Topic 8: HIV Risk Reduction
Tasks for Topic 8
- Assessing the patients' risk for HIV infection and building motivation to change risk behaviors
- Setting behavior change goals
- problem solving barriers to risk reduction
- Distributing specific risk-reduction guidelines
Generally, few cocaine abusers who do not engage in concurrent opioid use also use injection works (syringe, cotton, water), and thus tend to have low levels of risk for HIV infection from unsafe needle practices. However, most have substantial risk from unsafe sexual practices. Depending upon their level and type of risk for HIV infection, patients may be offered an HIV risk-reduction module in addition to their regular sessions.
The goals for this session are to -
- Assess the patients' risk for HIV infection and build motivation to change risk behaviors.
- Set behavior change goals.
- Problemsolve barriers to risk reduction.
- Distribute specific risk-reduction guidelines.
Therapists should help patients review their level of risk and their history of HIV testing. This can be done in discussion or by having patients complete a standardized instrument such as the HIV Risk Behaviors Inventory (Metzger et al. 1992). When using a formal test, scores should be presented in writing, with copies for the patients. Therapists should ask for patients' reactions to their level of risk and reflect and elaborate on their reactions.
Patient: "I guess I didn't realize how many people I had sex with since I've been on this run."
Therapist: "What do you make of this?"
This strategy can bolster awareness of risk and increase motivation for change.
Build Motivation To Change
In assessing and reviewing the level of risk, therapists should use the following motivational strategies. (From Miller et al. 1992.)
- Affirm the patient ("I think its great that you're willing to be honest with yourself and take time to look at your level of risk.").
- Reframe ("You're concerned about your level of risk, but you can't see yourself being celibate, either.").
- Roll with resistance ("You're jumping ahead a bit here. Right now, we're just getting a sense of where you are regarding drug injection practices and unsafe sex behaviors. Later on, we can talk about what, if anything, you want to do about it.").
- Explore consequences of action and inaction.
- Communicate free choice.
- Elicit self-motivational statements ("What do you want to do about this," "Tell me why you think you might need to make a change.").
If patients are ready to make a change, therapists work with them to set realistic, concrete risk-reduction goals for sexual and/or injection drug behavior risk, as appropriate (e.g., "I want to start using condoms with Jim this week"). Therapists should also encourage patients to identify barriers to risk-reduction goals (e.g., "You've come up with good, realistic goals that should lower your risk substantially. Now, what might get in the way of your meeting those goals?"). Barriers can include anticipated problems with negotiating condom use with a sexual partner, continuing to drink and frequent bars before using intravenously, acquiring condoms, and so on.
Therapists should encourage patients to apply some of the skills and problem solving strategies covered in earlier sessions to the problems they anticipate in meeting risk-reduction goals. This might include, for example, practicing assertiveness in the context of negotiating condom use, using positive self-talk to counter ambivalence about and objections to condom use, or using a problem solving strategy to clarify the connection between ongoing cocaine abuse and unsafe sexual practices.
Provide Specific Guidelines
As part of this module, therapists should offer specific information and provide handouts on risk reduction. Several areas should be covered, depending on the risk profiles of the patients.
- Clarification of the concepts of harm reduction versus abstinence
- Methods of transmission of HIV, other sexually transmitted diseases, and tuberculosis
- Risks associated with sharing injection-drug works
- Injection-drug works cleaning procedures
- Effective use of condoms
- HIV antibody testing
The practice exercise for this session involves use of the Change Plan Worksheet (exhibit 12) to clarify and set patient goals for HIV risk reduction.