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Implementation of HIV Prevention Interventions with People
Living with HIV/AIDS in Clinical Settings: Challenges and
Lessons Learned
Kimberly A. Koester Æ Æ Andre Maiorana Æ Æ
Karen Vernon Æ Æ Janet Myers Æ Æ Carol Dawson Rose Æ Æ
Stephen Morin
? Springer Science+Business Media, LLC 2007
of people living with HIV has emerged as a priority in the
US As part of a cross-site evaluation this study examined
the processes by which 15 clinic-based projects imple-
mented interventions funded under the Health Resources
and Services Administration's (HRSA) HIV Prevention
with Positives (PwP) in Clinical Settings Initiative. We
conducted 61 in-depth interviews with researchers and
interventionists across the 15 projects. Intervention imple-
mentation was feasible assuming several key components
were in place: (1) internal leadership to overcome resistance
and foster interest and motivation among clinical providers
and staff; (2) adequate attention to creating seamless flow
between clinic practice and intervention; and (3) ongoing
training that met clinician and staff needs as prevention
interventions become a regular part of care. Interventions
well matched to the clinical environment and the patient
populations were feasible and acceptable to health care
providers, prevention interventionists, and clinic staff.
Integrating HIV prevention into the clinical care
implementation ? Qualitative process evaluation
HIV prevention with positives ? Intervention
In the US, the shifting landscape of HIV prevention in-
cludes behavioral interventions designed to reach people
living with HIV/AIDS (PLH/A) in healthcare settings.
Logic flows that since every new HIV infection begins with
an infected person, HIV prevention efforts must focus on
PLH/A (CDC, 2001). While the concept of promoting HIV
prevention among patients living with HIV in clinical
settings is not entirely new (Fisher et al., 2006; Richardson
et al., 2004), there are outstanding questions that warrant
closer inspection. Our objective in this article is to begin to
delineate ''optimal strategies'' (Del Rio, 2003) to effec-
tively intervene with patients in clinical settings to help
them reduce risk-taking behaviors. The first necessary step
toward this goal is to describe HIV prevention interven-
tions that are feasible at the clinic-level and acceptable to
health care providers, clinic staff and patients. Conversely,
it is equally important to outline challenging areas that may
impede the successful implementation of clinic-based HIV
prevention interventions.
Our qualitative evaluation examined the processes by
which 15 demonstration sites, funded under the Health
Resources and Services Administration's (HRSA) Special
Projects of National Significance (SPNS) Initiative on
Prevention with HIV Infected Persons Seen in Primary
Care Settings, sought to address the issues uniquely related
to the integration of HIV prevention and care in order to
implement clinic-based HIV prevention interventions. We
present findings from the first phase of an on-going process
evaluation specifically focused on the opportunities and
challenges associated with intervention implementation
among the demonstration projects.
Evaluating HRSA Demonstration Projects
In September 2003, HRSA funded 15 demonstration sites
and an evaluation center under the SPNS HIV Prevention
with Positives (PwP) in Clinical Settings Initiative. The
purposes of the PwP Initiative were to test whether
K. A. Koester (&) ? A. Maiorana ? K. Vernon ?
J. Myers ? C. D. Rose ? S. Morin
Center for AIDS Prevention Studies, AIDS Policy Research
Center, University of California, 50 Beale Street Suite 1300,
San Francisco, CA 94105, USA
e-mail: email@example.com
AIDS Behav
DOI 10.1007/s10461-007-9233-8
Page 2
behavioral interventions in medical care settings helped
people living with HIV reduce their risk of transmitting
HIV and to identify appropriate intervention models for
particular patient populations and care settings. Research-
ers in the demonstration sites were advised to adapt
existing evidenced-based interventions utilizing either a
Provider (e.g., MDs, NPs, PAs) or Specialist (e.g., health
educators, social workers) delivered model. See Malitz
et al. (2007) in this issue for a description of the history of
the SPNS Initiative.
