reducción de riesgo Obtener las referencias necesarias para los servicios apropiados What is CTR? HIV Counseling, Testing, and Referral (CTR) is a collection of activities designed to increase clients’ knowledge of their HIV status; encourage and support risk reduction; and secure needed referrals for appropriate services (medical, social, prevention, and partner services). An estimated 21% of people infected with HIV do not know they are infected with the virus. Studies have shown that learning one’s HIV status results in substantial reductions in risk behavior. Testing is a critical component of prevention efforts because when people learn they are infected, they can take steps to protect their own health and prevent HIV transmission to others.

27 Elementos Centrales de CTR
Servicio voluntario y ofrecido previo consentimiento informado Proveer información y educación al cliente Proveer consejería centrada en el cliente Trabajar con el departamento de salud y los proveedores de salud mental para establecer estándares y pautas a seguir What are the core elements of CTR? CTR has 8 core elements. HIV CTR Providers must: Ensure that CTR is a voluntary service delivered only after informed consent is obtained from the client. Provide information and education to the client about: the HIV test and its benefits and consequences risk for HIV transmission and how HIV can be prevented the type of HIV antibody test available/used the meaning of the test result, including the window period for HIV sero-conversion (the time after infection, before antibodies are produced by the body, during which an antibody test might be negative despite the presence of HIV) the importance of obtaining test results and explicit procedures for doing so where to obtain more information, counseling, or other services (medical, mental health, or substance abuse care, etc) Provide client-focused HIV prevention counseling to address readiness for testing personal risk assessment steps taken to reduce risk goals for reducing risk realistic plans for achieving those goals support systems referral needs plans for obtaining results, if necessary (if testing is done and the CBO is not using rapid testing) Work with the health departments (state, local, or both) and community mental health providers, establish clear and easy guidelines and sobriety standards to help counselors determine when clients are not competent to provide consent. Use an HIV testing technology approved by the FDA. Deliver test results in a manner that is supportive and understandable to the client. Assess referrals in support of risk reduction or medical care, provide appropriate referrals, and help link clients with referral services. A system must be in place for emergency medical or mental health referrals, if needed. Track referrals made and completed.

28 Elementos Centrales de CTR (cont)
Pruebas del VIH aprobadas por la FDA Entregue los resultados de forma entendible y alentadora/compasiva Evalúe, provea, y ayude a los clientes con referencias Seguimiento a las referencias

29 Como implementar CTR? Puede ser implementado en clínicas, en la comunidad y otros servicios Deber ser voluntario y proveído después de obtener consentimiento. Puede ser implementado en forma anónima o confidencial. How does CTR work? Clients can receive CTR at clinics, dedicated sites, and through outreach or other services. CTR should be undertaken voluntarily and only with informed consent. Several HIV test technologies have been approved by the FDA; they vary by fluid tested (whole blood, serum, plasma, oral fluids, and urine) and time required to run the test (conventional vs. rapid tests). Testing options facilitate access to testing and increase acceptability of testing. CTR can be delivered anonymously or confidentially. CTR may be provided by self-referrals or by referrals from other related services. CTR can be conducted using rapid or conventional HIV tests.

30 Como implementar CTR? (cont)
Se puede proveer a auto-referencias o referidos por otros servicios. Puede ser implementado con Pruebas de VIH convencionales o rápidas (aprovadas por el FDA) How does CTR work? Clients can receive CTR at clinics, dedicated sites, and through outreach or other services. CTR should be undertaken voluntarily and only with informed consent. Several HIV test technologies have been approved by the FDA; they vary by fluid tested (whole blood, serum, plasma, oral fluids, and urine) and time required to run the test (conventional vs. rapid tests). Testing options facilitate access to testing and increase acceptability of testing. CTR can be delivered anonymously or confidentially. CTR may be provided by self-referrals or by referrals from other related services. CTR can be conducted using rapid or conventional HIV tests.

