1. Incorporating prevention interventions into
a busy practice
Presented By: BETH PACE, M.ED
Wellness Specialist
NO/AIDS Taskforce

2.  To obtain basic information regarding HIV/AIDS
transmission, rates and prevalence in Louisiana, and harm
reduction strategies for reducing risk of HIV exposure and
transmission in young men who have sex with men
 To obtain a brief review of current guidelines and peer-
reviewed research regarding prevention counseling and the
barriers to its implementation, including personal
discomfort and attitudes toward human sexual behaviors
 To obtain practical strategies for implementing harm
reduction techniques to reduce sexual risk
 To receive a brief review of person-centered counseling
theory and its role in sexual health counseling

3.  Knowingly exposing another individual to HIV should carry
a criminal penalty.
 1) agree 2) disagree
 HIV testing in jails and prisons should be mandatory,
without obtaining a person’s informed consent.
 1) agree 2) disagree
 Risk reduction plans should always be based around
condom use 100% of the time, reducing the number of sex
partners, talking about STIs and HIV with new partners,
and routine testing.
 1) agree 2) disagree
 Unprotected anal intercourse with an anonymous partner
is the way I most enjoy sex.
 1) agree 2) disagree

4.  MSM: Men who have sex with men.
 Gay, bi, queer, pan
 There are other names used to identify men
who have sex with men:
 Down-low
 MSMW: Men who have sex with men and women
 questioning, STRAIGHT, other…
 The act of engaging in sexual activity, either
penetrative or non-penetrative acts, with a
man, no matter how the client self-identifies
 How do we find out what our clients lives are
like?

5. 0 100 200 300 400 500 600
Perinatal
Heterosexual Contact
MSM who inject drugs
Injection Drug Use
Men who have sex with men
Cases with a Reported Risk
252
Cases where no identified risk was reported: 429 total
HIV Cases diagnosed January – December 2011
1,247 persons were newly diagnosed with HIV in Louisiana
482

7.  Modes of transmission
 Fluid exchange: blood, semen, vaginal secretions, and breast milk
 Anal intercourse
 Anal and rectal tissues are delicate, easily damaged, and don’t provide natural lubrication, and that can
provide entry for pathogens
 Co-occurring sexually transmitted infections increase transmission risk.
 Condom use: condoms are not used as a birth control method, just for STI prevention
 What lessens the incentive to use condoms?
 Reticence to talk about sex
 Both providers and clients experience this
 Doctors assume patients will bring it up if they need to, patients assume doctors will bring it up if it’s
necessary.
 “Bare backing” or “Raw” sex is on the rise
 Youth feelings of invincibility
 Treatment optimism
 Undetectable viral load
 Clients engage in their own “rational” risk reduction strategies that have nothing to do with condom
use or disclosure of status
 Substance use plays a role in lowered inhibitions and higher risk activities
 Prevention Fatigue
 Rates & prevalence of HIV & STIs in our geographic area.
 “Among African Americans, black MSM are the hardest-hit subpopulation. Studies have found that
almost 50% of black MSM are infected in some cities.” (CDC, 2009)
 “For African American men, sexual behavior with other men accounts for 63% of all HIV infections
nationwide.” (CDC, 2007)
 Culture, masculinity, and sexuality interact to create a complex landscape for HIV risk for MSM.

8.  When the intervention is medical, HIV
prevention works!
 Anti Retroviral Therapies: Treatment as prevention
 CD4, Viral Load, and transmission risks
 Viral Suppression
 Pre Exposure Prophylaxis
 Reduction in mother to child transmission of HIV
 Screening blood for transfusion recipients
 When the prevention efforts are behavioral,
there are larger barriers to prevention.
 Injection drug use
 Sexual transmission of HIV (and other STIs)
 Substance use and sexual risk behaviors

9.  July 16, 2012: The FDA approves
Truvada(emtricitabine/tenofovir disoproxil
fumarate) to reduce the risk of HIV infection in
HIV negative individuals who are at high risk of
infection.
 The iPrEx trial evaluated Truvada in 2,499 HIV-
negative men or transgender women who have
sex with men and with evidence of high risk
behavior for HIV infection.
 Results showed Truvada was effective in
reducing the risk of HIV infection by 42 percent
compared with placebo in this population.
Efficacy was strongly correlated with drug
adherence in this trial.

10.  A. I think a healthy sex life is an integral
part of the human experience.
 B. It’s not that important to me.
 C. I love it! I just don’t like talking about
it….
 D. Expressing myself sexually is a challenge
for me.

