There are many substance abuse and mental health organizations throughout the country but minimal effort has been expended in targeting Human Immunodeficiency Virus (HIV) prevention programs toward people with mental illness and chemical dependency. The severely mentally disabled population are at a higher risk for HIV infection than the general population (Perehenets, Mamary,& Rose, 2006). HIV prevention programs are at a commodity and rarely within this vulnerable population recognized as a sexually active population let alone at risk of HIV infection. In the health promotion program the proposed program will be a prevention case management approach to reducing the incidence of HIV in people with mental illness or dual diagnosis. The program will include a variety of professional health services, psychiatric care, and individually tailored education on HIV, other sexually transmitted diseases, and safer sex, as well as drug/alcohol treatment as needed. Health promotion being the objective of this program there will be active progress to reduce HIV infection among mentally ill and substance abusing population. The process will include working individually with each client to facilitate the identification and modifying risky behaviors, while also treating mental illness and substance abuse issues in an active effort to improve wellness (Aids Alert, 2008).
In Cleveland, Ohio, there is a limited effort directed toward addressing the issue of HIV/AIDS among people with mental illness and chemical dependency. At the same time, there is a growing phenomenon of HIV transmission through sexual activity among the severely mentally disabled individuals. Mental illness does not increase risk in and of itself, a person with mental illness can, of course, engage in high risk behaviors for HIV infection. Studies of people with Severe Mental Disabilities show that between 4% and 19.4% are HIV positive. In all cases, the seroprevalence rates among people with mental illness are higher than that of the United States population in general (Courns et. al., 1991; Sucks et.al.,1992; Susser, Valencia, and Conover, 1993).
It is critical for the severely mentally disabled clients to be provided with adequate education about HIV/AIDS and prevention strategies. The typical severely mentally disabled client suffers from a severe thought disorder exhibiting periods of active mental illness and remission. Active periods may include symptoms such as hallucinations or paranoia. Negative symptoms, which appear during remission, may include anxiety, depression, or impairment in thought (DSM IV). During periods of active illness, a client is less likely to engage in unsafe sex or other high-risk behaviors. During periods of remission, however, a client may resort to sex and/or drug using behaviors in an attempt to self-medicate (Aids Alert, 2007). Ironically, one of the periods of greatest risk is when a client receives effective case management, including medication and counseling.
Researching agencies across the United States it was found that rarely did individuals with severe mental illness have any knowledge of the HIV infection or ways to prevent the spread(Aids Alert 2007). Thus it is critical that severely mentally disabled clients be provided adequate education about HIV/AIDS and preventive strategies. The health promotion project will specifically address three priorities: (1) Promoting Healthy Behaviors and Life Styles, (2) Increasing and improving healthcare, (3) Increasing knowledge.
Literature Review
A total of six articles reviewed for this project all where consistent in the recommendation to reduce HIV among the severely mentally disabled population. To reduce the transmission of HIV among clients in this population, risk prevention and education are essential (Aids Alert, 2008). A challenge among this population is the continuous need for intensive case management because studies showed following education and risk reduction activities are taught after 6 months at risk behaviors returned (Berkman, Pilowsky, Zybert, Herman, Conover, Lemmelli, Cournos, Koepner, & Susser. 2007).
In review of the literature one of the weakness is that the reality of sustain prevention behaviors where not demonstrated nor did the articles at hand speak about the need for intensive case management once a person with persistent mental illness present being HIV positive or living with AIDS. Clearly the project being proposed would offer continuous individualized, comprehensive, prevention case management approach, coupled with risk-reduction counseling as well as pre and post counseling for testing for HIV.
Prevention Case Management ensures that clients have the necessary infrastructure established in their lives to allow them to focus on treatment and healthy living. The case manager links the client to essential services such as healthcare, housing, entitlements, and training. Assisting in daily living skills, such as budgeting and medication compliance, and acts as a liason between medical doctors and psychiatrists working with the client. Once the client has been linked to resources to meet his or her needs and receives psychiatric care to minimize or control symptoms, then the focus on reducing risky behaviors associated with increased risk of HIV infection.
There are many substance abuse and mental health organizations throughout the country but minimal effort has been expended in targeting Human Immunodeficiency Virus (HIV) prevention programs toward people with mental illness and chemical dependency.
Conceptual Model
The High Risk Prevention Program is based in behavioral science theory. The education and prevention group sessions and prevention case management both use a combination of the AIDS Risk Reduction Model (ARRM) and Harm Reduction theory as a framework to guide interventions. For example, the education portion of the group sessions teaches people what behaviors put them at risk for HIV or other sexually transmitted infection. The participants activiely show the knowledge they are gaining through the “High risk, Low risk, No risk” game, where a behavior is written on a card and given to each person. Participants are then asked to stand under the sign that shows the level of risk the behavior carries. This is based on the ARRM principle that in order to change behavior, one must first label it as risky. The prevention portion of the group teaches participants how to reduce likelihood of infection through safer sex practices. This is based on both the ARRM principle that a person must make a commitment to change (e.g., use condoms for every sexual encounter) as well as the Harm Reduction principle that people are going to do risky things, so they should be given ways to at least reduce the risk. The ARRM states that the last step to changing behavior is to take action to perform the desired changed (Lanier,M. & Gates,S., 1999). The High Risk Prevention Program witnesses this principle in prevention case management clients, since they are seen and intervened upon over a long period of time (sometimes years), whereas group session clients are seen only once.