The Enhancing Prevention with Positives Evaluation
Center (EPPEC) at the University of California, San
Francisco designed a comprehensive evaluation of the
demonstration projects. The EPPEC quantitative evaluation
measures the outcomes of the interventions over time for
both provider and patient behavior change, and assesses the
cost of the interventions. The objectives of the qualitative
evaluation are to understand how and why the outcomes of
the interventions are produced (Patton, 1992). The specific
aims of this on-going qualitative evaluation are to: (1)
provide context for better understanding of the outcome
variables, (2) assess feasibility and acceptability of inter-
ventions across clinics, and (3) document the implemen-
tation process for replication of successful interventions.
The study design includes in-depth interviews and a review
of secondary data, e.g., intervention manuals over three
phases: pre-implementation, implementation, and post-
implementation. This article presents findings based on
pre-implementation data collected as part of a larger pro-
spective evaluation study.
Pre-implementation Phase Sample and Recruitment
We conducted in-depth interviews with 15 PIs, 1 co-PI, 15
project directors, and 30 interventionists (n = 61). Our
sample of interventionists was self-evident in five clinics
morethantwointerventionists,weaskedthe projectdirector
to assist us in purposively selecting whom to interview. Our
sampling criteria were that they had already undergone
training, but not yet begun implementing the intervention.
Interview Process and Guides
All participants were interviewed between April and
December 2004. Interviews typically took place in a pri-
vate space within the clinic or nearby. In-depth interviews
were conducted by one of the first three authors using a
semi-structured interview guide. Interviews lasted from
40–60 min. Participants were asked questions pertaining to
the planning and goals of the intervention; the particular
challenges of designing and developing the interventions;
training of interventionists; and clinic and patient popula-
tion issues that affected the development, implementation
and integration of the intervention. All interviews were
audio-recorded and transcribed verbatim.
Data Analysis
Our analytic approach followed a process called Framework
Analysis (Ritchie & Spencer, 1994). This type of analysis
originatedinthecontextofapplied socialpolicyresearch. In
contrast to basic or theoretical research, social policy re-
search responds to specific information needs which can
then be translated into action. The benefit of this type of
analysis is that the stages of analysis are transparent and
follow a well-defined procedure of sifting, charting, and
sorting of the data. Employing an open process is particu-
larly useful when data are produced for an audience that is
unfamiliar with qualitative data analysis. In our case, we
find this visible and explicit analytic approach to be useful
when working collaboratively on a study consisting of team
to build confidence in the qualitative research findings.
After importing the transcribed interviews into Atlas.ti,
software developed to facilitate the organization and man-
agement of qualitative datasets, we familiarized ourselves
with a subset of the data. The analysis team individually
read seven interviews, making note of their observations
and potential codes to share during team meetings in the
early stages of codebook development. We re-read the
subset of interviews, meeting bi-weekly for 6 weeks to
discuss observations and to refine our codebook. With the
establishment of the codebook, each interview was coded
by a primary analyst and verified by a secondary analyst.
The first author read all coded interviews to check for
consistency in the application of the codes. Segments
associated with a particular code of interest were synthe-
sized into a summary and visually displayed in a chart to
facilitate the comparative similarities and differences across
interviews and intervention models.
As noted earlier, HRSA recommended using either a Pro-
vider or a Specialist-delivered intervention model in their
call for applications. While the majority of researchers
followed these recommendations and selected either a
provider or a specialist model, a minority designed inter-
ventions that included peers, or created a model using both
providers and specialists or a combination of providers,
specialists and peers. Table 1 illustrates the characteristics
AIDS Behav
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Table 1 Site characteristics
Intervention modelPatient eligibility Theory and/or models adapted Brief description of intervention components
Johns Hopkins
All patients eligible,
including new and
returning patients
Transtheoretical Model of Behavioral Change
(TTM) (Prochaska, DiClemente, &
Norcross, 1992)
Computerized behavioral risk assessment
generates stage-based profile for provider.