31 Componentes de CTR Preparación (organización) Implementación
Control de Calidad Evaluación de la capacidad What are the components for implementing CTR? Implementation Procedures Assessing Quality Assurance of CTR Agency readiness to implement CTR

32 A. Preparación (organización)
Personal certificado en CTR Personal depende del número y tipo de prueba Asegurar confidencialidad, cumplir con OSHA, y los requisitos técnicos (ej. temperatura, luz, superficies planas) 6. Staffing: CTR can be implemented using paid or volunteer staff members who are trained in HIV CTR. If rapid HIV testing will be used, involved staff members must also be trained to perform rapid HIV tests. All polices, quality assurance requirements, and local and state requirements related to rapid HIV testing must be followed. The number of staff needed depends on the number of tests to be done and the type of test used (rapid or conventional). 7. Environmental and structural issues CTR can be implemented at any location where confidentiality of clients can be assured (e.g., private area or room) and where a specimen can be collected according to minimal standards as outlined by the Occupational Safety and Health Administration. If rapid testing is used, the setting must have a flat surface, acceptable lighting, and ability to maintain temperature in the range recommended by the test manufacturer for performing the test.

33 B. Implementación de CTR
Reclutar clientes Proveer información clara y simple Consejeria centrada en el cliente Administrar la prueba del VIH y dar resultados Dar referencias a los clientes Although HIV CTR may be conducted in a clinic or dedicated setting or in less conventional places as a part of outreach or other services (Comprehensive Risk Counseling and Services or other prevention interventions), each instance of CTR must follow a similar set of procedures, as follows. 1. Provide clear and simple information 2. Client-centered counseling 3. Testing methods 4. Client referrals 5. Staffing: 6. Environmental and structural issues 7. Recruitment of clients

34 1) Reclutar Clientes Referencias internas y externas: consejería del VIH, CRCS, y otros servicios Realizar alcance comunitario activo ej. anuncios de prensa, PSA, avisos en periódicos locales, anuncios en internet 8. Recruitment of clients Programs should use both active and passive recruitment methods: Referrals and recruitment can be done with HIV prevention counseling, Comprehensive Risk Counseling and Services, or other agency services. Referrals and recruitment can be done at other CBOs or agencies that serve populations at high risk for HIV (e.g., substance abuse treatment facilities, correctional facilities, shelters). Send press releases and public service announcements to radio stations and TV stations that serve specific populations at high risk for HIV. Advertise in local newspapers (e.g., neighborhood, gay, alternative). Post announcements on the Internet. The best recruitment strategy will depend on the setting in which CTR is being offered and any specific populations being targeted for this public health strategy.

35 2) Dar información La información debe de incluir:
Factores de riesgo para el VIH y prevención Tipos de pruebas y colección del espécimen Pruebas anónimas vs. confidenciales Cuanto tiempo toma la prueba 1. Provide clear and simple information The client is first given information about HIV and the HIV antibody test. This information must include: a discussion of the risk factors for HIV and how HIV can be prevented the type of test to be used and the manner in which the specimen will be collected the difference between anonymous and confidential testing the timeframe for testing, including when the results will be available and the importance of obtaining the results the meaning of positive and of negative test results the window period for HIV sero-conversion (so that the client can determine whether testing at a later time might provide more information) the need for partner services if the test result is positive the jurisdiction’s requirements for reporting positive test results to the health department

36 2) Dar información (cont)
El significado de resultados (positivos y negativos) El periodo ventana para la sero-conversión Servicios de contactos si los resultados son positivos Requisitos de la jurisdicción para reportar resultados positivos 1. Provide clear and simple information The client is first given information about HIV and the HIV antibody test. This information must include: a discussion of the risk factors for HIV and how HIV can be prevented the type of test to be used and the manner in which the specimen will be collected the difference between anonymous and confidential testing the timeframe for testing, including when the results will be available and the importance of obtaining the results the meaning of positive and of negative test results the window period for HIV sero-conversion (so that the client can determine whether testing at a later time might provide more information) the need for partner services if the test result is positive the jurisdiction’s requirements for reporting positive test results to the health department

