Prevention with Positives: A Training Exchange Transcript

Dr. Bradley-Springer:

Good afternoon to everybody and welcome. My name is Lucy Bradley-Springer and I'm the Director of the Mountain Plains AIDS Education and Training Center. I'll be chairing today's teleconference. We will be able to entertain a couple of questions after each section and then hopefully will be able to answer questions at the end of all the presentations.

Slide 2 shows the four people who are contributing to this conference. There are four AETCs and one external partner, and we have collaborated to bring you today's program. The AETCs are the Mountain Plains, Northwest, Pacific, and Pennsylvania MidAtlantic AETCs; and the external partner is the Partnership for Health. All of these groups have contributed prevention with positives materials developed by multidisciplinary panels of prevention experts. The AETC National Resource Center (also known as the "NRC") coordinated this training exchange. And I would like to thank all of the partners for their many contributions to this program.

The purpose of the training exchange is shown on Slide 3. Prevention with positives materials have been developed in response to an emerging need to incorporate HIV prevention into medical care of people living with HIV infection. During grant year 2003/2004, the AIDS Education and Training Center National Resource Center coordinated a workgroup of several AETCs interested in strong prevention with positives materials. The prevention with positives materials being presented today were identified as a result of that dialogue. These materials were carefully compiled to reflect the diverse training needs in HIV prevention.

The objectives of this training exchange can be seen on Slides 4 and 5, and they include:

	Sharing state-of-the-art training materials;
	Discussing the lessons learned from implementation;
	Increasing awareness of materials already developed;
	Offering a working knowledge of training resources; and
	Providing adaptable materials for customized training needs.

Slide 7 gives you an overview of how the afternoon will progress. We have five topics and five speakers:

	First, Rob Carroll's presentation will provide a brief overview of the prevention with positives initiatives focusing on the promotion of behavior change and employing motivational intervention.
	Next, Dr. Jean Richardson's Partnership for Health program encourages providers to address safer sex and disclosure through message framing, repetition, and reinforcement.
	My presentation will provide a brief overview of methods and materials for engaging patients in a process whereby providers learn through self-study and face-to-face interactive classes to gain an understanding of patient-targeted intervention.
	Dr. Linda Frank will then discuss Prevention in Primary Care with materials focused on the integration of procedures and comprehensive philosophies concerning HIV prevention and primary care and counseling.
	Our final presentation is an important over-arching topic that is of concern in all of our presentations. Dr. Carolyn Dawson-Rose will discuss approaches to addressing provider concerns about legal ramifications involved during prevention work with HIV-infected patients.

Dr. Rob Carroll, who is the Washington State Coordinator for the Northwest AIDS Education and Training Center, will be presenting on Prevention With Positives: Promoting Change While the Clocks Tick. Rob, please go ahead.

Dr. Carroll:

Thank you, Lucy, and thank you all for joining us today. Now the training platform that we have here is a slide set with some training notes, and its intention is as a primer of sorts: Prevention With Positives 101. This slide set was developed in response to training requests from a variety of mid- to low-volume provider clinics. It is meant to provide a brief overview to a multidisciplinary audience on a number of topics. These include the rationale and history driving the prevention with positives movement. We also cover the basic principles of behavior change theory, including motivational interviewing. Finally, the set provides basic guidelines for implementing a prevention for positives intervention program.

Now one note here: This slide set may be especially helpful for ancillary support staff members who will not be directly responsible for implementing prevention with positives programs but must have a basic understanding of their operational rationale. Further, I see this set as an appropriate introduction to concepts and skills that may be more fully addressed in further, more comprehensive trainings such as those which will be covered this morning by my colleagues.

Now implementing the slide set does not involve, in and of itself, extensive skills training in motivational interviewing. However, the ideal trainer would possess a thorough understanding of behavior change theory, as well as a basic understanding of the principles and philosophical groundings of motivational interviewing. Now this would ensure that any questions which may arise during the training would be appropriately answered or appropriately referred out.

This slide set was piloted at a number of low- to mid-volume HIV care settings in both urban and rural environments, as well as to a group of reproductive health and family planning clinicians and administrators. And it has been modified in response to these pilots.

Now, at this point, I'd like to make a few comments on some of the specifics of implementing the slide set.

	First of all, in response to feedback during pilot testing, Slides 13, 14, 15, 16, 17, 18, 19 were added to provide a historical grounding and rationale to explain the increased importance of and emphasis on prevention with positives programs.
	Within this group of slides, it is recommended that individual trainers insert at Slide 16 geographic and topic-specific epidemiological data such as charts or graphs downloaded from local health department websites.
	In presenting some of the slides, it may also be helpful to plan in advance with some specific exemplar statements. This is especially relevant for Slide 35 on Motivational Interviewing Principles, Slide 38 on Key Communication Skills, and Slide 39 on Brief Intervention Talking Points. Now an example of this may be, for example, on Slide 35 where there's mention of developing discrepancy, have a statement prepared where you could say, for example, in working with a client who has a goal of increased condom use, you may want to say that, "While this is their goal, their expressed goal, what they've told you would seem to contradict this intention." It's probably best to draw this from your own clinical background.

Now one area which may raise concerns and questions during presentation has occurred at Slide 32 with mention of documentation. This often raises concerns about legal and ethical implications; but, when properly handled, I've found that it can create an important area for further discussions.

Finally, in terms of modifying the slide set, amongst the family planning providers with which this was piloted, there was the feeling that, with only slight changes, the slide set could be an appropriate tool for providing basic training for other secondary risk prevention audiences and topics, including other sexually-transmitted infections. Specifically, these modifications would involve removing the majority of the rationale slides that I mentioned earlier which would include Slides 13, 14, 15, 17, 18, 19, and 22. Now other appropriate rationale slides could be inserted here. Also, maintaining Slide 16, the epidemiological data slide but of course using topic-specific and region-specific material. And, finally, some of the providers felt that it would be helpful, time allowing, to potentially add case studies targeting topic- and audience-specific challenges such as chlamydia or hepatitis C.

Now that concludes my presentation. I thank you for your attention and would welcome any questions.

Dr. Bradley-Springer:

Starting on Slide 40, Dr. Jean Richardson is the Principal Investigator of the Partnership for Health Program and she's going to talk about strategies for improving patient/provider communication. Go ahead, Jean.

Dr. Richardson:

Thank you. My name is Jean Richardson, and I'm Professor in the Department of Preventiv Medicine at the Keck School of Medicine.

What I'd like to do is to highlight a couple of things about the research first and then go into exactly what the training program is about.

