Clinical Considerations

Risk Reduction Interventions and Strategies for HIV/HCV

HIV prevention programs that primarily dispense AIDS information have not been shown to influence risk behavior levels because, as evidence from studies demonstrates, knowledge by itself is necessary but not sufficient to produce behavioral changes. Intensive, small-group programs that simultaneously target knowledge, attitudes, motivations, and cognitive and behavioral skills have been tried and found to produce reductions in high-risk sexual behaviors, including some that are substance related, among people with serious mental illness.

Effective elements from randomized outcome trials of these HIV risk-reduction interventions (Kelly 1997; Otto-Salaj et al. 2001) include

1) information and skills training in sexual assertiveness, negotiation, problem solving, use of condoms, and risk self-management;
2) intensive sessions (6­15 hours to achieve reductions in high-risk behaviors);

3) training participants to become AIDS educators or advocates;
4) booster or maintenance sessions, which appear to be necessary to sustain safer behaviors;
5) gender sensitivity training employing single-gender groups for dealing with same-sex partner issues or for decreasing patients' anxiety about discussing sexual issues with the opposite sex, or mixed-gender groups for increasing generalization from group exercises to real-life situations for heterosexual patients;
6) inclusion of sexually abstinent patients to train those who may not remain abstinent or who may validate for other patients the legitimate choice of an abstinent lifestyle; and
7) harm reduction as the ultimate goal for both sexual and drug-related risk behaviors. Patients can benefit from participating in mixed­HIV serostatus prevention groups; no one need reveal their HIV status unless they wish to do so.

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Whatever the group's composition, group leaders should leave time at the end of each session to discuss patients' personal issues privately and to address their needs by making appropriate referrals, including ones to HIV test sites.

Because HCV shares modes of transmission with HIV, groups focused on HIV risk reduction may also wish to impart information about HCV and the possibility of acquiring HCV infection through high-risk behaviors. Prevention efforts aimed at HCV are essential for patients who are currently (or at risk for) injecting drugs, because injection drug use is the risk factor responsible for the majority of HCV cases. Once staff have received training to perform prevention interventions, they typically become motivated to start intervention groups for patients.

Keeping groups going can be difficult in programs that have little patient turnover; groups work best in day programs and outpatient programs. In inpatient units, short lengths of stay may limit the number of sessions patients can attend, but that should not discourage staff from setting up such programs. In the case of HIV-positive patients, individual counseling can reinforce patients' motivations to protect themselves and others. Clinicians can encourage disclosure to sex partners and use of condoms. Fully informed decisions about risk and protection of others are the goals.