Brief counseling by primary care provider
during routine medical visit
University of
Male patients reporting
sexual activity with
other males in last
6 months
TTM (Prochaska & DiClemente, 1983, 1984;
Prochaska, DiClemente, & Norcross, 1992)
Computerized behavioral risk assessment
generates stage of change-based brief
message and prescription printed for primary
care provider delivery during routine clinic
UC DavisPatients with sex or drug
riskain last 6 months
TTM (Prochaska & DiClemente, 1982;
Prochaska, DiClemente, & Norcross, 2005)
Motivational interviewing (Miller &
Rollnick 1991)
Self-administered written risk assessment info is
used by primary care provider to conduct
brief stage-based counseling using elements
of motivational interviewing during routine
clinic visit
County of Los
All returning patients
reporting sexual
activitybin last
3 months
Partnership for Health (Richardson et al.,
Provider administers sexual health risk
assessment to determine brief HIV prevention
loss-frame messages and a behavioral
prescription delivered by primary care during
routine clinic visit
St. Luke's
Hospital, New
All returning patientsMotivational interviewing (Miller & Rollnick
1991) TTM (Prochaska & DiClemente,
Social worker administers brief risk assessment
during first session, four motivational
interviewing sessions in total which may or
may not coincide with primary care visits and
are in addition to routine case management
University of
All patientsMotivational interviewing (Miller & Rollnick,
1991) TTM (Prochaska, DiClemente, &
Norcross, 1992) Harm Reduction
Intervention group received minimum of four
counseling sessions with Specialist using
motivational interviewing and six peer
support group sessions
El Rio Health
Center Tucson
All patientsSocial Cognitive Theory (Bandura, 1994)
Adaptation: Healthy Relationships
(Kalichman et al., 2001)
Group views film clips to initiate discussion on
relevant topics such as stress and HIV,
disclosure, relationships and safer sex/risk
reduction. Five sessions, 120 min each, over
5 weeks.
Provider + Specialist-delivered (Mixed)
DeKalb County,
GA Health
Patients reporting sexual
activitybor drug use
in the last 3 months
TTM (Prochaska, DiClemente, & Norcross,
PCP gives brief prevention message every
6 months. Targeted risk behaviors are
assessed by the health specialist and tailored
stage-based counseling is provided in
conjunction with regularly scheduled primary
care visits every 3 months
Whitman Walker
Washington, DC
Health Educator
Male patientsTTM (Prochaska, DiClemente, & Norcross,
PCP provides brief risk reduction message.
Specialist conducts risk assessment and
tailored stage-based counseling during 3,
30 min counseling sessions within 45 days of
Drexel University
Health Educator
Female patientsGender and Power Theory (Wingood &
DiClemente, 2000) AIDS Risk Reduction
Model (Catania, Kegeles, & Coates, 1990)
PCP determines risk and stage of change based
on a personalized discussion of risk and
delivers a stage-based prevention message.
Intervention group receives additional five
facilitated Specialist led group sessions and
two peer led support sessions.
AIDS Behav
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of each of the 15 sites including type of intervention,
intervention theory or adaptation, intervention description,
eligibility criteria, and type of risk assessment. For the sake
of comparison, we briefly lay out the four main interven-
tion models below, followed by an in-depth description of
the implementation issues associated with each.
1. Provider-Delivered PwP Interventions (n = 4)
The patient's primary care provider (PCP) delivered the
intervention during routine HIV care visits. Patients' risk
and, in some cases, stage of change (Prochaska & Di-
Clemente, 1984) was assessed using either computer-as-
sisted technology or during
administered by the provider. Using this information, the
provider delivered a brief prevention message tailored to
the patient.
2. Specialist-Delivered Interventions (n = 3)
Specialist interventions occurred either in conjunction
with or apart from routine clinical visits and took place
over four to five counseling sessions in individual or group
settings. Counseling topics included safer sex, medication,
drug use, relationships, disclosure, emotional well being,
assertiveness training, and other patient-defined priorities.
a face-to-facesurvey
3. Specialist + Provider-DeliveredInterventions(n = 5)
A hybrid of the above models, the providers used brief
stage-based or prescribed prevention messages based on
patient risk assessment delivered during a routine visit. In
addition, the patient attended three to five counseling ses-
sions with a health educator or social worker covering
content areas similar to those described under the Specialist
intervention. Of the fifteen sites, four were a combination
of provider- and specialist-delivered, while one site de-
signed a provider-delivered, specialist-delivered and op-
tional group sessions led by a peer-delivered intervention.