You'll see two slides on Slides 45 and 46 that present some background information showing that what we might expect from a synthesis of research is about one-third of HIV positive patients are abstinent at any point in time, about one-third are low-risk sexually active, and about one-third are high-risk sexually active. And by that I mean unprotected anal or vaginal sex usually measured within the prior three months.

Slide 46 is data that's coming out right now from Steve Morin JAID's August 1, 2004 showing what the level of counseling is in outpatient HIV clinics with regard to safer sexual behaviors. And just by looking at those numbers - and you can reference the article - the level of regular counseling of patients is fairly low. Our study, which was started in 1998, was funded by the National Institute of Mental Health and we surveyed six clinics and then implemented an intervention study with three arms to it:

	One arm was safer sex counseling using advantages-framed messages;
	One arm was safer sex counseling using consequences-framed messages; and
	One arm was the control in which we counseled about medication adherence.

The results of that study are published in AIDS May 21, 2004 and, in that analysis, what we found was that there's a great difference in unprotected sex based on the number of partners that people have. Overall - and we surveyed on people who were sexually active - 34% engaged in unprotected anal or vaginal sex with any partner in the prior three months. For those with one partner, it was 26%, and for those with two or more partners, it was 51%. For those with one partner who was HIV negative, 20% engaged in unprotected anal or vaginal sex, even though in most cases disclosure had already occurred.

So that's a summary of some of the background. When we implemented our program and had a program of brief provider counseling in the field for a ten-month period looking at advantages- vs. consequences-framed messages, we found that the consequences-framed message showed a reduction in unprotected anal or vaginal sex of 38% for those with two or more partners at baseline.

So what is a loss- and a gain-framed message or advantages- and consequences-framed message? If you take a look at the slides, Slides 48, 49, 50, 51 explain that, and they're basically whether you emphasize the advantages of protection and using protection or whether you're counseling is emphasizing some of the consequences, the negative consequences, of high-risk behaviors or unsafe behaviors. And, as I said, in the research, we found that emphasizing some of the consequences of unsafe behaviors seemed to have and did have the 38% reduction in unprotected anal or vaginal sex at follow-up.

As a consequence of the study, we've worked with both PAETC and the CDC to make our materials available to trainers around the country. We've done train-the-trainer programs and we've also done direct clinic trainings. So what I'd like you to do is take a look at Slides 56-57, which outline some of the core elements of our training program. The intervention is basically designed to train medical care providers - clinicians, MDs, RNs, PAs, nurse practitioners - as well as support people in the clinic - health educators, social workers, other professionals - and, in fact, all staff in the clinic are invited to the training. We conduct an orientation which is one hour of description of the study and the basis for the training, and then we conduct a four-and-a-half hour training program in the clinic, inviting everybody in the clinic, and a two-hour booster session follows six weeks later. We also work with clinics on maintaining the program.

In conjunction with the training, we have many types of materials that we have developed. We have developed posters. There are posters that are available which go in the waiting room and basically introduce the idea of prevention. These do not mention HIV; they really talk more about the issues of maintaining health. And that was done because, in many cases, HIV clinics are not separate from other treatment-oriented clinics. We also have exam room posters which are more specific to the issues of HIV prevention. Patients are given brochures which reiterate the messages and flyers, and the flyers deal with specific topics such as the issues of disclosure, what does it mean to be safe, what does viral load have to do with prevention, and so on.

We have slide sets that go with this, training manuals for each provider who comes to the training, and chart stickers where providers can indicate that they have counseled the patient. And, in this case, we do not record the patients' actual behaviors in terms of their sexual behavior; we record that counseling has taken place.

Rob has already described some of the theories that are used in prevention for positives programs, and stages of change is certainly incorporated in ours in terms of repetition and reinforcement and targeting messages to the level that the patient seems to be at; but framing is another aspect of this and these are really motivational messages that are important to consider. And, as I said, those are indicated in your slide set.

So when we train, we train entire clinics. We ask the clinic to shut down for the four-and-a-half-hour period and we provide a training. Now the training involves a number of different things:

	We talk about data first of all as part of why we're doing this and what the results have shown.
	We talk about theory and communication skills.
	We talk about our provider counseling outline, and I'll get to that in a minute.
	We talk about the theory of framing.
	We do a number of role-plays and we have recently developed a training video, and the training video (which will be available soon) addresses the issues of several different types of patients: patients with multiple casual partners, patients with sero-discordant partners, and patients who are abstinent but may consider having a sexual relationship in the future.

The provider counseling outline is in Slides 60-61. The steps in this counseling outline are first of all to introduce Partnership for Health. This is just basically introducing the concept of this as a partnership between the patient and the provider to talk about how to keep the patient safe, how to keep their partner safe, and how those behaviors can help the provider give the patient the best care possible.

The second step is to ask questions about any problems the patient may have with practicing safer sex. And we spend quite a bit of time working with providers about how to ask questions that are direct but also non-judgmental and how to listen to answers in a non-judgmental way. When patients respond, we encourage providers to reinforce and find any healthy behaviors that they can reinforce and complement as well.

The next step is to discuss messages concerning protecting yourself, protecting your partner, and disclosing sero status prior to initiating new sexual relationships. These messages are the framed messages emphasizing the consequences of unsafe behaviors for those who have multiple or casual partners who might be considered more high-risk patients.

The fourth step is to work with the patient to set realistic goals together and, again, the emphasis here is that these goals are set together. If the patient is not invested in the goals, it's unlikely that the goals will be reached. But the provider also has a role in helping the patient to establish safer sex goals.

The next step is asking the patient for questions and providing referrals if needed. In many cases, once the door of talking about sexuality is opened, there are a lot of issues that may arise - whether it's domestic violence, mental health, need for support groups, housing, and so on. So referrals are very important.

Finally, we talked about being supportive and letting the patient know that you will talk again at the next visit, that this is a step-wise approach, that people don't change immediately if change is needed, and that it will take time and continued conversation and support over time. But it's basically letting the patient know that the safer sex discussion is a continuing and ongoing discussion. So, in a sense, this is very brief discussion but it's from a very credible source, it's repeated over time so that it becomes a normative part of the healthcare interaction.

I've indicated in Slides 66 and 67 some of the concerns that have been raised. Obviously, time is always a critical issue. And the first time that a provider talks about it, it may take a little over five minutes; but we find that on follow-up visits, in three to five minutes it's possible to continue reinforcing and continue with this discussion.