37 3) Consejería centrada en el cliente
Preparar al cliente para la prueba Evaluaciones individualizadas de riesgo Enfoque en reducir el riesgo actual del cliente Metas realistas de cambio de comportamiento Identificar barreras y ayudas para lograr este paso 2. Client-centered counseling Client-centered counseling techniques should be used to help clients determine their readiness for testing and to provide support systems to access while waiting for and after receiving the test results. Client-focused counseling also assesses the client’s ability to cope with a positive test result. An individualized risk assessment should be conducted during the counseling session to determine the client’s risk behaviors. This information should be used to help the client better understand his or her risk and to enable the client and the counselor to identify, acknowledge, and understand the details and context of the client’s risk. The counselor should focus more on reducing the client’s current risk and less on general education about HIV transmission modes and the meaning of HIV test results. Next, the counselor should negotiate a concrete and achievable behavior change step to further reduce HIV risk. Behavioral risk-reduction steps can be established for each client. Identifying (using interactive discussion, role-playing, recognizing social support, or other methods) the barriers and supports to achieving a step will increase the likelihood of success. Clients with ongoing risk behaviors should be referred to additional prevention and related support services. After all aspects of the HIV antibody test have been disclosed, the client can make an informed decision about whether to be tested. The client should then provide consent (oral or written, as required by state and local policy).

38 4) Prueba de VIH y Resultados
Colectar el espécimen (sangre o saliva) Realizar la prueba de acuerdo a las instrucciones del fabricante Resultados al comienzo de la sesión de resultados (la misma cita para pruebas rápidas o cita de seguimiento para pruebas convencionales) 3. Testing methods A specimen is obtained and a conventional or rapid HIV antibody test is conducted according to the procedures outlined by the test’s manufacturer. If conventional HIV antibody testing is used, results are given at a second appointment. If rapid HIV antibody testing is used, a follow-up appointment may not be needed to deliver test results but may be desirable for additional prevention counseling. Results should be provided at the beginning of the results-giving session, using explicit language. Counselors should never ask the client to guess the test results.

39 5) Referencias a los clientes
Las referencias se dan en cualquier momento Conocimiento de recursos para referencias, (ej. consejería, servicios de contactos, y programas para PLH) Obtener consentimiento para compartir información 4. Client referrals Referrals for additional services may be made at any point in the CTR process for other services such as STD and viral hepatitis screening, housing, substance abuse prevention and treatment, etc. Agencies implementing CTR must be prepared to refer clients as needed. For clients who need additional help decreasing risk behavior, providers must know about referrals sources for prevention interventions and counseling, such as partner services and health department and CBO prevention programs for persons living with HIV. Consent for release of information to other agencies must be obtained as well as any inter-agency referral forms must be completed.

40 C. Control de Calidad Calificaciones del consejero usando La Guía de Procedimientos del CDC Consejeros entrenados apropiadamente en consejería, técnicas de pruebas y supervisión adecuada Implementar métodos de control de calidad ej. Supervisión, revisión de casos, conferencia de casos, encuestas de satisfacción

41 D. Evaluación de Capacidad
¿Capacidad para implementar CTR (personal, fondos, infraestructura, etc.)? ¿Habilidad de reclutar a la población para CTR? ¿Habilidad de implementar CTR con fidelidad? Assess the Agency’s ability to plan and implement CTR using its available resources. Does the Agency have the capacity to implement CTR (staff volunteers trained in CTR, appropriate facilities for conducting either conventional or rapid HIV testing). Does the Agency have the ability to recruit high risk populations for CTR? Does the Agency have the ability to implement CTR with fidelity to its core elements?

