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= HIV/AIDS AND = ASSUMPTIONS
Case manager’s influence on the dissemination of HIV prevention information to their Seriously Mentally Ill Clients
Mentors:  Julie Tennille MSW, Michael Blank= PhD, Phyllis Solomon PhD
Dara H= older
My assumption: SMI won’t be exposed to HIV risk behaviors
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SERIOUSLY MENTALLY ILL (SMI)
•Serious mental illnesses refers to disorders <= b>with psychotic symptoms, such as schizophrenia, schizoaffective disorder and = manic-depressive disorder as will as severe <= b>forms of other diseases such as major depression, panic disorder, obsessive-compulsive disorder..(5)
•
•
= •Estimated 2.8 million Americans suff= er from <= b>Serious Mental Illness.
•
Faced with stigma, and face many of the challenges of impoverished populations: victims of crime ,homelessness etc
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SMI- HIV RISK FACTORS
•Risk behaviours incl= ude: unprotected sex, sharing needles, coerced sex for women with SMI (6), having = multiple sex partners, trading sex for housing, food= , money, drugs or alcohol‏(1)
•
•
•Risk Factors include:
•        = ;            &n= bsp;            = ;   socioeconomic status
•    symptoms of their ment= al illness
•    patient housing <= /b>
•    personal autonomy<= /span>
Note the similarities between  the ri= sk behaviors for SMI and individuals without SMI

Sexual coercion: the use of physical force or threat of force, emotional abu= se, or financial incentives or other means to result in sexual behavior– often not in the position to provide for themselves.

Research shows that 38% of Female SMI have been sexually abused as adults w= ith 76% of homeless SMI having a history of sexual abuse
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SMI,HIV and SUBSTANCE ABUSE
•HIV prevalence
•SMI (4%-22%) vs. general pop (0.3%-0.8%)‏= (1
•HIV Transmission Rate
•SMI 13-76 times the rate of the general pop‏(1
•
•Substance Abuse
•53%of SMI are also current or previous drug abusers<= /span>(2)‏
•37% of= SMI were current or previous alcohol abusers(2)‏
• = ;
•
•
•
One of the reasons that substance abuse is as heavily discussed during case management activitIes
The potential to significantly impact the problem of substance abuse by targe= ting the SMI– as was reported in JAMA IN 1990
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THE PATH INTERVENTION
•Preventing AIDS through Health (PATH)
<= span style=3D'color:white;mso-color-index:0'>•RCT @ Hall- Mercer CMHC
<= span style=3D'color:white;mso-color-index:0'>•RESPECT+ CBOM
<= span style=3D'color:white;mso-color-index:0'>•360 clients & 32 Case Managers (CMs)‏
<= span style=3D'color:white;mso-color-index:0'>•Role of relationships
•Training of CMs to educate their clients = on issues of safer sex & drug use
Blood testing will identify those who are HIV positive at baseline. Breathalyzer and urine testing will supplement clinical interviews and ot= her measures to identify substance abuse co-morbidity. Using a longitudinal experimental and control group design, we will randomly assi= gn case managers to deliver the intervention to consenting participants in t= heir caseloads who meet inclusion criteria. Participants will be in treatment = at a large CMHC in Philadelphia. Independent interviews will be conducted with case managers and consumers before the intervention, and again at 3, 6 and 12-months post intervention and focus on changes in risk behaviors, fidel= ity of translation of the intervention, cost and outcomes. Breathalyzer and u= rine tests at 12-months will supplement self-reports of use of alcohol, cocain= e, marijuana, benzodiazapines, and opiates.

The program hinged on the Relationships between the clients and their CMs<= /b>: strength and longevity, generally seen as someone that can help them with their problems and has been there for them in the past.

Training:  CMs will be taught to use bo= th educational information and demonstration– clients’ retention= of this knowledge is gauged periodically using the survey

The RESPECT program was developed by CDC and is the first HIV prevention prog= ram to show one-on-one counseling can reduce at-risk sexual behavior in a multi-site demonstration. The NIDA Community-Based Outreach Model (CBO= M) was designed to reduce the risk of HIV and other blood-borne infections in dr= ug users.