In terms of modifying this intervention, we do have the materials all available in English and Spanish, and we're just finishing up the provider manual in Spanish now. There are a couple of possible suggestions for add-ons. One of those is to add on couples counseling for those sero-discordant couples, which I think would be very important to be working on and there are some models in the literature for that. And a second is group counseling for those who are high-risk and having difficulty or needing more support to change high-risk behaviors.

Other modifications that can take place - and we have been working on these as well - is how might this need to be changed going into a Veterans Administration clinic or into a women's clinic and so on? And we have tried out the intervention in those locations and have suggestions for some of that kind of work as well as in terms of clinics with particular patient populations where specific a modification may be needed.

I see my time is about running out, so I would be happy to answer questions at this point.

Q&A

Dr. Bradley-Springer:

Jean, I actually have a question for you. It looks like most of your work is focused on unsafe sexual activity. Have you looked at using this method and this way of approaching prevention with positives with people who were infected through drug use and who may be creating risk through drug use?

Dr. Richardson:

No, we haven't. All of our outcome data is focusing on unsafe sexual behavior. We had some drug users in our samples. California I think has less transmission due to drug use than some other states may have. So I suspect that, again, this might be another modification as we start working more with clinics nationally that we need to spend more time perhaps in collaboration with others about how does this need to be modified when you have a high proportion of people who are simultaneous drug users, drug using at the same, that they are being treated for their HIV disease in outpatient clinics. But I think that that will be something that we will need to deal with as we start taking this to the national level.

Dr. Bradley-Springer:

Good. Are there any other questions on the line?

Eddie Edmondson: (University of Washington)

Yes, Dr. Richardson, I was wanting to know, what was the follow-up period in your study that showed the 38% reduction?

Dr. Richardson:

Yeah. We had the intervention in the field for a ten-month period of time and so patients were surveyed at baseline and then we began the surveys again ten months later and collected the follow-up data. So over that period of time you would have expected people would have received the intervention maybe at least every other month in most of the clinics that we were at, so perhaps five times - three times, five times - as well as receiving written materials.

Eddie Edmondson:

I was curious. Earlier studies that I've read in the past talking about, and there's not a direct correlation but, fear-based kind of messages would be effective in the short term but not in the long term in terms of changing behavior. And I was just wondering in terms of the dramatic results and the consequences or loss frame as opposed to the positive frame, do you have any sense of why that is?

Dr. Richardson:

Well, first of all, I don't think you should necessarily equate fear-based with consequences-based. They're not necessarily the same thing. Just one reference to that: you can give a consequences-framed message, first of all, in a very supportive way, and I think that's really important to emphasize. For example, saying something like, "I am really concerned about you. I'm concerned about your health. I'm concerned that you may expose yourself to something else that may make it harder to treat." Now does that sound like a fear-based message? Perhaps. But it's also a real reflection of reality. It's a reflection of what clinicians do, which is to try to also warn about potential health outcomes of behaviors - whether it's smoking or excess weight or whatever it is - it's part of a very normal part of a clinical role. There are certainly cautionary issues there. Fear-based is often over-exaggerating the level of risk involved. When I was a kid we had something called "Reefer Madness." You know, that's the TV/video that we saw about marijuana use. It was over-exaggerating the risk of the behavior. This is a very realistic presentation of the risk and it should be presented in a very supportive way. So I wouldn't say that consequences-framed necessarily goes into fear-based.

Eddie Edmondson:

Thank you.

Dr. Bradley-Springer:

Thank you, Jean. We're now up to Slide 70 and this presentation stems from my work at the Mountain Plains AIDS Education and Training Center in conjunction with Denver Health, the Denver Prevention Training Center, and some funding through the Centers for Disease Control.

The program itself is called "Positive Steps" and we're looking at, once again, improving patient/provider interactions for HIV prevention, and you will see that a lot of what we have implemented in this program is based on some of Dr. Richardson's work.

Slide 72 describes what STEP stands for. It's "striving to engage people," and to get people talking about prevention messages is the goal.

Slide 73 describes the CDC demonstration project that this is a component of, and that project is called "Incorporating HIV Prevention Into Medical Care Settings," or the "PICS" program. The intent of the entire project is to get providers who work with infected people to incorporate prevention messages and prevention training into all of their interactions with patients in the healthcare setting. What the AIDS Education and Training Center is doing with the Prevention Training Center is to create a multiple education approach to getting the information out. The components of that process are listed on Slide 74. They include:

	A set of patient education materials;
	A provider poster;
	For the providers, an electronic self-study module;
	An interactive four-hour face-to-face class; and then
	An interactive two-hour booster class.

And I want to talk first about the patient education materials. On Slide 75, it shows you a picture of the outside of the brochure that was developed and one of the things that we did in conjunction with the committee who was working on the PICS program is to come up with some ABCs that the providers are promising to the patients in those clinics. So that this brochure tells the patients that their providers are always going to support them in their medical care, want to begin to talk about the things that people do that are safe and help them stay safe and healthy, and then to help their patients make choices that work for them, so individualizing and looking at the context of that patient situation.

In addition, we have some brief messages that are on the next two slides inside this brochure that basically says, "Here are some things that some people do sometimes to protect themselves and their partners from HIV." And it gives lists, including using condoms and talking about HIV, not using drugs, limiting the number of sex partners.

And then if you go to Slide 77, it talks about getting sterile needles and syringes, not having sex when you're drunk or high, avoiding people and places where risky behavior is encouraging, getting help to stop using drugs, and not having sex as an option. And there are others in that brochure. On the back of the brochure, there's a place for each clinic to put a little sticky that says, "This is how you get a hold of us. This is what you do after hours. Here's an email address in case that works better for you, and a telephone." So there are ways to get information to the patients that they can take with them.

Now the posters, like Dr. Richardson's, are put together and they're based on where they're going to be posted. And, unfortunately, on Slide 78, I have more than waiting room posters. The waiting room posters are the ones on each side. The poster that says, "Let's start talking," is supposed to go into waiting room as is the poster that says, "Is a baby in your future?" We're working with six clinics that were selected by the CDC for this project and they're in very diverse areas where there are more women in some clinics, more men in some clinics, and then in some clinics we have a majority of drug users as opposed to sexually infected, etc. So those two posters, as with Jean's project, have generic messages that basically say, "Let's start talking about your health. Let's help you stay healthy," but don't specifically mention HIV infections.

Then we have three posters that go in exam rooms, and the one in the middle on Slide 78 is one of those posters that go in the exam room; and that poster does say that we want to focus on not sharing the virus. So it's mentioning the virus at that point.