12.  a. I feel totally comfortable talking about sex with clients.
 b. I often feel uncomfortable talking about sex with clients.
 c. I feel more comfortable talking about sex with certain clients,
especially when I feel like I understand where they’re coming
from.
 d. I’m worried about damaging the rapport that I’ve built with
clients, and so I don’t have in depth discussions about sex.
 e. I’m sure if they have questions, they’ll ask me.
 f. I don’t feel comfortable talking about sex with clients because
I don’t feel like I’ve received enough training in that area.

13. Where our
clients are
Where we
think they
should be!!!
Who decides what a
good risk reduction
strategy would be?

14.  Work to manage discomfort and to identify
barriers in talking to clients about sex and risk.
 In bracketing our beliefs and expectations, we
can come from a more open minded, flexible,
innovative and creative place when talking about
harm reduction. We can, with great empathy,
support our clients’ wishes and desires while
reducing the spread of HIV and AIDS in our
community.
 “Addressing health issues ‘from’ the perspective
of the target population rather than ‘about’ them is
emphasized.”
(Gastaldo, et al. 2009)

15.  Carl Ransom Rogers was an American
psychologist who was one of the founders of the
humanistic approach to psychology
 Rogers believed that therapists and helping
professionals must exhibit three major traits:
 Empathy
 Genuineness or Congruence, and
 Unconditional Positive Regard
 “It is not that this approach gives power to the
person; it never takes it away.”
 “…not a matter of doing something to the
individual, or of inducing him to do something
about himself. It is instead a matter of freeing
him for normal growth and development.”

16.  Carlos is a 43 year old Hispanic man who has been
seeing you for three weeks complaining of general
anxiety and problems in his marriage.
 Over time, Carlos shares with you that he has been in
a same sex partnership with an HIV positive man for
roughly four months.
 Carlos tested positive for HIV one month ago. He has
been avoiding the risk of transmitting HIV to his wife
by avoiding all sexual contact with her.
 According to Carlos, however, his wife has expressed
the desire to have another child, and has been
making sexual advances towards him that have been
difficult for him to avoid.
 Last week, he had penetrative sex with his wife
without using a barrier (condom) and is feeling
intense guilt.

17.  A. I feel upset that this client would
knowingly expose another person to HIV.
 B. I strongly identify with the wife in this
scenario. She’s getting deceived.
 C. I empathize with Carlos. He seems to be
struggling with his culture, sexual
orientation, and identity.
 D. I feel mixed emotions about this case.

18.  unconditional positive
regard… is defined as
accepting a person
without negative
judgment of .... [a
person's] basic worth.
 Virtuous Cycle
 What is conditional
positive regard?
 Vicious Cycle
Increased Self
Awareness
Increased Self
Acceptance
Increased Self
Expression
Reduced
Defensiveness
Increased
Openness

19. What can I ask a client to
briefly assess if they are
already implementing any
harm reduction strategies?
How can I validate their
efforts (if any) and appeal
to their value system
without seeming judgmental
or dismissive?
How can I be empathetic
while still asking for
realistic safer sex goals?
 What are the things you already do to reduce
your risk of exposure to HIV and STIs?
 What would be your ideal sex
life/partnership/relationship?
 What’s a way that you could add one small thing
to your existing risk reduction efforts?
 When was the last time someone told you that
you deserve to have the kind of safe, healthy,
and happy sex life you want for yourself?
 As providers, can we check in with ourselves to
make sure that we believe the above statement?
 If not, how can we [bracket] our values in order
to be genuine, empathetic and offer UPR?

20. How do you feel about HIV+ people, their sex
lives, and what they desire?
a) HIV+ people have an extra responsibility to protect others from
the transmission of HIV which precludes their own personal needs.
b) HIV+ people need the same love, intimacy, physical contact and
sexual expression than do HIV- people.
c) The responsibility for protecting oneself from exposure to HIV and
STIs is equal between both sex partners.
d) HIV+ people face certain barriers to the sex life they want, such
as shame, guilt, stigma, issues around disclosure and judgment from
partners, that must be addressed before they can have the sex life
they desire.

21.  Asking broad questions about sexual
relationships
 #1 What are the qualities of a healthy
relationship?
 #2 Is there sufficient choice to make this
relationship healthy?
 #3 What does a healthy, equitable power
balance in a relationship look like?
 #4 What are you seeking out of your sexual
relationships?