42 Servicios de contactos (PS)
PS=Partner Services por sus siglas en inglés Servicios de contactos (PS)

43 Servicios de Contactos (PS*)
Identificar las personas infectadas Notificar a los contactos de la posibilidad de exposición al virus Proveer a las personas infectadas y sus contactos una serie de servicios médicos, de prevención y psicosociales What is Partner Services? Partner services are a broad array of services aimed to 1) identify infected persons, 2) notify their partners of their possible exposure, and 3) provide infected persons and their partners a range of medical, prevention, and psychosocial services. Source: MMWR 2008

44 Tipos de Servicios de Contactos
Tres estrategias primarias para notificar a los contactos de posible exposición al VIH: Proveedor Personal Referencia del contacto What are the different types of Partner Services? Three primary strategies can be used to notify partners of possible exposure to STDs or HIV infection: Provider, Self, or Contact referral. Often, more than one strategy may be used to notify different partners of the same infected patient. The strategy will depend on the particular patient, the particular STD, and partner circumstances. For example, a patient with an STD may feel that he or she is in a better position to notify a main partner, but would prefer that the Disease Intervention Specialist (DIS) notify other partners. Source: NCSD 2008

45 Principios de PS Centrado en el cliente Confidencial
Voluntario y no coersivo Sin costo Basado en evidencia Cultural, linguisticamente, y edad apropiado. Accesible y disponible para todos Integral y complementario What are the principles of Partner Services? The following principles serve as the foundation for providing partner services to persons with HIV infection or other STDs and their partners: Client centered. All steps of the partner services process should be tailored to the behaviors, circumstances, and specific needs of each client. Confidential. Confidentiality should be maintained and is essential to the success of partner services. Confidentiality also applies to data collected as part of the partner services process. Voluntary and noncoercive. Participating in partner services should be voluntary for both infected persons and their partners; they should not be coerced into participation. Free. Partner services should be free of charge for infected persons and their partners. Evidence based. Partner services should be as evidence based as possible. Culturally, linguistically, and developmentally appropriate. Partner services should be provided in a nonjudgmental way and be appropriate for the cultural, linguistic, and developmental characteristics of each client. Accessible and available to all. Partner services should be accessible and available to all infected persons regardless of where they are tested or receive a diagnosis and whether they are tested confidentially or anonymously. Because of the chronic nature of HIV infection, partner services for HIV should be available on an ongoing manner. Comprehensive and integrative. Partner services should be part of an array of services that are integrated to the greatest extent possible for persons with HIV infection or other STDs and their partners.

46 ¿Como funciona PS? Ofrecido a todas las personas con diagnóstico reciente o infección reportada alguna vez, al momento del diagnóstico o tan pronto como sea posible después de este. Informar las personas de su exposición potencial a ETS, y referirlas a servicios, asi romper con la cadena de infecciones y reducir la morbilidad. How does Partner Services work? Partner services are provided almost exclusively by health departments, often by STD or HIV program staff members. PS should be offered to all persons with newly diagnosed or reported HIV infection at least once, typically at diagnosis or as soon as possible after diagnosis. Participation in partner services is voluntary only if it is informed and not coerced. The effectiveness of partner services PS attempts to inform people of their potential exposure to STDS, and to refer them into care, thereby breaking the chain of infection and reducing morbidity.