For the purposes of manageability, we assigned this latter
intervention to the provider + specialist category.
4. Peer-Delivered Interventions (n = 3)
Similar to the specialist intervention, the peer inter-
ventions occurred in conjunction with or apart from routine
clinical care during four to nine individual or group
counseling sessions. The curricula were modular and 2 of
the 3 interventions were meant to be tailored to patient
priorities. Topics covered included sexual behavior, dis-
closure, adherence, stigma, drug use, and emotional well
Table 1 continued
Intervention model Patient eligibilityTheory and/or models adaptedBrief description of intervention components
University of North
Carolina, Chapel
Hill Social
Patients reporting sexual
activity or IDU in last
6 monthsc
Motivational interviewing (Miller & Rollnick,
PCP delivers a brief prevention message based
on a computerized risk assessment during
regularly scheduled primary care visits.
Intervention group receives in addition: 3–40-
min motivational interviewing sessions w/
social worker over 3 months
Owen Clinic, UC
San Diego
Health Educator
Patients reporting risk in
last 6 monthsc
TTM (Prochaska & DiClemente, 1983)
Motivational interviewing (Miller &
Rollnick, 1991) Harm Reduction
Intervention group received brief loss frame
message from provider based on
computerized risk assessment during primary
care visits. Intervention group receives
additional stage of change assessment and
targeted counseling with health educator in 4
one hour sessions
Health Boston
All MSM patientsIMB theory (Fisher & Fisher, 1993) TTM
(Prochaska & DiClemente, 1984)
Motivational interviewing (Miller &
Rollnick, 1991)
Nine sessions (intake, four module sessions,
four booster sessions) based on computerized
modular workbook guided by peer
interventionist. Client chooses modules.
Sessions last 50 min
Mt. Sinai Hospital,
Patients diagnosed with
HIV for at least
3 months
TAP adaptation (McKirnan et al., 2001)Four educational sessions focusing on
medication adherence, safer sex practices,
mood management, communication skills,
alcohol/drug use over six months.
University of
Patients over age of 45
reporting unprotected
sex in last 12 months
IMB theory (Fisher & Fisher, 1993)
Adaptation: NIMH HIV Prevention Trial
Group sessions facilitated by a peer focusing on
building skills and increasing knowledge and
motivation 4 sessions in total, two sessions a
Risk defined as shared injection equipment, practiced unprotected sex with + or unknown partner, or someone other than a regular sex partner
Sexually active defined as oral, vaginal or anal sex
Sexual activity or risk is not defined
AIDS Behav
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Provider-Delivered Interventions
Intervention Description and Rationale
Interventionists in these four locations were HIV PCPs,
predominantly infectious disease physicians. With one
exception, the PIs of these interventions were themselves
HIV PCPs. This was important for several reasons. First, at
least one provider, the PI, was convinced of the importance
of providing HIV prevention on a routine basis during a
clinic encounter. Second, as a PCP working within the
clinic, they had some power to affect the clinical practices
of other providers, including persuading the medical
director to endorse and enforce the changes necessary to
implement the intervention. Finally, they were not per-
ceived as outsiders by the other providers, and were able to
leverage these collegial relationships when necessary to
gain acceptance of the PwP intervention from reluctant
Interviewees among these sites perceived that integrat-
ing HIV prevention and care would continue to increase in
popularity, and they believed themselves to be leaders in
clinic-based HIV prevention. They were aware and clearly
supportive of the national PwP trend (due to conferences,
new federal guidelines, and increased interest within the
medical establishment) to provide prevention services to
people living with HIV/AIDS. Thus, PIs recognized the
need for PCPs to become proactive in the area of HIV
prevention and selected a provider- rather than specialist-
or peer-delivered intervention. Further, PIs described three
underlying reasons to explain their choice of intervention
model. First, PCP interventions are effective because of the
persuasive power of the physician to facilitate patient
behavior change. Second, PCP interventions are effi-
cient—patient-physician contact is virtually guaranteed
whereas a specialist required an additional appointment.
