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Community Based HIV Prevention Research:

Lessons LearnedKENNETH VOGTSBERGER, M.D.

STAFF PSYCHIATRIST

ATCMHMR

DAVID DESMOND, M.S.W.

ASSISTANT PROFESSOR, RET.

UTHSC, SAN ANTONIO

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OVERVIEW OF PRESENTATION

HOW A NIDA GRANT INFLUENCED THE SUBSTANCE ABUSE DIVISION, DEPARTMENT OF PSYCHIATRY, UNIVERSITY OF TEXAS HEALTH SCIENCE CENTER OVER A 10 YEAR PERIOD

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BACKGROUND OF MULTI-SITE STUDY

• NIDA OBJECTIVES: PREVENT DRUG ABUSE AND REDUCE TRANSMISSION OF HIV

• NIDA GOALS: TEST AND EVALUATE DIFFERENT MODELS /INTERVENTIONS TO REDUCE HIGH RISK DRUG ABUSE AND SEXUAL BEHAVIORS AMONG IDUS AND THEIR SEX PARTNERS

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BACKGROUND

• SEPT. 1987-SIX NADR, 5 ATOM PROGRAMS FUNDED

• SEPT. 1988-TOTAL OF 54 CITIES AND 63 SITES FUNDED

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LOCAL COMPETING APPLICATIONS

• SAN ANTONIO METROPOLITAN HEALTH DISTRICT

• UNIVERSITY OF TEXAS HEALTH SCIENCE CENTER, SAN ANTONIO

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SHOTGUN WEDDING:OFFSPRING NAMED FRIO

STREET PROJECT (FSP)

• $2,500,000 FOR PROJECT,1988-1991 (PI’s second grant appl, first funded project)

• HEALTH DISTRICT: OUTREACH AND RECRUITMENT

• MEDICAL SCHOOL: DATA COLLECTION, INTERVENTION (Health Belief Model), AND DATA ANALYSIS

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WHY DID WE GET FUNDED????

• LOW SEROPREVALENCE COMMUNITY• LARGE HISPANIC IDU POPULATION• MADDUX/DESMOND TRACK RECORD

WITH NIDA• PI WITH EXPERIENCE AS TEACHER AND

DIRECT PATIENT CARE PROVIDER• HEALTH DISTRICT TRACK RECORD IN HIV

TESTING/COUNSELING• THE L------- WORD

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A FAMOUS SAYING THAT APPLIES TO GETTING

FUNDED:

THE ONLY THING WORSE THAN NOT GETTING WHAT YOU WANT,

IS GETTING WHAT YOU WANT.

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FSP AS BASIS FOR 10 YEARS OF GRANT FUNDING

• $400,000/ 1991-1992 EXTENSION AND FORMATION OF THE SW RESEARCH CONSORTIUM (NIDA)

• $3,064,000/ 1989-1994 IMPROVING RETENTION ON METHADONE MAINTENANCE (NIDA)

• $972,000/ 1992-1995 STEPS PROJECT (CSAT)

• $2,300,000/ 1994-1999 COPA PROJECT (NIDA)

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ADDITIONAL GRANTS

• $150,000/ 1996-1999 SUPPLEMENT FOR NEW MINORITY RESEARCHERS (NIDA)

• $36,000/ 1997-1998 FEMALE CONDOM MULTI-SITE STUDY (NIDA)

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DOING THE WORK

• ESTABLISH FIELD OFFICE• HIRE STAFF/ISSUES WITH OUTREACH

WORKERS• TRAIN STAFF/TEAMBUILDING• MULTI-TASKING FOR ALL STAFF• RECRUIT SUBJECTS-THE INFAMOUS AIA

QUESTIONAIRE/ REFINE PROCESS• IMPLEMENT/REFINE THE INTERVENTION

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DOING THE WORK

• DO FOLLOW-UP ASSESSMENTS 6 MONTHS POST-ENROLLMENT (A POPULATION OF HEROIN ADDICTS RECRUITED FROM THE STREETS!!)

• STAFF ATTRITION

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MEETINGS, BLOODY MEETINGS!!