47 Componentes de PS Preparación de la organización Implementación
Control de Calidad Evaluación de capacidades

48 A. Preparación (organización)
Entender las leyes relacionadas a PS (ej. legales, HIPAA, limites en comunicación) Estándares de confidencialidad y ética Involucrar otras partes interesadas para el apoyo de las actividades de PS Barreras estructurales (ej. sistemas de reporte, Internet, seguridad de computadoras) Organization Preparation Legal authority (HIPAA, duty or privilege to warn) PS should adhere to applicable state/local laws, regulations, or statutes. A program should assure that policies and procedures developed (e.g., IPS methods, patient confidentiality, ethical conduct of employees) are in compliance with these laws, regulations, and statutes. Laws relevant to provision of these services include the following: --- the legal authority for the public health agencies for partner services; --- provisions related to privacy and confidentiality (e.g., requirements of the federal Health Insurance Portability and Accountability Act [HIPAA]); The HIPAA Privacy Rule allows protected health information to be disclosed by those public health authorities who are mandated to notify individuals of their potential exposure to a communicable disease --- provisions related to duty or privilege to warn and criminal transmission and exposure; and } --- the ability of the public health agencies to coordinate with other agencies (e.g., law enforcement). Confidentiality and Ethnics All PS activities must adhere to standards of confidentiality and ethics. Need to have well-trained staff that understands the legal basis and restriction of their practice (e.g., duty or privilege to warn), the extent to which they are protected from civil litigation, and how to coordinate with law enforcement officials in ways that protect the civil and procedural rights of the persons involved. Engagement of key stakeholders Engagement of key stakeholders can determine the success or failure of PS program. Important stakeholders include, among others, department programs, all partnering agencies, community clinics, CBOs, and agencies that service impacted. Environmental and structural issues (surveillance and disease reporting systems, Internet, computer security) To maximize the number of persons offered partner services, health departments should strongly consider using individual-level data, but only if appropriate security and confidentiality procedures are in place. At a minimum, health departments should use provider- and aggregate-level data from their surveillance systems to help guide partner services. For implementing Internet PS, it is critical that IT managers/staff and current program policies and procedures be consulted regarding issues of security, access to sexually explicit websites. Need computer access in clinics, Internet access, computer/Internet knowledge, fast Internet connections, address firewalls protecting Internet-enabled computers from gaining access to sexually explicit websites, and anti-virus and anti-spyware software.

49 B. Implementación de PS Identificar los pacientes índices
Obtener información sobre contactos y dar consejería de como reducir el riesgo Tratar los pacientes índices o referirlos a servicios médicos para tratamiento Referir los pacientes índices a otros servicios Implementation Procedures In general, these elements are relevant for partner services for HIV, early syphilis, gonorrhea, and chlamydial infection, although differences in how they are implemented vary by infection. Index Patients identifying index patients (i.e., infected persons who are candidates for partner services) and prioritizing them for partner services; introducing partner services to index patients and conducting interviews to elicit information about their partners; counseling index patients about reducing their risk for acquiring or transmitting infection to others and referring them for additional prevention services, if needed; treating index patients or linking them to medical care and treatment; and referring index patients to other services. Partners notifying partners of their exposure; counseling partners about reducing their risk for acquiring HIV infection and other types of STDs and referring them for additional prevention services, if needed; offering partners STD/HIV testing; treating partners or linking them to medical care and treatment; and referring partners to other services.

50 B. Implementación de PS (cont)
Notificar los contactos de su exposición y dar consejería de como reducir sus riesgos Ofrecer a los contactos pruebas de ETS/VIH Tratar a los contactos o referirlos a servicios médicos para tratamiento Referir a los contactos a otros servicios

51 1) ID los pacientes indices
PS al momento del diagnóstico o tan pronto como sea posible Sistemas de vigilancia y reporte de enfermedades para identificar los candidatos Confidencialidad y seguridad de información Colaborar con otros proveedores de salud Ofrecer PS a proveedores de pruebas anónimas Identify index patients PS should be offered to all persons with newly diagnosed or reported HIV infection at least once, typically at diagnosis or as soon as possible after diagnosis. PS should use surveillance and disease reporting systems to assist with identifying persons who are potential candidates for PS. PS should establish and adhere to strict, jurisdiction-specific guidelines, policies, and procedures for information security and confidentiality. PS should collaborate with health-care providers who provide HIV testing, other HIV counseling and testing providers, HIV care providers, and HIV case managers to ensure that their clients and patients are offered PS as soon as possible after diagnosis and on an ongoing basis, as needed. PS should work with providers of anonymous HIV testing services to develop strategies for providing PS to persons who test positive, even if the person decides not to enter a confidential system.