Collaborative education and skill building sessions which would allow for longer term effects as opposed to just education

Randomized by Case manager

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Rapid Assessment Procedure
<= span style=3D'mso-special-format:bullet;color:black;position:absolute;left:-4.1= 4%'>•Intensive, team-based qualitative inquiry using triangulation and iterative data analysis = <= span style=3D'font-family:Arial;mso-ascii-font-family:Arial;font-size:88%;color= :white; mso-color-index:0'>to quickly develop a preliminary <= span style=3D'position:absolute;top:40.75%;left:8.8%;width:103.37%;height:6.0%'= >understanding of a situation from the insider's = <= span style=3D'font-family:Arial;mso-ascii-font-family:Arial;font-size:88%;color= :white; mso-color-index:0'>perspective<= b>.(5)
<= span style=3D'mso-special-format:bullet;color:black;position:absolute;left:-4.1= 4%'>•Uses interviews with key informants and <= /span><= span style=3D'font-family:Arial;mso-ascii-font-family:Arial;font-size:88%;color= :white; mso-color-index:0'>focus groups
<= span style=3D'mso-special-format:bullet;color:black;position:absolute;left:-3.7= 7%'>•Multifaceted approach to data collection and <= span style=3D'font-family:Arial;mso-ascii-font-family:Arial;font-size:88%;color= :white; mso-color-index:0'>analysis
<= span style=3D'font-size:88%;color:white;mso-color-index:0'>•RAP vs Ethnography
Used in conjunction with longitudinal studies—
Team effort
Shorter immersion time in the study environment
Less prone to bias since the information is analyzed by a team

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MY ROLE
•Intended Tasks
<= span style=3D'color:white;mso-color-index:0'>•RAP interviews
•Efficacy as gauged by Clients, Administrato= rs and CMs
Actual Tasks
Focus on- CMs
Working Alliances <= /span>
Perceptions on HIV = training and information = dissemination with SMI clients
RAP interviews: ecological- one time snapshots- I would have done post intervention to determine the how HIV prevention efforts had changed over time

Cause: IRB approval of the informed consent process

I only managed to interviewed mainly control case managers and managed to gauge = the way the information flowed through informal networks at Hall Mercer
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CASE MANAGERS
<= span style=3D'visibility:hidden'>•
• =
•
Baseline Results =
•= Desire and motivation
•= Absence of ongoing training and supplemental materials = &#= 13;
•= Priority given to housing and symptom stabilisation
•= HIV prevention efforts should be integrated into = = current CM activities
•= Assumptions  led CMs to exclude some clients f= rom = = HIV prevention efforts.(2)
Case managers were up to the challenge because (pragmatic view):easier = to do prevention  than to addre= ss the issue later. Even those that were squeamish about the task would have had someone make up for them

Ongoing training- yearly online training and optional training in the community- heavily education based which has been proven to have short term effects<= /font>

They saw the need to address the necessities before addressing since addressing th= ese might have protective effects..Lessen the risk

Assumptions: a natural human thing which happens in the absence of factual knowledge

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CASE MANAGERS
<= span style=3D'color:white;mso-color-index:0'>•Asexuality
<= span style=3D'color:white;mso-color-index:0'>•Marital Status
<= span style=3D'color:white;mso-color-index:0'>•Southeast Asian Sex Taboo
<= span style=3D'color:white;mso-color-index:0'>•Elderly
<= span style=3D'color:white;mso-color-index:0'>•Female
•
Assu= mptions
Asexuality; Actually an assumption I made. In Guyana, diagnosed SMI would be taken ca= re of their family and largely separate from society

Marital Status: It is generally assumed that married people are monogamous an= d as such at lower risk. This is quite an unfair assumption to make since the couple might be estranged/ just plain trifling
RAP 1 interview

Southeast Asian Sex Taboo: Some case managers made the assumption hat people of= SE Asian descent do not engage in any sexual behavior

Elderly: CMs have reported that they don’t discuss sex with the elderly because it is assumed that older people regardless of their mental health status don’t have sex

Female: CMs also believe that female are less likely to engage in risky sex despite the evidence that SMI females are more likely be victims of sexual coercion and ultimately RAPE


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CASE MANAGERS
<= span style=3D'mso-special-format:bullet;color:black;position:absolute;left:-3.6= 2%'>•Increased Awareness of the lack of prevention <= b>efforts.
<= span style=3D'mso-special-format:bullet;color:black;position:absolute;left:-3.7= 3%'>•More on-site HIV prevention efforts<= /b> including demonstrative techniques.
<= span style=3D'mso-special-format:bullet;color:black;position:absolute;left:-3.7= 8%'>•Dissemination of HIV prevention information <= b>beyond experimental group.
<= span style=3D'font-size:88%;color:white;mso-color-index:0;visibility:hidden'>• =
<= span style=3D'font-size:81%;color:white;mso-color-index:0;visibility:hidden'>• =
•
•=