And then if you look at Slide 79, the other two exam room posters give very specific messages. And the print is smaller so we want people to be in a place where they felt safe and comfortable to up to the wall and read the messages. But the two big messages on both of these posters are, "Protect yourself and protect others." We know that we want to prevent the transmission of this virus to other people, but we also feel like people with HIV infection need to understand that by doing these things to protect others, they will also be protecting themselves and we think that that's very important.

The provider poster on Slide 80 is a poster that is supposed to go up in places where the staff meet and go, such as the staff breakrooms, staff bathrooms, changing rooms, locker rooms, wherever. And these are just to remind providers that they should be assessing risks on all their patients, so it asks the question, "Did you assess risk on your last patient?" And there are some ABCs there about talking about the fact that there is risk, beginning an in-depth conversation, showing you care, and offering choices so that people will feel like they have someone to talk to, that control has not been taken out of their hands.

So we have those materials that are available at the clinic. Then there is a three-part training process that we ask people at each of these clinics to go to so the providers have a good background and have had some practice on doing these kinds of assessments and helping people make decisions about changing behaviors.

Slides 81 and 82 just give you an example of a self-study that is in the self-study module, and this is the case that we presented. The self-study module is available online to the people in the study at this point. It takes about a half an hour to go through. It's got several interactive components, including rollovers and graphics that expands itself as you move through the discussion of that graphic, and then, of course, this particular self-study.

The four-hour class is onsite. It includes short lectures with slides. It has a number of interactive activities, including discussions so that questions are posed and we ask for discussions about those questions. It includes activities that have messages in them as a result of those activities but are somewhat engaging to be involved in. It has cases. We have six cases and we ask that the group do those cases in role-plays. One of the role-plays is a demonstration role-play in which the presenters provide the role-play and the other five cases are done in role-plays by the participants in the session.

Part of the role-play is to ask the provider and the patient in the role-play to develop a plan, and we've provided prescription pads that are risk-reduction prescription pads and you can see part of one on Slide 84 which is some check-off areas where the patient can say, "Yes, I would do that," or "No, I wouldn't do that." And then at the very bottom - it's about twice as long as what you see here - at the very bottom, there's a space that says, "Here's something else I want to try." So if the patient doesn't like any of those or wants to add some ideas for harm reduction, for risk reduction, that can be written in. And then there's a place for the clinician to sign and date that and to use it as a memory aid for people when they come back to the clinic and talk about what they've done so far.

We base the training on four steps that are listed in Slide 85:

	Acknowledge that there are risks - people continue to take risks, even though they have HIV infection;
	Begin the conversation about those risks and how to decrease those risks {inaudible} risk reduction and stages of change as we talk about this;
	Offer choices - what are the choices, what is safer, healthier, or less risky than what you're currently doing, and what would you be willing to do of those things; and then
	Demonstrate concern and you demonstrate concern through showing that whatever you can do, you will do to help, but also acknowledging that you may not have all the information or skills that you need as a clinician to provide those services and to provide referrals and consults to the patient for places that they can go to get the support they need.

The two-hour booster course is also onsite and it is much more interactive even than the four-hour class, even though most of the four-hour class is interactive. It'll be a set of interactive discussions looking at the successes and the barriers over the time between the four-hour class and this class. It will be a chance to evaluate and to find out about how things can be changed to make the training better, but then also how things can happen at the site to make it easier to implement prevention messages and prevention education.

Slide 87 basically says that overall we are evaluating this process with a pre-test/post-test. We are getting demographic information on all of the people who are involved in the classes. We're getting verbal feedback as well as written feedback. We are planning on finishing the first set of four-hour classes as well as the two-hour booster classes by sometime in October or early November. At that point, we will go back to the drawing board, review and revise this whole set of materials, and put together a training platform that will be available to people at the AIDS Education Training Centers and then also through the website.

I would very much like to thank Mark Thrun for his work in this process. He has been the physician who instigated it and has been one of the presenters in this program so far and has really led the charge on this. At this time, I would like to stop and see if there are any questions in the queue.

Q&A

Octavio Vallejo:

Pacific AETC Hi. I'm just wondering if any of the previous speakers on the other slide kits, do they have any components to disclose with the providers and the controversial issues that brings along the double-exposure in regards to co-infection, super-infection, and all the re-infection. I think it's nowadays we have more questions than responses to provide the clients; and using the consequences-framed messages, I think that nowadays clients have more access to information and we exaggerate, as the previous speaker said, some of the risk of exposure on safe sex practices. I think we are going to lose their trust between the medical/client relationship.

Dr. Richardson:

Well, yeah. I mean, I don't think that providers ever want to say anything to their patients that they don't think is true or possible and so, you know, we're not encouraging in any way for that to happen. But there are consequences for the patient's own behavior of multiple STD infections. That can be very important to consider in terms of their medical management and I think, for that, it would be far better if an MD were responding to your question than to have me respond to it in terms of the medical management of those multiple infections.

In terms of the consequences for the partner, if the partner is negative or if the partner's HIV status is unknown, I think that that is pretty clear and those consequences are certainly very serious. And that is another component of this is not just the consequences for the patient but also the consequences for the partner. And what I find - and I think what most providers find - is that most people with HIV very much have a feeling that they do not want to infect another person. I mean, that is the proportion of people who would want to infect another person is just very, very small. It's much smaller than the proportion of people who are having unprotected anal or vaginal sex and are in fact putting other people at risk. These are not necessarily intentional desires to infect another person, but they are potentially serious consequences of those sexual behaviors which are not protected. And so raising that issue of whether in fact you are putting another person at risk, even if it's not your intention to do so, is an important consequence that people do consider and take very seriously in terms of really feeling that that's just not something that they want to do.

Dr. Bradley-Springer:

I think that when you're ever dealing with prevention, which is difficult, that we have to provide a broad spectrum of messages because some messages ring true with some people and they don't even phase another person; whereas, a different message might get to that person. So the issue of super-infection is a real theoretical concern and, as we move forward and find out more and more about super-infection with HIV, then I think that message will become more and more clear. But, as Jean said, there are other things you can get infected with and those are pretty clearly established, that other things can create problems with your immune system. So if you get gonorrhea, that's going to be a problem. And I'm not sure, Octavio, but is that getting to your question?

Octavio Vallejo:

Yes. My major concern is probably to have a section in the training curricula, something on how to respond to difficult questions. That's probably the main concern that I have and providing just the common definitions that in medical lingua we use. Because right now if people speak about super-infection, co-infection, or the latest is, well, the infection we used before, so now even the clients and providers are getting confused with so much - too much terminology and definitions. So, finally, just one very, very short comment. I think that we need to train, and the providers we need to train as well, how to support disclosure.

