Computer education may bridge affordability gap

Electronic counseling’ is easy and accessible

While there is a multitude of well-proven HIV prevention programs and models that resulted from studies funded by the Centers for Disease Control and Prevention (CDC) and other agencies, there are few options for the cash-strapped HIV clinic or doctor’s office.

Keeping this obstacle in mind, researchers from three universities and the CDC are collaborating with a Seattle computer consulting business to create a computer-assisted, client-centered, prevention and education CD-ROM product that will encourage risk-reduction behaviors and increase testing for HIV and other sexually transmitted diseases (STDs). Participants in the program include the University of Washington in Seattle; California State University in Long Beach; Indiana University School of Medicine in Indianapolis; and Resources Online, a Seattle computer business.

"We’ve been trying to figure out more efficient ways to get more people tested for HIV and STDs, and also to be counseled to reduce their risks," says Ann Kurth, CNM, PhD, a certified nurse midwife and STD fellow at the Center for AIDS and STDs at the University of Washington.

Studies have shown that brief sessions of counseling both before and after an HIV test is administered can result in significant risk reduction and behavior change, says Freya Spielberg, MD, MPH, assistant professor of the family medicine department at the Center for AIDS Research of the University of Washington.

"There are many venues, [such as] emergency rooms and STD clinics, where they don’t have the time or skilled counselors to provide this service, and we’re hoping we can create something that is similar to what is known to be effective prevention counseling," Spielberg says. "This is a client-centered approach for places that don’t have it, so they’ll be able to offer an effective replacement for pre-test counseling."

The theory behind the computerized counseling program is that most HIV/STD care is done in private practices where providers don’t have the time, money, or staff to do risk-reduction counseling, Kurth points out. "So our goal is to deliver this proven counseling technique through the computer to multiple sites," she explains. "Interactive computer counseling has been used for genetic counseling, smoking cessation; but as far as we know, this is the first time it’s been used for HIV and STD, client-centered counseling."

It’s not enough to provide educational materials because studies show these alone are not as effective as client-centered counseling, Spielberg says. "We’re going to try to come as close as we can to creating client-centered counseling, using an interactive computer program." While this approach won’t put a patient face to face with a counselor, it’s a cost-effective alternative that could be made available to many different HIV health care settings, Kurth says.

Client-centered counseling is an approach that has been recommended by the CDC and has been proven to be effective in reducing risk behaviors. Unlike the typical didactic counseling method, in which a physician asks questions, assesses risk, and then lectures the patient, client-centered counseling takes into consideration what the client needs and is capable of learning at that particular point in time. And the counselor helps them decide on a risk reduction plan that is attainable for them. "First you begin with a nonjudgmental attitude, which is critical to effective counseling," Spielberg says. "With this approach, the client does most of the talking."

Clients will describe their understanding of their risk for HIV, and the counselor heightens their awareness of risk by giving feedback, when necessary, she says. "You explore with them what happened during their most recent risk and what they have tried in the past to reduce their risk," Spielberg explains. "And then you help the client come up with a specific risk-reduction plan that the client feels can be accomplished."

Rather than asking clients to agree to never again have unprotected sex, which may be unrealistic for many clients, counselors ask clients to commit to carrying a condom with them the next time they go out. Or they may be asked to consider talking to their next partner about HIV before they have sex, she adds. "When this approach has been taken in STD clinic settings instead of didactic messages, studies have shown that clients contracted 30% fewer STD infections within the first six months of follow-up," Spielberg notes.

Cost is a big drawback

Client-centered counseling’s chief drawback has been the staffing cost and time needed to make it work, and this has kept it from being used in many private practices, clinics, emergency rooms, migrant health centers, and teen health clinics, Kurth says.

Also, there are sites such as emergency rooms where HIV testing is not routinely offered because they are unable to provide the necessary counseling, Spielberg says. "Some people at high risk may not seek health care outside of the emergency settings, thus an important opportunity is missed for early detection of HIV infection, she adds. "It is our hope that our interactive HIV computer counseling tool will make it possible for more venues to provide HIV testing so that access to HIV testing will be improved for people at risk."

The counseling tool’s researchers are building the computer program so that it is appropriate for various at-risk populations, for people of different ages, and eventually for provision in a variety of languages. "The structure is being set up so we will be able to expand it to allow a more tailored program for people of different ages and from different risk groups, as well as for people from different cultures," Spielberg says.

The development is funded by the CDC, which has requested a CD-ROM product as a starting point, Kurth says. "We’re looking at the possibility of adapting it down the road for web-based access," she adds. "But the reality is that there isn’t always web access for personal computers available for patients at many clinics, so that’s why the CDC decided on the CD-ROM version."

The program will have a user-friendly interface that asks patients risk assessment questions, followed by individualized counseling messages and negotiation of a realistic prevention plan, Kurth explains. "We’re basing it on well-validated elements that are programmed into the computer, incorporating common scenarios and counseling probes that are used by a good counselor."

Depending on how a person responds, there are different options, which is what will make this client-centered, Spielberg adds. "The program will go through different scenarios of education and counseling, enhancing clients’ perceptions of their own risk for HIV and STDs, or how to use condoms if that has been a problem for them in the past," she says. "What they receive will depend on how they respond to the risk assessment and what they identify as their most important concerns." This way, each patient selects his/her own risk reduction plan based on what they find realistic and what they think they can do.

The patient who has not yet started using condoms regularly may be routed to a short video showing realistic dialogue between a couple who are negotiating sexual safety. Someone who has used condoms that have broken may be routed to an animated clip on how to properly wear them, Kurth says. Since this computerized counseling program mainly will be geared toward youths, it is already designed for an audience that is used to digital communications and high-tech graphics, she explains.

For instance, the product will have a guide to take patients through the program, and the guide may reflect the patient’s own ethnicity. "There may be an African-American man or a Latino woman, or a physician in a white coat, and so they’ll pick the guide that they are most comfortable with at the beginning of the program," Kurth says.

The program also will be designed to run on a wide variety of computers to reflect the reality of what kind of hardware clinics have available. Likewise, the early versions of the program will be in English, but more options may be available for later versions in other languages, she says.

Once the program is fully developed, the team’s intent is to distribute it widely to make it accessible in many different venues. Users also would be able to customize the program by adding in phone numbers for local resources, for example, or by adding language modules when those become available. It could be distributed at low or no cost to health clinics and sold on a sliding income scale with the goal of making it accessible in many different venues where counselors are not available, Spielberg says.

"Our goal is for people to use this CD-ROM when there are no human counselors available, or to use it for an initial interview with follow-up by counseling staff," Kurth says. "If this is done in conjunction with HIV testing, then the goal would be to test more people."

Funding for the program’s development began in October 2002 with a plan to begin pilot testing and to design a randomized trial of the intervention in 2003.

(Editor’s note: For more information about the computerized, client-centered counseling program, go to jim@ronline.com.)