• WEEKLY ALL STAFF MEETING

• OUTREACH WORKERS MEETING

• FOLLOWUP STRATEGY MEETING

• RESEARCH STAFF MEETING

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LOCATOR FORM

DESCRIPTION OF SUBJECT

HANGOUTS

SIGNIFICANT OTHERS FOR CONTACT

CONSENT FORM TO CONTACT IN 6 MONTHS

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FOLLOW-UP FLOW SHEET

• LETTER (EMPHASIZE $)

• PHONE CALL

• “BE ON THE LOOKOUT”

• INTENSE SEARCH

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RESULTS

• 2,292 IDUS AND 349 SEX PARTNERS RECRUITED IN 2 ½ YEARS

• 20,000 BOTTLES OF BLEACH DISTRIBUTED

• 72,000 CONDOMS DISTRIBUTED

• 2,300 BLOOD SAMPLES TESTED, 33 HIV+ (1%)

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RESULTS

• HIGH RATES OF UNSAFE NEEDLE USE AT INITIAL ASSESSMENT

• HIGH RATES OF UNSAFE SEX AT INITIAL ASSESSMENT

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RESULTS

• 80 % SIX MONTH FOLLOW UP RATE• 1,673 BLOOD SAMPLES TESTED AT

FOLLOW UP, ONLY 1 CONVERSION• 60 % OF IDUS HAD AT LEAST ONE

TREATMENT EXPERIENCE(reported at initial assessment)

• 90 % OF IDUS HAD AT LEAST ONE JAIL/PRISON EXPERIENCE(reported at initial assessment)

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OUTCOME OF THE INTERVENTIONS

• AT 6 MONTH FOLLOWUP, BOTH STANDARD AND ENHANCED INTERVENTION LEAD TO REDUCTION IN NEEDLE RISK INDEX

• AT 6 MONTH FOLLOWUP, NO SIGNIFICANT CHANGE IS SEX RISK

• LOW SEROPREVALENCE MAINTAINED IN SAN ANTONIO THROUGH 1998

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ESTIMATED TOTAL NUMBER OF SUBJECTS RECRUITED FOR ALL

STUDIES: 1988-1999

5,575

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BENEFITS TO P.I.

• LETTER FROM THE PRESIDENT, UTHSCSA

• PROMOTION: FROM ASST. TO ASSOC. TO PROFESSOR

• PUBLICATIONS: 19 ARTICLES, 1 BOOK CHAPTER, 1 ABSTRACT

• THE ACADEMIC EXPERIENCE

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CHALLENGES FOR THE P.I.

• BALANCING TEACHING, SERVICE, AND RESEARCH

• DEALING WITH MULTIPLE, SEEMINGLY UNSOLVABLE PROBLEMS

• MULTIPLE RESPONSIBILITIES• DEALING WITH MULTIPLE

UNCERTAINTIES

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CHALLENGES FOR THE P.I.

• HIRING COMPETENT EMPLOYEES• TERMINATING PROBLEMATIC

EMPLOYEES• TERMINATING GOOD EMPLOYEES DUE TO

REDUCTIONS IN FUNDING• MONTHLY REPORTS, QUARTERLY

REPORTS, ANNUAL REPORTS, RENEWAL APPLICATIONS, AD INFINITUM

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P.I. SURVIVAL• DEVELOP RELATIONSHIPS WITH MENTORS• MAINTAIN HIGH VISIBILITY WITH STAFF• MAINTAIN A “CLINICAL CONNECTION”• USE TEAM APPROACH• USE TEAM PROBLEM SOLVING • DELEGATE EVERYTHING POSSIBLE, WITH

APPROPRIATE POWER, AND HOLD STAFF ACCOUNTABLE

• SET DEADLINES • ACCEPT THE IMPERFECTIONS OF SELF, FACULTY,

STAFF, AND NIDA

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RECOMMENDED TEXTS

• STARLING, GROVER. MANAGING THE PUBLIC SECTOR, 5TH ED, WADSWORTH, 1997

• WHITMAN, NEAL ET AL. EXECUTIVE SKILLS FOR MEDICAL FACULTY, 2ND ED, UNIVERSITY OF UTAH SCHOOL OF MEDICINE, 1993 (801-581-7234)

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P.I. SURVIVAL

• MANAGE YOURSELF

• MANAGE YOUR REACTION TO STRESS

• MANAGE THE AMOUNT OF STRESS