Principal Investigator: Shiela M. Strauss, Ph.D.
Funding Source: NIH
NDRI Center/Institute: Inst. for Treatment and Svcs. Research
Project Name: Supporting Alcohol Reduction in HIV+ patients: A Training for HIV Care Providers (Project STAR)
Project Period: 09/30/2006 - 05/31/2009
Project Description:
Objectives: Although morbidity and mortality of patients with HIV have decreased considerably in the past decade with the introduction of ARV therapy, many individuals with HIV continue to seriously jeopardize their health by using and abusing alcohol. These individuals experience more rapid disease progression and HIV-related complications as a result of alcohol use, are considerably less likely to be adherent to the medication, and are more likely to engage in risky sexual behaviors while under its influence, exposing both themselves and their partners to a variety of sexually transmitted infections. Of great concern is the considerable rate of co-infection of HIV and hepatitis C virus (HCV), with the consequence that end-stage liver disease, accelerated as a result of alcohol use among those co-infected, has become a leading cause of illness and death among co-infected individuals. Unfortunately, individuals with HIV infection and HIV/HCV co-infection are often not counseled about the risks that alcohol use poses to themselves and others. Importantly, HIV care providers are uniquely situated to screen and counsel their patients on alcohol reduction. To support such efforts among health practitioners, the National Institute on Alcohol Abuse and Alcoholism has created a Clinician’s Guide on a Brief Alcohol Intervention (NIAAA’s BI), and such brief interventions have consistently proven to be effective in a variety of venues and among a variety of populations. Unfortunately, because many HIV care providers lack experience, confidence, and skills to implement such an intervention, few routinely screen their HIV patients for alcohol use or sufficiently counsel them about the importance of reducing this use in order to preserve their health and that of their sexual partners. Thus, there is a critical need to train HIV care providers to use NIAAA’s BI and to put it into regular practice.
The Specific Aims are therefore:
(1) To develop a state-of-the-art provider training to encourage the implementation of NIAAA’s BI by (a) teaching participants how to screen patients for alcohol use, and (b) using the principles of motivational interviewing, how to effectively counsel them to reduce this use;
(2) To implement the training in 4 hospital-based, state licensed, comprehensive HIV Care Centers (Designated AIDS Centers - DACs) in New York City (NYC), and to obtain and analyze preliminary data regarding the impact of the training on providers immediately post-training, and 1- and 3- months post-training in their knowledge, attitudes, self-efficacy, perceptions of collective organizational efficacy, and actual use of NIAAA’s BI to assist patients in reducing their alcohol consumption. Two additional NYC DACs will serve as control condition sites, receiving the training after all of their data collection is completed; and
(3) To obtain preliminary data in order to examine the impact of the provider training on (a) the HIV provider organization, in terms of the organizational climate towards dealing with alcohol and HIV and HIV/HCV co-infection and the organization’s actual expansion of existing alcohol reduction services and/or the implementation of new services to reduce alcohol consumption, and on (b) patients’ alcohol reduction.
Methods: Recruited from a variety of HIV care organizations, HIV care providers involved in Phase 1 of the study will receive an initial version of the training at NDRI’s central offices, and will complete an initial set of assessment instruments. After modifications are made, the revised training and instruments will be delivered on-site to providers at 2 Designated AIDS Centers (DACs) during the study’s second Phase. After further modification to the training and instruments, providers in 4 final DACs will receive the training on-site during Phase 3. Two of these 4 DACs will receive the training immediately after baseline data collection, serving as “intervention” sites. The remaining 2 DACS will receive the training after all data collection is complete, and serve as “control” sites. To evaluate the training’s impact, providers in the intervention sites will complete quantitative instruments at baseline (pre-training), immediately post-training, and 1- and 3- months later. We will analyze changes in HIV care providers’ responses over time in the baseline and post-training periods on their knowledge about BIs’ components and effectiveness; their attitudes about, and self- and collective efficacy concerning BIs’ implementation; and their use of BIs. To provide an in-depth understanding of the providers’ evaluation of the usefulness of the training and their actual use of NIAAA’s BI, qualitative data will be collected from them in 1:1 interviews at the 1- or 3-month post-training periods. Because the first stage of NIAAA’s BI involves screening patients for alcohol use with the AUDIT, preliminary indication of the training’s effectiveness will be obtained in the 1-month post-training period by comparing aggregate patient baseline AUDIT with those obtained from these same patients 3 months later to determine alcohol reduction. To examine change over time in organizational actions taken and priority given to assess and counsel patients on alcohol reduction, organizational level data at baseline and 3-months later will be obtained from the program’s director. With the exception of training-related questions, HIV care providers in the 2 DACs in the control sites in Phase 3 will complete the same quantitative assessment instruments as those in the intervention sites at baseline and 1- and 3-months later, receiving the training after all data collection is completed. Analyses will compare Phase 3 intervention and control site providers on change over time in their knowledge, attitudes, and self- and collective efficacy concerning BIs, and their self-reported use of BIs, enabling an estimate of an effect size for the training intervention. Data from control site directors will also be collected at baseline and 3-months later, using the same instruments as those used with intervention site directors, again eliminating training-related items. After data analysis is complete, the training, assessments, and training protocol will be finalized.
Dissemination and Applications: Successful components of the training will be disseminated to HIV Care Centers and researchers through written reports in professional and scientific journals, at scientific and professional conferences, and through NDRI’s website and Training Institute. If the training is shown to be effective, the applicant team intends to apply for an R01 grant which will build on the results of this exploratory study. The larger study would expand the examination of the effectiveness of the training using a larger sample of programs that include a variety of types of HIV Care Provider Agencies (e.g., community-based, hospital-based programs), in diverse geographical regions (e.g., rural, urban). Such a study would also have a more extended follow-up period to assess the sustainability of the training’s impact on individual providers and organizational practices. There would also be an in-depth focus on the effectiveness of the BI on patients’ alcohol reduction.