52 Prioridades/pacientes índices
Mujeres embarazadas o pacientes índices con parejas embarazadas Comportamiento de alto riesgo Co-infecciones y ETS recurrentes Carga viral alta (>50,000 copias/ml) Infección aguda o reciente Prioritize index patients Establish criteria for prioritizing index patients to determine which patients will be interviewed first. Pregnant women and male index patients with pregnant partners. Pregnant women are at risk for transmitting HIV and other types of STDs to their fetus both in utero and during delivery. Newborns also are at risk for becoming infected with HIV through breastfeeding. Prioritizing pregnant women for interview gives DISs an opportunity to verify that the women have received appropriate treatment or, for those with HIV infection, have been successfully linked to medical services so that they can be treated with ART to reduce the risk for motherto-child transmission. Index patients suspected of or known to be engaging in behaviors that substantially increase risk for transmission to multiple other persons (e.g., have multiple sex or drug-injection partners). Such persons can facilitate rapid spread of infection through a community. This group includes persons who were previously named as partners by other index patients. Persons coinfected with HIV and one or more other STDs. Evidence suggests that STDs (both ulcerative and nonulcerative) facilitate transmission of HIV, increasing the likelihood that the index patient has transmitted or will transmit HIV to a partner (66). Persons with recurrent STDs. Recurrent infections might indicate nonadherence to treatment, untreated partners, continued exposure to STDs through high-risk behaviors, or infection with drug-resistant strains. In certain geographical areas and among certain closely defined populations, prevalence is sufficiently high that otherwise moderate risk behavior confers high risk for STD exposure (67). Persons with a high HIV viral load (e.g., >50,000 RNA HIV copies/ml). High serum viral load is associated with increased risk for HIV transmission (32). Therefore, index patients with a high viral load generally are more likely to have transmitted infection to partners. High viral load often is associated with acute infection but also can occur at different points during the course of the disease. Persons with evidence of acute infection (e.g., HIV RNA positive and HIV antibody negative) or recent infection (e.g., current positive HIV antibody test with recent negative HIV antibody test). Rapid follow-up for recently infected persons might provide information about networks in which transmission is active and ongoing and offer an opportunity to interrupt chains of transmission (70).

53 2) Entrevista/pacientes índices
Obtener los nombres de los contactos Entrevista cerca de la fecha de diagnostico o reporte Habilidades en consejería y entrevista Entrevistas preferentemente en persona Obtener información de redes sociales, lugares mas frecuentados, para planear actividades de prevención Interview index patients In general, partner names should be elicited (partner elicitation) during the original interview. If this is not possible, a reinterview should be scheduled. Programs should establish clear policies and procedures for the timing of interviews relative to date of diagnosis or report. Index patients should be provided information about the following: • the purpose of partner services; • what partner services entail; • benefits and potential risks of partner services for index patients and their partners, and steps taken to minimize any risks; • how and to what extent privacy and confidentiality can be protected; • the right to decline participation in partner services without being denied other services; and • options available for notifying partners. Program managers should ensure that policies and protocols are in place to safeguard the confidentiality of information shared with health department staff members during the partner notification process. Partner-elicitation interviews should be conducted by trained health department specialists; Successfully eliciting information about partners requires skilled counseling and interviewing; therefore, all providers conducting interviews on behalf of the health department should receive appropriate training. In general, interviews should be conducted in person. Telephone interviews might be conducted if no reasonable alternative exists Programs should use interview techniques that maximize the amount of information gathered in the original interview about the index patient’s partners. In addition to information about partners, interviewers also can elicit information about the index patient’s social network, including venues frequented, for use in planning additional prevention activities. Policies, procedures, and protocols should specify that all index patients receive an original interview as soon as possible after diagnosis, ideally within a few days. For index patients who are not willing or able to provide partner information during the original interview, a reinterview should be scheduled, preferably no later than 2 weeks after contact was first made (and sooner, if possible, for index patients with acute infections). Programs should develop criteria for establishing the interview period for index patients with HIV. Policies, procedures, and protocols should address interviews for persons with reactive rapid HIV tests, including when partner names should be elicited, when partners should be notified, and policies about notifying partners when a confirmatory test is not available.