Who of their families or relatives or friends knows the HIV status of the client and, around that, to start creating the stigmatization of HIV disease and encouraging disclosure.

Dr. Richardson:

One point I want to make. In terms of disclosure in our particular program, we're talking about disclosure to a sex partner prior to sexual relations specifically. And the reasons for that are a couple. First of all, if a third of the people are abstinent, many of those people will decide to initiate a new relationship at some time in the future. So this issue of disclosing to a new partner is always something that is potentially an issue for the abstinent patient.

Secondly, for people who have multiple casual partners, again, the process of establishing - and these may or may not be what you might call "relationships"; they could be very casual encounters - sexual encounters. But, again, it is a new person. So our disclosure is really talking about this issue of disclosing to somebody prior to sexual relations. We're not necessarily talking about disclosure to family or friends in this intervention, although one of the possible ways of talking about this is, "How did it feel to disclose to a family or friend? What was that like for you? Have you done that? Have you learned how to do that?" That whole process of learning to disclose to anybody may make it easier for a person to disclose to a sexual partner prior to starting sexual relations.

Dr. Bradley-Springer:

We're going to go on to Slide 88. Dr. Linda Frank is the Principal Investigator and Executive Director of the Pennsylvania MidAtlantic AIDS Education and Training Center and she's going to talk about a prevention curriculum that her group has come up with, and I would like to turn it over to Linda now.

Dr. Frank:

Hi, everybody. Greetings from Pennsylvania MidAtlantic and from Pittsburgh. I'm happy to be here today. I'd like to take you through a few slides that talk about the curriculum and companion reference tools that we've developed here at the Pennsylvania MidAtlantic AETC. The title of our curriculum is "The Secondary Prevention of Proactive Response to Prevention in Primary Care: A Guide for Training Providers." And I'd like to recognize my co-authors, Monica Fisher, Pat Lincoln from our local performance site in Delaware - Monica Fisher is here at our Pittsburgh local performance site - and Avram Machtiger at our Pittsburgh local performance site.

The curriculum goals that we've developed for this particular curriculum include:

1. To help clinicians and service providers integrate HIV prevention into primary care for patients who are positive;
2. To help clinicians and service providers integrate case finding into the primary care clinical encounter;
3. To assist clinical settings in developing procedures for such integration; and
4. To assist clinics in developing a comprehensive philosophy for prevention in primary care.

We've developed this curriculum and we have paired it with our case finding in "Secondary Prevention: Clinical Risk Assessment and Screening Guide," which is a pocket guide that has been distributed to all the AETCs that covers some of the key points about doing secondary prevention with people who are HIV positive, with HIV positive women, and determining sexual risk for all patients who come into primary care settings. And if anybody on the call would like a copy of it, they could please contact the Pennsylvania MidAtlantic AETC at (412) 624-0429 and we would be happy to send you a copy. We're also going to be making the curriculum available on our website [pmaatec.org].

The other thing that people should know is, in addition to this one pocket guide, we're developing five other additional pocket guides. There's going to be pocket guides on special issues related to people who abuse substances; that's number one. The second is going to be for the chronically and persistently mentally ill. The third is going to be for women. The fourth is going to be for adolescents. And the fifth one is going to be for prisoners and the recently incarcerated. So those pocket guides are going to be available by the end of December. We're working on those as we speak.

Now I want to get back to the curriculum philosophy if I could for a minute. [Slide 93] We've really decided that the curriculum that we develop really has to be evolving, that it has to be updated continuously, and it's going to be posted on our website. And we're going to try to have a mechanism where people who use the curriculum can give us feedback on an ongoing basis via our website because we know that, as we get more information about what works for people who are HIV positive in terms of prevention, that we need to update this and make sure that the latest things are getting integrated into what we have already developed.

Secondly, the curriculum is designed in such a way that it can be flexible to meet individualized needs and it's in modules, which means people can pick and choose the modules that they want to use for the target audience that they are doing the training. For example, you may be working with the prison population and you may want to use some of the initial chapters or modules of the curriculum and then pair it with some of the later chapters that talk about specific populations and specific issues for those populations. So we want it to be something that's usable because, as trainers, we know that lots of times you may only get an hour out there doing training with a particular agency, and you've really got to pare it down so you can deliver appropriate messages, targeted messages, that are going to be helpful to that particular clinic, that particular setting, that particular community program. The third thing is that the curriculum is interactive. That is that we include didactic information as well as we've provided experiential exercises that go with the various chapters that are included in the curriculum. Thirdly, we include process and outcome components. There's pre- and post-tests. And, finally, the fifth characteristic of our curriculum is that it's inclusive. We want to get input from the field, as I mentioned earlier, via our Pennsylvania MidAtlantic AETC website.

I should point out that the curriculum that we've developed has been pilot-tested. We were asked by the Texas/Oklahoma AETC to come down and train the curriculum to people from the Texas Department of Health, and we did that last December. And, as a result of that training, we have revamped the curriculum and added more to the curriculum than we had however many months ago that was - six or eight months ago. In addition, the Texas/Oklahoma AETC videotaped the initial training that we did, and we're developing a very succinct - not we, but the Texas/Oklahoma AETC is developing a very succinct - video that's going to be available sometime within the next several months that summarizes some of the key components of the curriculum. So stay tuned for that and you'll be hearing from Texas/Oklahoma AETC when they get that product finished.

Now when we developed the curriculum, we figured that it was very important to cover some of the key issues around prevention with Postives. There are two slides on the curriculum modules, Slides 94-95. The first module gives background and the CDC guidelines. And we have a module that specifically talks about using prevention with postives in the clinical encounter. We have a module on developing specific client skills for behavior change. And our Chapter 5 is on application of behavior change theory to prevention. And then we also thought it was important to try to link - to have something about linking - HIV-positive clients into clinical care, because that's one of the major components in the CDC initiative as well as one of the major focuses for HRSA, the Ryan White CARE Act. And that is that we want to identify people out there who are not identified as HIV-positive and not in care and we want to get them into care and keep them in care. And so that's why we included a module about this, and it's something that every Ryan White CARE Act provider is focused on out in the field - whether you're Title I, Title II, Title III, it's all the same that we've really got to identify those people to get them in care.

And then Module 7 focuses on adherence prevention and HIV treatment. And we thought that since a lot of HIV-positive patients who are in clinics are getting educated about adherence that wouldn't it be a good idea to include some messages about HIV prevention along with the adherence, because in a lot of ways we're trying to get patients to adhere to medication but we're also trying to get them to really focus on this secondary prevention issue. So we thought that it was important to get that chapter in there.