Finally, perhaps the most important rationale is that they
believed the time had come for PCPs to be involved in HIV
Prevention Concept, Intervention Content and Tools:
Provider Interventions
Integrating HIV prevention counseling into a 20–30-min
routine patient visit demanded brevity. The content of the
prevention counseling or prevention messages depended
on the theoretical basis of the intervention and the
information reported by the patient on the risk assess-
ment. All four interventions assessed patient risk just
prior to the routine clinic encounter or in a face-to-face
discussion with their clinician. Aided with specific risk
information such as sexual activity, condom use, number
of sexual partners, and use of illicit drugs, PCPs were
able to provide tailored recommendations to patients or
embark on a discussion with patients about risk taking.
For example, in one site, clinicians relied on a printed cue
sheet included in the patient chart containing a tailored
and scripted prevention message, e.g., a patient reporting
having had receptive anal sex without a condom with
HIV-negative casual partners was advised to think about
how having unprotected, receptive anal intercourse in-
creased his chances of catching an STD. In another
location, clinicians were trained in motivational inter-
viewing (Miller & Rollnick, 1991) and were expected to
help patients identify risk and facilitate goal setting
around risk reduction following the tenets of harm
reduction, which focus on small incremental steps toward
change. The PI described the applicability of motivational
interviewing below:
It's the technique; you don't have to know anything
about the topic that you're working with really.
'Cause all you're doing is probing your patient's mind
and getting them to come up with their own answers.
It's gonna be far more powerfulif they come up with it
themselves. That's why we chose motivational inter-
viewing, not didactic, not the proscriptive, even
though our prescription says we've agreed to work on
the following things before our next visit. And it has a
list of high-risk activities that the patient is gonna
choose one that they want to work on because they
feel a sense of responsibility. PI
Three of the 4 provider-delivered interventions were based
on the Transtheoretical Model of Behavior Change Theory
(Prochaska & DiClemente, 1984). They included an
assessment of the patients' stage of change for key risk
behaviors, a tool to convey this information to providers,
and training that instructed PCPs on how to best impart
stage-based counseling messages. These interventions
appealed to PCPs because they allowed them to deliver a
very specific and tailored behavioral message, without
requiring a lengthy counseling process. It also closely
mirrored their familiar clinical paradigm, in that they were
able to ''diagnose'' a behavior by isolating a specific risk,
stage that risk in terms of willingness to change, and
then deliver the corresponding ''prescription''—the stage-
specific prevention message.
Implementation Challenges Encountered
Sites faced distinct challenges associated with imple-
menting provider-delivered interventions. Project staff
needed to make HIV prevention a clinical priority, cope
with PCP skepticism regarding time constraints and clinic
flow, and address the need for training and skill-building in
risk assessment and behavioral counseling. PIs, because of
AIDS Behav
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their ''insider knowledge'' as clinicians, understood these
The practicing physician is always pressed for time.
Even with a half an hour appointment. These folks
are so complex and require so many referrals and so
on, that a half an hour is often not enough time. And
now we're gonna add 5 min to it. And I think that's a
big psychological barrier for a doc. PI
Meanwhile, some PCPs anticipated feelings of discomfort
associated with changing the way they approached the to-
pic of HIV prevention:
The whole issue of trying to change how you talk to
patients is a little awkward. I've known these people,
I mean, some of them for many, many years. And I
have my own way of talking to them about these
issues. So, I'm not sure yet what's gonna happen if I
try to change the way I speak to patients to fit these
models. But, I've elected to give it a try. Provider
PIs raised awareness of the importance of clinic-based
HIV prevention by presenting their colleagues with
compelling local and national epidemiological studies
illustrating the rise in STD cases. Two sites conducted
formative research to identify the extent to which pre-
vention was already occurring and the extent to which
PCPs felt it was their responsibility to conduct prevention.
Armed with this essential formative data, PIs proceeded
to develop an intervention that resonated with their PCPs
and addressed their concerns in an informed way. In a
couple of sites, researchers solicited input on intervention
design from the PCPs so they were included in the
process and felt some allegiance to the intervention.