54 3) Tratar pacientes indices
Trabajar con otros proveedores servicios de VIH y manejadores de caso para las cubrir necesidades de atención de pacientes índices. Referir o conectar directamente los pacientes infectados con VIH a servicios médicos y manejadores de casos quienes los conectaran a los servicios de atención Provide treatment for index patients Program managers should create strong referral linkages with HIV care providers and case managers to help ensure that the medical needs of index patients are addressed. HIV-infected index patients who are not receiving medical care should be referred or directly linked to medical care or to case managers who can then link them to care services.

55 4) Referir pacientes indices
Identificar los recursos psicosociales y otros servicios de apoyo Evalúe las necesidades inmediatas para hacer las referencias apropiadas. Refer index patients to other services Because of the diverse needs of many index patients with HIV and other STDs, program managers should identify resources for psychosocial and other support services. DISs routinely should be provided updated information about referral resources. Many referral needs can be addressed through linkage to medical care and HIV case management; however, DISs should screen for immediate needs and make appropriate referrals.

56 5) Notificar contactos Notificar contactos de posible exposición dentro de 2-3 días Evaluar posible reacción violenta antes de la notificación Prioridad en contactos a notificar Preferencia a referencia de proveedor. Apoyar paciente si decide por referencia de contacto. Permitir auto-referencia si lo permite las regulaciones estatales o locales Notify partners of exposure All identified partners should be notified of their possible exposure as soon as possible, typically within 2–3 working days of identification, unless a potential for partner violence exists. Program managers should ensure that protocols include screening for potential violence with each partner named before notification. If the provider considers a violent situation possible, the provider should seek expert advice before proceeding with notification. DISs should follow up on referrals for partner violence services to verify that referred persons are safe and have accessed these services. Programs should establish criteria for prioritizing the order in which partners are notified. Criteria should be based on behavioral and clinical factors that confer a higher likelihood of the partner having been infected as a result of exposure or, if already infected, of transmitting infection to others. PS should strongly encourage provider referral but be supportive of index patients who choose contract referral for selected partners. Programs should allow for self-referral as permitted by state and local laws and regulations. Index patients who choose self-referral for certain or all partners should be informed of its disadvantages and informed about methods for accomplishing the notification safely and successfully. Self-referral should be discouraged if screening indicates a potentially violent situation.

57 Reduccion de riesgo/contactos
Proveer consejeria de prevencion  Determinar necesidad de intervenciones adicionales y referencias Proveer entrenamiento adecuado y supervision a los consejeros Offer risk reduction interventions for partners All partners of STD/HIV-infected index patients should receive prevention counseling. Program managers should develop protocols for screening partners to determine whether they need additional risk-reduction interventions and refer them for such interventions. Program managers should develop protocols to ensure that DISs conducting prevention counseling receive adequate training and supervision and ensure that quality improvement plans are in place.

58 6) Pruebas VIH/ETS a contactos
Realizarlas al momento de notificación O referir a otros servicios de pruebas Seguimiento con quienes no se hizo las pruebas durante la notificación  Test rápidos maximizan el numero de pruebas y resultados entregados Recomendar nuevas pruebas en 3 meses a contactos con resultados negativos Offer HIV/STD testing to partners Testing for STDs/HIV should be done at the time of notification. Partners who are not tested at the time of notification should be escorted or referred to the health department for testing or linked to other health-care providers who can provide these services. DISs should follow up on partners not tested at the time of notification to verify that testing has occurred, test results were received and understood, and other referral services were accessed. Program managers should explore ways in which screening for HIV, screening and treatment for other STDs Partner services programs should consider using rapid HIV tests to maximize the number of partners who are tested and receive test results. When notification is done in the field, rapid tests should be used or a blood or oral fluid specimen should be collected for conventional testing. If neither of these is possible, the partner should be escorted or referred to the clinic for testing. Partners who test negative for HIV antibody should be advised to be retested in 3 months.