Now we realize that patients now are extremely complicated. Patients are not simple. People are not simple. And HIV occurs in people. And so we learned this very well when it came to educating patients about adherence, that people have complicated clinical situations, they have complicated lives, and so therefore we felt that we needed to focus modules that address specific populations of patients who are going to be seen in clinical practice. And I'm not going to go through each module, but I wanted to point out that we do have specific modules on men, substance users, adolescents, women, the mentally ill, prisoners and the recently released, and we felt that we needed to include those as separate modules that provide specific information that relates to secondary prevention that may be useful to trainers and to providers and people in the community that are working with these populations in relation to secondary prevention.

Module 14 is a module on cultural competence because we felt that even though we tried to integrate some issues around cultural competence throughout the curriculum, we really thought that it was a good idea to include a module on cultural competence because it's so important in getting messages across - whether it's about adherence or secondary prevention or any kind of educational piece that's provided to HIV positive patients. Module 15 is a module on evaluation of secondary prevention, interventions, and programs that we thought might be useful to some agencies, to some organizations.

And then Module 16 is support resources for trainers where we have experiential exercises listed.

Slide 96 is our companion materials which I talked about earlier in my presentation and which I'm not going go over again. But you can take a look at that. I've included a sample module, which is our Module 5, which is the application of behavior change theory to secondary prevention. And each of the modules has objectives and the objectives are listed here for you; and then the module goes through components of behavior change - knowledge, skills, motivation, resources, and support - and then goes through each one of those issues. And then further on we talk about the stages of behavior change and apply those to secondary prevention: the pre-contemplation stage, the contemplation stage, all of the others.

And you can read these at your leisure, but it takes the framework that Prochaska and Di Clemente developed really for use with substance users and applies it to working with patients around secondary prevention. And so it gives providers the idea - and I'm sure they already have this - that changing any kind of behavior of course is a gradual process, whether it's adhering to medication, whether it's changing sexual risk behavior, whether it's changing drug-using behavior, it all takes time, it all takes ongoing intervention as part of clinicians and support providers that are working with HIV-positive clients.

So I am going to stop there and take questions if people have questions for me about what we've done. The last slide [Slide 116] that you have in my set is our website address which is pamaaetc.org. I'd encourage all of you to go there and send us a message if you need additional materials. We will be posting our curriculum at the beginning of next month on our website and you'll be able to download the entire curriculum from our website. Thank you very much.

Q&A

Dr. Bradley-Springer:

So, Linda, when did you start developing this massive curriculum?

Dr. Frank:

About two years ago. And the pocket guides, the first pocket guide was developed, we began working it last September. Oh, by the way, we do have a pocket guide on risk assessment for trans-gendered population if people are interested in that. But the one that we developed that is a companion piece to this curriculum is the "Case Finding and Secondary Prevention Clinical Risk Assessment and Screening Guide." And if anybody wants a copy of it, they can call our office and we'll be happy to send you a copy.

Dr. Bradley-Springer:

Okay. So basically this is a long, drawn-out process. It takes a few years to get these things together.

Dr. Frank:

Well, you know, one of the things that I think is important to think about too as people think about developing the curricula is that there's a lot of work that goes into this because you have to really think through what the audience is going to be, and in our curriculum we have, in addition to just the slide, we have trainer notes as part of the curriculum that has additional information beyond what's on the slide that will be able to be found when people download the curriculum and they print it out.

Dr. Bradley-Springer:

Great. And, by the way, if you are going to be downloading, be sure when you print it out, you print it out in the Notes page too, because that's the only way you'll get those notes. Any other questions?

Patricia Coury-Doniger: (Eastern Quadrant STD/HIV PTC)

Yes, hello. I just wanted to mention that we here at the University of Rochester who provide the public STD HIV prevention services developed an individual-level intervention that's named staged-based counseling, which is also an adaptation of stages of change trans-theoretical model of behavior change theory. And this has been adapted for use with persons living with HIV and AIDS, and that curriculum, which is named Prevention and Management of Sexually Transmitted Diseases in Persons Living with HIV/AIDS, is on the AETC website under Curriculum.

Dr. Bradley-Springer:

Thank you, Linda. On Slide 117, we were going to start the final discussion of the afternoon. Dr. Carol Dawson-Rose is our last presenter. Carol is the Nurse Coordinator for the Pacific AIDS Education and Training Center and she's going to talk about legal concerns, some of which we have already mentioned in the process of today. And I'd like to turn it over to Carol.

Dr. Dawson-Rose:

Thanks, Lucy. This is Carol and this slide set is a little bit different than the other slide sets that we've walked through so far because it really addresses a component for providers who are integrating HIV prevention into their clinical practice. So basically this slide set, for your background information, has been used as part of a larger training with HIV care providers and it usually takes about a half hour to go through this material with a group. That's what it's taken thus far.

Ethical and legal concerns always come up for us when we're doing this training with providers and that's why we've broken out this specific slide set. This presentation has been piloted before, or it's been used before - six times so far - primarily with HIV primary care providers, physicians, nurse practitioners, physician assistants, as well as part of a nursing HIV mini-residency program that was delivered to the San Francisco AIDS Education and Training Center and these are primarily nurses working as case managers and also in public health settings.

If you go to Slide 119, you can look at the objectives for this slide set are to explore really not only legal concerns but ethical concerns of providers who have questions about these issues when they are trying to integrate prevention into the practice setting. It's important to get across I think that we really want to take some time to explore this and have people talk about what the issues are for themselves and who also discuss the prevention with positives framework which is really focused on working with patients who we want them to protect themselves and then also protect other people.

Slide 120 is a background slide that some of the other presenters also have as part of their slides in terms of what's the CDC policy and just to give us some information on government programs that are mandates as part of our funding streams that we integrate prevention into care and just to bring up some of the issues that different states have different - they do this differently or they go about it differently in the legal setting as well as practice setting. And I think that's one of the things that I want to talk about in terms of these slides that I think is very important to get across is that the answers to a lot of the issues that come up when we're discussing ethical and legal concerns with providers really depends a lot on the location where they're practicing. It depends on the site that they're practicing - the institution as well as the state.

There are differences in state law that can have an impact on how clinicians approach this issue with a patient. For example, to give you a small example, we know that in the state of North Carolina where the law says that the physician has a duty to report if they are aware that a third party is being exposed to HIV by one of their patients. It's based on an STD model and there's a legal policy that governs that practice of the provider. And that differs from the state of California where physicians or other providers do not have a duty to warn a third party that may be exposed if the physician becomes aware of that exposure.