Overall, PIs and their staff worked on the logistical
preparations to understand the flow, context and culture of
the clinic in order to make the intervention seem com-
plementary rather than controversial and obtrusive to
other clinic services and procedures. A PCP interviewee
described the positive results produced from these careful
I think that the only way that this intervention worked
was that the PI just had this dogged determination to
keep us all on top of it. But the fact that the PI drilled
it into us and gave us all kinds of reminders, you must
protect this day, and got the division to buy into it and
the clinic to buy into it and how we schedule things
that day. And that seems like a minor point but if the
scheduling didn't work then the whole thing was shot
from the beginning.... They had it arranged so that
people who were on call, somebody else covered
their beeper. Because it's the only way it could get
done. Provider
Implementation Resolution: HIV Prevention Becomes
We observed a pattern among providers indicating that the
formal and informal support among providers contributed
to building momentum to conduct HIV prevention in the
clinical encounter. PCPs' first-hand experience and frus-
tration with patients returning with STDs fostered support
for HIV prevention in the clinical environment. Many
lacked training and experience with behavioral counseling,
but once trained, they expressed optimism that incorpo-
rating HIV prevention into the medical visit was feasible:
I think my comfort level in discussing the details of a
patient's personal life as far as the sexual life I think
need to be better. So just bringing up these things and
finding out that every once in a while I'll kind of
stammer and not let the words just flow out as they
should when I ask these questions, I think it's more in
the interest of hey I've got to get better at this (but) I
have to become more knowledgeable in this area.
Once trained in behavioral counseling and in intervention
delivery, PCPs perceived the value in providing specific
and tailored prevention messages as they believed they
were more effective in generating behavior change than
generic messages they had been accustomed to delivering:
I think it helps to have the idea of the transtheoretical
model of change behind it, because [now] I'm kind of
shotgunning a couple of different risk factors. I just
kind of say, ''don't do that. Be good''.... it's the
targeting to the individual I think that's going to help
get the message across better than the kind of bulky
''be a good person'' kind of message that I'm sending
which isn't so specific. Provider
Specialist-Delivered Interventions
Intervention Description and Rationale
The three sites employing specialist-delivered interven-
tions worked with health educators or social workers. Each
site described an expansive concept of what HIV preven-
tion entailed. Rather than brief targeted behavioral mes-
sages, they designed a broad curriculum and an open
format that allowed the patient to identify issues for dis-
cussion. Research staff explained they designed interven-
tions intended to enhance the capacity of pre-existing
''specialists,'' e.g., case managers and social workers,
whose role was to support patients in negotiating between
physician directives and the social issues they faced day to
AIDS Behav
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day. This intervention model would be difficult for physi-
cians to provide within the time-constrained context of a
primary care visit because they were specifically designed
to encourage lengthy in-depth engagements between pa-
tient and specialist.
Sites that chose specialist-delivered interventions had
some HIV prevention activities in place prior to this
intervention. One of the clinics had already implemented
an annual risk assessment and offered HIV testing services
to sex partners. However, the two other sites were not
exceptional in their HIV prevention efforts prior to the
intervention. Although individual providers and medical
directors endorsed HIV prevention, the clinics did not have
written procedures, practices or guidelines in place at the
organizational level.
Prevention Concept, Intervention Content and Tools:
Specialist Interventions
The specialist sites were unified on two key concepts: (1)
the prevention intervention must address a range of social,
economic, and psychological issues, and (2) the patient
must actively engage in the intervention process, rather
than passively receiving education or messages. The cen-
tral issues to be addressed included stigma, disclosure,
loneliness, self-isolation, personal responsibility and qual-
ity of life—all of which require intensive and interactive
interventions. One site described its intervention goals as
''health maintenance, healthy sexuality, happiness, and
well being.''