22.  The all-or-nothing approach
 limitations
 What’s the cost vs. the benefit of using condoms? Are
you ready to make a change?
 Decisional balance worksheet
 What’s available to our clients?
 Using condoms, pulling out, using more lube, non-
penetrative sex acts
 What are you getting out of the sex you’re having? What
do you like about it? What don’t you like about it?
 Other ideas?
 Creative risk reduction
 Spectrum of risk (a scaling question)
1 2 3 4 5 6 7 8 9 10

23. Client is a 25 year old African American MSM who
has been HIV positive for three years.
Client reports that he has tested positive for both
gonorrhea and syphilis in the past six months
Client shares that he “only bottoms” with
anonymous partners, but when he is using cocaine
and alcohol, he will also act as the penetrative
anal partner.
The client has shared that he suspects he has been
re-infected with gonorrhea.
Client appears receptive to risk reduction
counseling, but you are unsure of where to start.

24.  A. It frustrates me that he’s putting other
people at risk.
 B. I recognize some of his current efforts to
reduce the risk of exposing his partners to
HIV, but he needs support.
 C. He’ll never be able to implement
successful risk reduction techniques until he
addresses his substance use.
 D. Due to his past history, I feel like no
matter what information I impart to him, it’s
unlikely that his behaviors will change.

25.  1. I’d ask him about his condom use.
 2. I’d like to know what he is seeking to gain
from these behaviors.
 3. I want to know more about his substance
use in relation to his risk behaviors.
 4. I want to assess his knowledge of HIV
transmission and risk factors.

26.  What behaviors can we support?
 He’s self-referred for treatment today, his health matters to him
 When he’s sober, he reduces the risk of transmitting HIV to
partners by acting as the receptive anal partner.
 He seems curious about risk reduction counseling.
 Other behaviors to support?
 What information should we impart?
 Ask him how much he already knows
 What would he like to know more about?
 What does he want to get out of his time with us?
 What goals can we set? How?
 Using condoms, pulling out, using more lube, non-
penetrative sex acts
 What is he getting out of the sex he’s having? What
does he like about it? What doesn’t he like about it?
 Other ideas?

27.  Service providers’ attitudes
towards MSM can be negatively
affected by beliefs that pervade
the general community
 How does our culture view MSMW?
 MSMW are often perceived as “selfish, sneaky,
and really sick” by others in their community.
 What does seeking help for distress mean to the
personal and cultural concept of masculinity?
 We may need additional training
to provide appropriate and non-
judgmental HIV prevention
counseling
 Why do people lie?
 A fear of discrimination and rejection
 Homophobia and negative attitudes toward
men’s same sex-behaviors create an unsafe
environment for honesty
 Previous experiences with personal biases and
negative judgments around sexuality
 Prejudiced and judgmental
beliefs can be “unlearned”
through education and
exposure to members of
socially de-valued groups
 What resources are available
to you for continuing education
and training?
 http://www.hiv411.org/page.php?
pID=107&n=Training
 2 day, HIV counseling, testing and
referral training
 Certified by the Louisiana Office of
Public Health
 Practice talking about sex!
A specific focus on African American men who have sex with men
(and women).
Saleh, L. D., Operario, D., Dillard Smith, C., Arnold, E., & Kegeles, S. (2011). “We're going to have to cut loose some of our
personal beliefs": Providing hiv prevention to african american men who have sex with men and women. AIDS
Education and Prevention, 23(6), 521-532. doi: doi: 10.1521/aeap.2011.23.6.521

28.  How do we measure success in our practice?
 Empathy, genuineness, UPR.
 Creating a safe space
 What are realistic goals we can set for
ourselves?
 Expanding the bounds of our competence to
issues that our clients are facing in their daily
life and communities
 Where can we get support in our prevention
efforts?

29.  Grant funded by the CDC (10 1003) for Region 1 of
Louisiana (Greater New Orleans)
 High risk HIV+, and high risk HIV- persons
 Designed for persons who struggle with issues such as
substance use/abuse, physical and mental health,
social and cultural factors that affect HIV risk
 Intensive, one-on-one, individual client centered
counseling for adopting and maintaining risk
reduction behaviors
 Free and Incentivized
 Clients who receive positive test results for STIs are
an appropriate referral to this program
 Injection drug users are also appropriate for CRCS

31. www.hiv411.org
http://www.positivelite.com/compone
nt/zoo/tag/news/gay%20poz%20sex
http://prepfacts.org/the-questions/
www.noaidstaskforce.org
http://www.theroot.com/views/cheat-
sheet-talking-about-safe-sex
Helpful Websites:

32. A full list of references is available by request