Now, having said that, the other part that's inherent in here is that there are ethical concerns that providers have and then the legal concerns. So this is just a background for people to refer to on sort of setting the stage.

On Slide 121, there's an open discussion about the ethical and legal concerns, and I think it is helpful for trainers to be able to provide a definition of what they would identify as an ethical concern and a legal concern, but that it has been very beneficial to sort of have this open discussion with providers so they can identify what are their ethical concerns. You know, patients reporting sex with someone that they know to be negative and not disclosing, patients who are having sex with somebody who's underage - some different concerns that providers have in terms of what are the ethical dilemmas that I am in - and then also to talk about legal concerns. What should I put in the chart? Do I need to report behavior to someone? I have found it helpful when approaching this to start first with the ethical concerns ,it makes for a richer discussion and people are willing to explore it a little more. And then turning to the legal issues, that if there are legal issues that sort of govern the questions, it shuts down the conversation if you start with that. So I think it's helpful in training on this to sort of have an open discussion.

Slide 122 really just talks about what exists now: confidentiality policies, that differ by state, differ by funding sources, what are the HIPAA regulations, and really how your institution interprets those. And it's just important to bring these issues up in sort of a logical manner when doing this training.

On Slide 123, you will see what are some of the provider concerns, and this is the background for some of the things that come up. People may or may not want to include this as a slide when they're doing the training, if you will, but have some of the responses to these when you are doing a training. These are the responses that often come up when we're talking to providers about integrating prevention and they know or uncover behaviors that they don't know what to do in terms of, "How do I document that in the medical record?" You know what I just referred to before: "What are my ethical obligations when I know someone's at risk? Am I liable if somebody becomes infected and I knew that risk was taking place?"

Now in terms of documenting in the medical record, I'll refer back to what Jean was talking about and I think Rob was talking about also, which is that what we talk to physicians and nurses about doing when they're documenting in the medical record is really to have the full discussion with the patient and then, when they document, document prevention discussed and what's the plan for the patient, but not identifying a specific behavior, identifying a specific person who may be at risk for HIV infection. And so we try to talk about it in that way. And the other thing is that we really try to get people to take these issues to their own institution and I'll refer to that a little bit later.

What I have for an example, I have an example in here of California law and these are some of the issues that we talk about when we're talking about the California law: how to talk to your patient if you want to use CDC-funded partner counseling and referral services or what we've got reporting to the partner. So how can providers get support for patients who (a) want to disclose to a partner or want a partner disclosed to but don't want to be involved in that? So that is a funded program that is available at the state level here in California and in most other states.

And also what we really talk to providers here about in California is talking to your patient, but also trying to have a discussion with your patient and telling them what your concerns are; or if you feel that somebody else needs to know about behavior that's going on, that you are going to discuss that with your patient before you disclose personal behavior.

On Slide 125 where it says, "Where do I find answers?" I've got a list of resources that trainers can go to and providers can go to to find out information on this. Most of the legal information is going to be provided through state and medical professional associates, but I also refer people to the HIV Criminal Law and Policy Project and the Web page is on Slide 125. In addition, there is a link under Resources that are part of the Web page to the National Resource Center with this training platform. There is a paper that's called "Crime and Punishment: Is There a Role for Criminal Law in HIV Prevention Policy?" and Leslie Wolf is the first author on that and that gives you an excellent background about what has happened about this issue on a state-by-state basis and what some of the issues are if people want to look at that later.

The last thing that we do that I've outlined here on Slides 126 and 127 is just a case study, and this is a case that comes up a lot and you can use this and review this and people may have other cases that you want to use. It talks really about the provider role on 126 and then on 127 really goes through this "What are your ethical concerns? What are your legal obligations?" piece to sort of guide that case study discussion. So we try to make it very clear when we do this that we are not here to give legal advice and to try to encourage people to rely on their institutional support, legal counsel, that kind of support, and not to take the legal advice from us as trainers that this is set up as a framework for some of the issues that may come up and saying again that it really varies depending on where you're doing the training and the institution where you're doing the training. They also may have guidelines about these issues.

So I think that's all I want to say about these slides, and I'd love to entertain any questions or comments about the slides.

Q&A

Dr. Bradley-Springer:

If there are questions, please feel free to go ahead and call in. I would like to talk briefly about the last slide, which is Slide 129. If you have questions that we did not address or that you have concerns about that come up later, you can email the NRC and ask questions, and they will be sure to follow up. And the person you're going to be sending that email to is Teri Lassiter and her email address is on the final slide. The NRC will either be forwarding questions to those people who were on this conference call and were presenting or will answer them themselves or will find the answer for you somehow. So there is an opportunity to discover the answers to those questions later.

Elaine Gross:

Hello. This is Elaine Gross from Newark. I have a question for Lucy. Can you talk a little bit about what barriers you faced when you were trying to plan a four-hour program in a clinic that the clinic had to shut down and then the two-hour booster?

Dr. Bradley-Springer:

There certainly are a lot of barriers. Now the advantage that we have is that we're part of a CDC-funded study and the CDC was able to go in and say, "You have to show up." So that is helpful. What I have done in the past when the CDC wasn't there to strong-arm for me is to try to be as flexible as possible so that we would obviously work with the clinic to find out when the best time was. But then the other thing that I would offer is I would say we can come in on Tuesday morning and take half the staff on Tuesday afternoon and do the class, spend the night, and then do the class again first thing the next morning if that will help you. That way, you don't have to completely shut down the clinic. We're actually doing a similar thing to that in Nashville this week because they have a large staff, so we'll be doing half of their staff in one morning and half of their staff in the afternoon. It is hard to get, as you well know, it's hard to get busy clinicians away from the clinic unless you have something that gets them away.

One thing that I do think is important with this particular project that we're doing is that the CDC does support that everyone in the clinic get an opportunity to go to the class. So in the event that if I had something that I needed to teach and I couldn't get all the clinicians, I would get everybody else and get it percolating up. And then volunteer to come back later when the clinicians were more available.

Elaine Gross:

Okay. And what's your sense, especially not in your region but where you're doing it in Nashville, that they thought that this was important enough to devote four hours to?

Dr. Bradley-Springer:

Well, as I said, this is part of a CDC-funded study so they're getting funds to do this study and the CDC has told them that everybody in their clinic will attend. So there is a strong-arm method there. The good news is at the sites where we have done it so far, which is in Denver and in New York City, we've gotten positive feedback that it was a worthwhile thing to be there. It's not like going through an OSHA training. {Laughter} Any other questions?