59 7) Tratar los contactos Referencia a proveedores de servicios y manejo de casos, para las necesidades médicas de los contactos positivos Referir o conectar directamente los pacientes infectados a manejo de casos (servicios de atención) Informar a los contactos expuestos dentro de las primeras 72 horas sobre PEP Provide treatment to partners Program managers should create strong referral linkages with HIV care providers and case managers to help ensure that the medical needs of HIV-infected partners are addressed. Partners who test positive for HIV should be linked as soon as possible to early intervention services, medical care, and HIV case management, through which they can receive complete medical evaluations and treatment, assessment, and referral for psychosocial needs, and additional prevention counseling. Follow-up should be conducted to verify that HIV-infected partners have accessed medical care or HIV case management at least once. Partner services programs implementing postexposure prophylaxis (PEP) should develop protocols to ensure that persons exposed to HIV within the previous 72 hours are informed of the option of PEP, including risks and benefits as they relate to the exposure risk. Staff members conducting partner services should be aware of the options for persons to access PEP, whether through existing programs, urgent care facilities, emergency departments, or private physicians.

60 Referencias Identificar fuentes de referencias para servicios sicosociales y de apoyo Referir contactos infectados con VIH para intervención temprana, atención medica, y manejo de casos Seleccionar y referir contactos negativos a otros servicios médicos, sicosociales y de prevención Refer partners to other services Because of the diverse needs of partners, program managers should identify referral resources for psychosocial and other support services. DISs routinely should be provided updated information about referral resources. Many referral needs of partners testing positive for HIV will be addressed through linkage to early intervention, medical care, and HIV case management; however, DISs should screen for immediate needs and make appropriate referrals. Partners testing negative for HIV should be screened and referred for other medical and psychosocial needs and prevention services.

61 C. Control de Calidad Evaluaciones frecuentes, rutinarias y estandarizadas Usar instrumentos de colección de datos, bases de datos seguras, listas de contactos y referencias, reportes de actividades y herramientas de observación. Assessing Quality Assurance of Partner Services Quality assurance and monitoring must be conducted through frequent, routine, and standardized evaluation Documentation is vital to the evaluation of PS Quality Assurance activities can include various data collection forms or secure, password protected databases, including contact and referral logs, activity report forms, and activity observation tools.

62 D. Evaluación de la capacidad
¿Tiene capacidad para implementar PS? (ej. personal, seguridad, colaboraciones)? ¿Tiene la habilidad de identificar pacientes y sus contactos para PS (ej. Sistemas de vigilancia epidemiológica y reporte)? ¿ Tiene la habilidad de implementar PS con fidelidad a sus elementos centrales? Agency readiness to implement Partner Services Assess the Agency’s ability to plan and implement PS using its available resources. Does the Agency have the capacity to implement PS (e.g. staffing, security measures, community partners,)? Does the Agency have the ability to identify patients and partners for PS (e.g. surveillance and disease reporting systems)? Does the Agency have the ability to implement PS with fidelity to its core principles ?

63 ¡Gracias!

64 Shared Action Es financiado por The Centers for Disease Control and Prevention (CDC) para proveer servicios GRATUITOS de consultoria y asistencia técnica a organizaciones de bases comunitarias que implementen programas de prevención del VIH : Infraestructura Organizacional y Sustentabilidad del Programa Intervenciones Basadas en Evidencia y la Estrategias de Salud Pública Evaluación y Monitoreo

65 Funded by the Centers for Disease Control and Prevention
Contact Information Miguel Chion, MD, MPH (213) Oscar Marquez (213) Funded by the Centers for Disease Control and Prevention