Targeted Testing and Linkage to Medical Care | Protocol-Based Counseling (PBC) | Comprehensive Risk Counseling and Services (CRCS) | Evidence-Based Interventions | Social Networks Strategy for HIV CTR
Targeted Testing and Linkage to Medical Care
The Protocol-Based Counseling Quality Assurance Standards (QA) were created as part of a Centers for Disease Control and Prevention (CDC) funded project to assess what it takes to create quality assured prevention counseling in the real world. The project required the development of tools to help risk reduction specialists (RRS) understand and implement the 2001 CDC Revised Guidelines for HIV Counseling, Testing, and Referral (PDF) [CDC]. As a part of this project, the Texas Department of State Health Services (DSHS) convened a Prevention Counseling Tools Advisory Group. The Advisory Group helped to determine the required core elements for the counseling tools and helped to develop quality assurance plans; these standards are a result of their work.
In early 2005, DSHS staff conducted a series of statewide presentations highlighting the implementation and evaluation of the Protocol-Based Counseling (PBC) project in Texas. The presentation (PowerPoint : 7,901 kb) is available for review. Please contact either or if you have questions about the presentation.
The Quality Assurance Standards and related forms support the implementation of protocol-based counseling by DSHS contractors.
As you read this document, please keep in mind the following:
- Protocol-based counseling (PBC) is an evidence-based intervention.
- This intervention can be carried out separately from testing and referral.
- There have been replicated studies that show this intervention reduces clients' risk behaviors and new STD infections.
- This intervention focuses on plan-based prevention counseling. Plan-based counseling provides a framework for risk reduction specialists to use during the session and makes it more likely for the essential elements of the intervention to be covered. The essential elements of a prevention counseling session include:
- Introducing and orienting client to the session
- Enhancing client's self-perceived risk
- Exploring client's most recent risk
- Reviewing client's previous risk reduction experiences
- Summarizing patterns of risks and triggers (putting risk in context)
- Negotiating a realistic and acceptable risk reduction step
- Identifying sources of support and providing referrals
- Summarizing and closing the session
- In Texas, this intervention also includes:
- Supporting test decision counseling (when appropriate)
- Providing results simply and supportively
- Providing partner elicitation (when appropriate)
- QA refers to actions taken by supervisors and program managers to ensure that the intervention is consistently implemented across risk reduction specialists and across settings. Quality assurance activities include ensuring risk reduction specialists receive training and other activities to further his/her development; assessment of client satisfaction and client flow; record keeping; and evaluation activities including risk reduction specialist observation, feedback, and documentation review.
Protocol-Based Counseling Quality Assurance Standards
Comprehensive Risk Counseling and Services
Comprehensive Risk Counseling and Services (CRCS) is an individual-level multi-session HIV prevention intervention focused on persons who have difficulty initiating or maintaining HIV risk reduction behaviors. It is a hybrid of long term HIV risk reduction counseling and case management. CRCS in Texas is based on the national guidelines designated by the Centers for Disease Control and Prevention. Quality Assurance (QA) Standards and tools were created to ensure consistent quality services are provided for persons accessing CRCS.
Evidence-Based Behavioral HIV Prevention Interventions are science-based interventions that work to prevent HIV transmission or acquisition among individuals or within a target population. These interventions have been proven to work with a target population that is at high risk of transmitting or acquiring HIV/STDs. All the interventions had positive results for behavioral or health outcomes in the target populations studied. Each of these interventions has been proven to work through scientific research.
There are two levels of behavioral interventions:
- Group Level Interventions (GLI) involve one or more facilitators working with a specific group of individuals over a finite period of time. The goal is for members of the groups to change their own knowledge, attitudes, and/or beliefs about HIV transmission or acquisition. The target population, number of sessions, learning objectives, and other specifics of the interventions vary widely based on the original research.
- Community Level Interventions (CLI) involve training members of a community or target population to talk to others in their own community. The goal is to change the community norm regarding attitudes, knowledge and beliefs about HIV transmission and acquisition among members of that community. Specifics of the interventions also vary widely based on the original research.
Quality Assurance (QA) Standards were created to ensure consistent quality services are provided for persons accessing Group or Community Level Interventions.
Social Networks Strategy for HIV CTR
The Social Networks Strategy (SNS) is a cost-effective, incentive based recruitment strategy for reaching and providing HIV CTR to persons who are unaware of their HIV status by using existing social networks. It includes a targeted and focused approach shown to be very successful in reaching highest risk, hard to reach individuals with undiagnosed HIV infection and getting them connected to CTR services. The SNS for CTR is based on the underlying principle that people in the same social network share the same risks and risk behaviors for HIV.
Agencies using SNS for CTR identify clients or peers who are HIV positive or at high risk for contracting HIV (high risk HIV-negative clients), and enlist them to become recruiters. The recruiters identify their “network associates,” who are basically people in their social networks (e.g, friends, sex or drug partners, family members, etc.) who they believe are at risk for contracting HIV and would benefit t from HIV CTR services. The recruiters then talk with their network associates, and discuss with them the benefit of receiving CTR services. The recruiters also refer/direct the network associates to the CTR services provider to get tested for HIV.
As these individuals come in for CTR services, they can also be approached and enlisted to become recruiters and reach out to their friends and family members. And the process starts over again. Recruiters are intended to be short-term (unlike peers advocates or peer educators) and require some training and minimal supervision. They are not intended to be employees or volunteers of the agency. Their goal is strictly to talk to and refer their friends (network associates) to get tested. Incentives can be used to encourage recruiters to talk to and refer their friends.
Research has clearly shown that a Social Networks approach is successful in reaching people with undiagnosed HIV infection. From 2003 to 2005, a two-year demonstration project funded by the CDC, showed that agencies using a social networks approach for HIV testing had a 6–13% positivity rate for HIV:
9 CBOs in 7 cities participated (Philadelphia, PA (2); Orlando, FL ; San Francisco, CA; New York, NY; Boston, MA; Lafayette, LA and Washington, DC
424 Recruiters enlisted
3,179 Network Associates tested
179 New positives identified
These rates were highest among MSM and transgender individuals. This prevalence is six times higher than the average of most HIV CTR programs. Using the targeted approach of Social Networks, agencies may actually test less people, but, because they will be testing the “right” people, they may have a significantly higher positivity rate.
A more thorough overview of the strategy can be found at: www.cdc.gov/hiv/resources/guidelines/snt/overview.htm [CDC]