John Toney:

I guess you kind of answered part of the question. I was wondering where this had been piloted, and you've mentioned a couple of sites in Denver. Has it been offered to private practitioners at this point?

Dr. Bradley-Springer:

Right now because we're in this study that the CDC is doing, we really aren't offering it outside those six clinics. But, as soon as we get finished with this study, we will make it available more widely so we could go into private practitioners' clinics.

John Toney:

And when you say that you could provide it, does that mean that you would be funded to continue doing this or would this be separate?

Dr. Bradley-Springer:

It would be separate from the CDC study, so we would want to work - I don't know where you're located - but we'd want to work with the AETC in your area, the AIDS Education and Training Center.

John Toney:

Right. Well, since I'm in Florida and I'm part of the faculty of an AETC, that would be helpful.

Dr. Bradley-Springer:

We have had a question come up online.

Desiree Loeb-Gruth:

Hi, Lucy. This is Desiree Loeb-Gruth from the Delta Region AIDS Education and Training Center. We've been toying with the whole topic of self-administered HIV risk assessment for sexual behaviors and drug-use behaviors as a tool that one can use to go over on their provider visit and I'm wondering if any of the people involved in this conference call had tried implementing such a strategy and how it's worked out.

Dr. Bradley-Springer:

Actually, there is a self-assessment form that the CDC study is using. It's really not that different from what I see every time I go to my dentist or my physician's office. It's a little more specific asking about number of sexual partners in the last three months and those kinds of things. So that is a form that's been developed, but I'm guessing that other people who presented on this call also have those kinds of tools. Anybody want to chime in?

Dr. Dawson-Rose:

This is Carol. I can chime in about this. I mean, on a couple of different projects that I work on, this is an area of pretty big interest because of thinking that it would cut down on time. People could do it confidentially. And that's sort of what we're coming up against. The projects that I'm working on are research projects and so, because they're research projects, people are filling out this kind of information. However, they're going into the research record and not the medical record because that's one of the issues that comes up is once we gather this information and we know it, when we put it in the medical record, will it cause problems for our patients in terms of reportable behavior? And so we have used it, but it's been as part of a research study. We haven't used it in clinical practice where it's going into the medical record chart.

Desiree Loeb-Gruth:

Right. And the one that we're developing we don't expect that it will go into the medical record either, especially in our Louisiana state clinics that have big forms, committees, and take a lot of muscle to even get a new document into the medical record. Our Title III clinics are a little bit easier in that way.

But some of the issues that we've had in developing one or developing standardized language across cultures and literacy levels are really not only words that can be deciphered and well understood but words that are well accepted within a community. So, we've looked at piloting some different ones with different kinds of questions to different kinds of communities.

Dr. Dawson-Rose:

I think that that's one of the issues that comes up over and over again and one of the reasons why with Pacific we've really focused on not having a standard set of questions, if you will, that people will answer and for people to just open the conversation with their patients and to explore some of the risks and the contexts which really vary by people, by setting, by population and what the contexts of risks are. I mean, we know that from the work that we've done with people who are HIV positive that it's hard to standardize.

Dr. Bradley-Springer:

This is Lucy, and it sounds like Delta has a good project in hand. Especially given the issues that Carol has addressed related to legal and ethical issues.

Desiree Loeb-Gruth:

Right. And I think that a lot of providers don't really know how to open the conversation -- and we're kind of used to using some sort of a check-off form; and if that form doesn't go into the chart, it kind of makes it easier to open the door and begin talking about some behaviors that are difficult to discuss.

Dr. Bradley-Springer:

I think that I like the idea, especially if it gets handed back to the patient so the patients literally take it with them when they leave.

Desiree Loeb-Gruth:

Exactly. And I think, coupled with that Rx form that you all had, I think it would really make kind of a nice partnership of the patient doing one part and the provider doing the prescription.

Dr. Bradley-Springer:

Right. And in the CDC project, there's actually a place in the chart to document what has been checked off on the prescription form that the patient takes with him or her; but I see fewer legal ethical issues related to that because it says, "This is what I want to do" or "This is what I plan to do," as opposed to "This is what I've been doing."

Dr. Dawson-Rose:

One thing that I wanted to bring up, and I don't know if this is a role for the NRC but I know because of my work on - there's a HRSA demonstration project that is going on with 15 clinics nationally and I know that a lot of people are working on this kind of a tool that you mentioned - and I'm wondering if this is something that people would want to explore further because I think that providers do think it would be very helpful to have a trigger for them to be able to talk to their patients and what goes into developing that sort of assessment tool or risk assessment that people can do individually.

Dr. Bradley-Springer:

Okay. Other questions? I actually have one for you, Carol, before somebody chimes in and it's related to, what can you tell a state like North Carolina - and North Carolina's probably not the only state - where what do you tell a clinician in that state? It's kind of like being in the military with the "don't ask; don't tell" policy. So how do you deal with that?

Dr. Dawson-Rose:

Well, I think that it needs to - I think, based on my experience - people really need to work with the providers in a clinic. And if you are mandated to report it to your DIS (Disease Intervention Specialist) officer, as happens in the state of North Carolina, how can we as practitioners in this clinic talk about these issues and work with this person as our colleague to try to figure out a way that this is going to work best for decreasing exposures and for working with patients? And that is sort of the experience that I've had with people is that they have this conversation in a clinic-wide level with the providers there and then try to further have the conversation with their legal people at the university where they were practicing and then also bringing in the folks that they are mandated to refer to to do contact tracing. And they have seemed to work out - they've seemed to work out an arrangement about, "Let's really try to focus on this and try to work on decreasing this behavior, and as long as everybody's working on that, we'll support the patient in that and not report them." I would say let's try to have the conversation with all the players that are involved in making these kinds of decisions or who's going to be reporting that kind of thing.

Dr. Bradley-Springer:

We have reached our allotted time for today's conference call. I want to thank all of you for joining us and I hope that the information that you've heard this afternoon is helpful to you in your practice and in your teaching. We're hoping that you'll be able to incorporate what you've learned today into your practice, your education, and your interventions with your colleagues and your patients. We hope that you share this information with other trainers or perhaps even use some of these slides or a whole set of these slides in presentations that you are putting together as a starting point for your own prevention with positives training. Thank you so much for being here this afternoon. And if you have questions, you have a resource to get those questions back to the presenters. Thank you so much.