It is essential to provide education about the risk of HIV transmission to practitioner, community members, and clients. All of these groups need to understand what HIV is, how it is transmitted, and how to change risky behaviors in order to prevent infection. Without this knowledge, the disease will continue to be misunderstood and it will continue to spread through people with mental illness and/or substance dependence.
Group sessions will be provided at local community organizations that provide mental health and substance abuse treatment, thus reaching a larger community. Experience shows that many people with mental illness are reluctant to go to an unfamiliar place and/or are likely to isolate themselves at home. Staff will provide outreach to homeless drop in centers and group homes to assist in reaching marginalized populations.
Providing prevention education materials and the tools necessary for clients to practice prevention and risk reduction techniques nurses and other supportive staff will offer clients a variety of safer-sex products, including condoms, female condoms, dental dams, lubricants, and pamphlets about specific sexually transmitted disease or HIV. Free anonymous or confidential OraSure testing will be provided to participants following each session.
In addition to education and prevention seminars, it is important to assist clients through learning, understanding, and implementing a risk-reduction life style. Prevention case management is critical in ensuring that clients have the necessary infrastructure established in their lives to allow them to focus on treatment and healthy living. The case manager will link the client to essential services such as healthcare, housing, entitlements and/or job training. The case manager will assist with daily living skills, such as budgeting and medication compliance, and act as the constant between medical do ctors and psychiatrists working with client.
Project Goals and Objectives
The first goal will be to increase knowledge and awareness around HIV and other sexually transmitted disease and prevention models, such as safer sex practices to clinical staff. The objective will be to provide education session about HIV and other sexually transmitted disease to employees and interns to ensure internal agency staff members are informed with accurate knowledge about high-risk behaviors associated with HIV and STD’s. A secondary objective for this goal will be for staff members comfort and capability to talk with clients about sexual behaviors and HIV/STD prevention.
The second goal will be to decrease behaviors that put people with mental illness and substance abuse problems at risk for HIV infection through comprehensive case management while supporting clients’ physical, emotional, social and mental health. The first objective will be to provide prevention case management services to 45 unduplicated clients. The intervention will be providing case management services to 30 clients each month, with overlap from month to month ( the average number of case management encounters will be two per client, per month).
The second objective for the goal number two is to provide prevention and education sessions to One hundred and Eighty clients. With mental illness and/or substance use to increase knowledge about high risk behaviors associated with HIV/AIDS, other sexually transmitted disease, and safer sex. The intervention will be for multidisciplinary staff to provide prevention education sessions. Seminars will rotate through the community and will be held throughout the year, with an average of one seminar per month. Free, anonymous HIV testing will be provided through collaboration with an established testing provider. The outcome will be that clients achieve an increase in knowledge and awareness of issues around HIV, other sexually transmitted disease and safer sex, as evidenced in pre – post test result analysis.
Evaluation Component
Evaluation of the project’s success has two components. The first component is a pre/post test to assess client’s knowledge of HIV, safer sex, and sexually transmitted disease. This evaluates the Education and Prevention component of the Project. Post-test scores that are higher than pre-test scores will show that the Education and Prevention session improved the participants knowledge of HIV, and other sexually transmitted diseases and safer sex.
The second evaluation component is a documented review of client goals. This evaluates the Prevention Case Management component of the project. After establishing rapport with the client, the Prevention Case Manager will collaborate with the client to formulate a personal goal about HIV or other sexually transmitted disease risk reduction or safer sex. Typically, the Prevention Case Manager checks in with the client about this goal at each session to evaluate one or more of the following: the client’s knowledge about HIV and prevention, his or her attitudes about changing risky behaviors, and skills available to implement a change.
There is a formal written review of the client’s goals that takes place every ninety days and is kept in the client’s record. Progress is determined by both the client’s personal assessment of his or her achievements and the Prevention Case Manager’s clinical opinion. Optimal outcomes in Prevention Case Management evaluation will demonstrate increase in condom use, cessation of injection drug use, or decreased number of sexual partners.
Barriers and Challenges
The adoption of Evidence Based Interventions can be best implemented under real-world conditions. The agency implementing the change must also have the ability to offer capacity building activities for the adopters of the intervention. Just adding responsibility to staffs all ready full scheduled can be a barrier to the motivation and successful implementation of the interventions.
The level of care also needs to be assessed when offering Prevention Case Management when in fact the client is aligned in needed intensive case management simply to manage basic needs and this intervention would not have any significant change in behavior. The severly mentally ill client will present with challenges of psychiatric stability and that does need prioritizing.
Successful behavioral change is not a one-time event. Change occurs over time, and with small steps which accumulate to make large differences. Change must be maintained over time and interwined into the culture of the person and their support system. The clinicians must remain flexible and meet their clients where they are moving them to risk free behaviors in their time line, pulling on their strengths.
Nurses must expand their efforts to design and implement interventions which support promotion of health and prevention of disease and disability. Preventing and staying healthy is complex, focus is not only on the client but their family, their support system and their beliefs. The nurses approach needs to be comprehensive looking at primary, secondary and teritarty levels of prevention and involve the client and community in the planning. The Aids Risk Reduction Model allows the nurse to understand and predict clients behavior including how they use and adhere to recommended therapy.
Health promotion being the objective of this program there will be active progress to reduce HIV infection among mentally ill and substance abusing population. The process will include working individually with each client to facilitate the identification and modifying risky behaviors, while also treating mental illness and substance abuse issues in an active effort to improve wellness (Aids Alert, 2008).
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