# Presentation: 735447

## Moving Clients from“Kiss and Tell” to “Tell and Kiss”Supporting Conversations Around Patient Self Disclosure of HIV or STD StatusGreg Mehlhaff, BS, Assistant DirectorLinda DeSantis, M.Ed., Behavioral Training CoordinatorAlice Gandelman, MPH, Director 

## CA STD/HIV Prevention Training Center (CA PTC)

- _[www.stdhivtraining.org](http://www.stdhivtraining.org/)__ _

## Supporting Self Disclosure of HIV/STD Status

- Another option for STD partner management
- Course developed to enhance provider skill
- Address complex issues around disclosure
- Many patients need skills and assistance
- Similar issues with patients infected with HIV and other STDs
- HIV/STD co-infection

**Notes:**
Acknowledge Provider Referral is still preferred but Self Referral might need to be looked at when other methods aren’t an option for client.

May not be able to identify partners in traditional ways – another reason to look at self disclosure
Brainstorm:
How many of you have had clients close down with regards to provider referral?  
What do you do then?

## Missed Opportunities?

- Sex partners: 3-named, 7-known, but _refused_ to name.
- Sex partners : 1-named, 1-marginal, 4-known, but _declined_ to name.
- Reported 2 sexual partners (_declined_ to release locating information)
- Sex partners : 2-named, 23-known, but _declined_ to name.
- Reported 4 sex partners during the interview period (_declined_ to name)

**Notes:**
Present this as an example.    To illustrate challenges of provider referral.

Vast majority are not named but in every case at least one was known.
Difference between named and known

Ask:
Does this look familiar?
Why do you think folks might refuse or decline?

## Rationale

- Important prevention intervention for persons living with HIV/STD
- Most infected persons want to prevent transmission to others
- Many want to disclose their HIV serostatus
- Many want to talk to their providers about disclosure issues
- 75% choose to self disclose their HIV status to partners – (CA PCRS data)

**Notes:**
Tie in from previous question – Why do you think this is?
Similar reasons to course development.

It may not translate the same for STD’s but co-infection issues still exist 
Sero-sorting = HIV+ engaging in risk with other HIV +
High rates of syphilis among HIV+
65% co-infection
Lack of knowledge of STD within HIV+ MSM community
Perceived Severity!  Syphilis is not so bad!

## Disclosure Activity

**Notes:**
Process with questions....
What were you feeling when you thought about disclosing?
Imagine telling the person who would be most affected...
What exactly will you say?
What did you do to prepare to disclose
Now imagine having a third party (who you don’t know) tell this person.
How are you feeling about this?

Explore feeling....potential defensiveness...complex issues/feelings 

## Challenging Clients/Patients

- Resistant to giving partner names
- Distrustful of Public Health
- Anonymous partners
- Internet partners/CSV partners
- Only one partner (steady, spouse)
- May have substance use or mental health issues
- Concerns about confidentiality
- Personal safety/fear of violence

**Notes:**
Brainstorm:
What challenges do you face with clients around interviewing or provider referral?
Check in with bullets:  ie...why might a client be distrustful?

Discuss typical approach as very heterosexist.
Increase altruism and community care taking very high within Gay community

Trust issues exist within PH – but not reflective of you as providers but is inherent is history – stigma, discrimination.  Newer issues within this community

Check in with when will provider let go of partner notification and switch to other options of getting partners notified ...assist with self disclosure.
Acknowledge data collection.  Redefining success and possible lowering case dispositioned.

## Missed Opportunities!

- Sex partners: 3-named, 7-known, but _refused_ to name.
- Sex partners : 1-named, 1-marginal, 4-known, but _declined_ to name.
- Reported 2 sexual partners (_declined_ to release locating information)
- Sex partners : 2-named, 23-known, but _declined_ to name.
- Reported 4 sex partners during the interview period (_declined_ to name)

**Notes:**
Lets look back to previous discussion.
Might some be related to challenges?
Might we be able to reduce these numbers by looking at other approaches.

## The Model

- 4-Step model to facilitate positive disclosure outcome
- 1) Transition from topic at hand to self disclosure
- 2) Discuss whom the client is considering telling
- explore concerns, benefits, confidentiality, other things client might also be disclosing
- 3) Coach client regarding a specific disclosure
- anticipated reaction of person being disclosed to (DV)
- offer opportunity to practice (what s/he will say)
- provide appropriate referrals
- 4)Summarize discussion

**Notes:**
This is a model that has been found to be useful for HIV providers.
Describe model as working in a context and bridging to topic of Disclosure -  for providers here, most are already talking about partners -  
How can you make a shift from Provider Notification 
When might it be good to shift from getting names to discussing self referral.
How might you do this?
Come up with scenario...
Then demonstration!

## Self Disclosure in Syphilis Partner Management?

**Potential disadvantages**
- Difficult to document notification
- May take more time to Tx partners
- Uncertainty that patient will follow through
- Patient may not be clear about disease or action to take
**Potential advantages**
- Might be most acceptable option for patient
- More effective with email notifications
- Anonymous partners may be seen again in same setting
- May be able to maintain primary relationship
- Use fewer program resources
- Dual disease disclosure (Syphilis/HIV)

**Notes:**
Ask:  What do folks thing about self disclosure model
Brainstorm:
What are disadvantages/advantages

## Conclusions 

- May prevent or address missed opportunities
- Less emphasis on *how* to effectively disclose, or of potential consequences of disclosure
- Developed training to increase providers’ comfort and skill level to effectively discuss HIV/STD disclosure issues with their clients/patients
- Discussion of HIV/STD status can be very risky for clients/patients *and* providers

**Notes:**
I AM NOT SURE ABOUT THE CHANGES TO THIS SLIDE...HELP!

## Contacts

- Linda DeSantis, M.Ed., Behavioral Training Coordinator
- CA STD/HIV Prevention Training Center
- CA DHS/STD Control Branch
- 510-883-6661
- _[ldesanti@dhs.ca.gov](mailto:ldesanti@dhs.ca.gov)_
- Greg Mehlhaff, BS, Assistant Director
- CA STD/HIV Prevention Training Center
- CA DHS/STD Control Branch
- 510-883-6649
- _[gmehlhaf@dhs.ca.gov](mailto:gmehlhaf@dhs.ca.gov)_
- Alice Gandelman, MPH, Chief Disease Prevention Section
- Director, CA STD/HIV Prevention Training Center
- STD Control Branch
- 1947 Center Street, Suite 201
- Berkeley, CA  94704
- ph: (510) 883-6657, fax: (510) 849-5057
- _[agandelm@dhs.ca.gov](mailto:agandelm@dhs.ca.gov)_