These interventions differ from the ''scripted'' provider-
delivered messages; patients and specialist worked together
to identify factors that patients perceived put them at risk,
to understand patients' motivation to engage in risky
behaviors, and to identify strategies patients could use to
successfully change those behaviors. They used a variety of
frameworks including Motivational Interviewing, the
Transtheoretical Model, and the Social Cognitive Model
(Bandura, 1994). Some had one-on-one counseling; others
used discussion groups (see Table 1). Most of the inter-
ventions included risk assessments that were computerized,
on paper, or administered by the specialist, and some fol-
lowed a curriculum outlining the content for each session.
Yet beyond the predefined categories of risk on the
assessment, patients worked with the specialist to identify
and address other behaviors or issues the patients deemed
relevant or problematic in terms of HIV transmission. All
three sites discussed the importance of patient engagement,
defining the process as a dynamic exchange between
patient and specialist:
In health belief models and in medical management
of disease or social problems, things are seen quite
linearly, and that the change is progressive (which it
isn't always). And the doctor is the expert and that
information is known and delivered, and then the
patient digests it and then somehow changes. And
there has been a whole lot of research that shows that
that is not the case, and it's just the shutdown of two
parties in the interaction. So the whole technique of
doing MI really shifts the power dynamic. It takes
more time to do certainly. This is the biggest criti-
cism. It takes longer to get a sense of what people's
beliefs and feelings are than to give a flier. Specialist
Implementation Challenges and Resolutions
Implementation challenges associated with specialist-
delivered interventions were minimal. Researchers directed
their energies toward creating or modifying behavioral
counseling interventions for their clinical settings and
securing appropriate training for the specialists. Because
most existing counseling interventions were designed to be
with a mental health focus, the protocols and trainings were
not as difficult to locate and adapt as the provider-delivered
interventions. In general, the PIs and project directors in
these sites did not have to undertake extensive efforts to
develop buy-in from the providers or clinic staff. Perhaps
because the specialists in all three clinics were counselors
or educators by training and profession, they did not need
to be convinced of the need, importance or validity of
behavioral interventions. Clinical providers were not asked
to take on any additional responsibilities or demands on
their clinic time other than referring patients to the inter-
vention services.
Recruitment and retention of patients were anticipated
as the major concerns of the specialist interventions. All of
the interventions were multi-session models with sessions
designed to last a minimum of 30 min. Two of the three
interventions required clients to return for independent
counseling sessions, separate from their medical appoint-
ment. The third clinic intended to coordinate all the inter-
vention sessions with the patients' medical visits. PIs,
project directors and specialists expressed concern that
some patients, particularly high-risk patients, would be
unwilling to participate or have difficulty returning for the
intervention sessions. They cited a variety of social barri-
ers, such as substance abuse, marginal housing, lack of
transportation and chaotic life circumstances. Sites proac-
tively strategized to address some of these potential barri-
ers. The interventionists and project directors believed that
the powerful nature of the intervention in terms of meeting
patients' needs would best facilitate retention. They all
discussed the importance of ''connecting'' or establishing
rapport with patients during the first session. And finally,
AIDS Behav
Page 8
they attended to practical issues such as providing trans-
portation, placing reminder telephone calls in advance of
sessions, and making an effort to discuss issues that pre-
vented patients from coming in. However, project staff
realistically expected that patients would continue to have
competing priorities as indicated by the high rate of no-
shows to routine clinic appointments.
Provider + Specialist-Delivered Interventions
Intervention Description and Rationale
Five of the fifteen sites designed mixed or hybrid inter-
ventions which combine the intervention efforts of PCP
and specialists. PIs took seriously the CDC guidelines
outlined in Advancing HIV Prevention: New Strategies for
a Changing Epidemic (2001) to incorporate HIV preven-
tion counseling as standard of care. However, they ex-
plained that patients' needs would likely outstrip the
resources of the providers therefore they added a specialist
intervention component. In three of the five clinics, PIs
expressed skepticism that providers would be effective in
changing patient behavior, or that PCP would take the time
to carry out the new standard of care:
Since we have a history of having health educators at
our clinic, we thought that the mixed model would
probably be a good choice for us. From the beginning,
relied solely on our providers to provide the messages,
and we felt that we needed something in addition to
our providers to back that up. And to go with just the
specialist model, I know that, that there are some sites
that are just doing like social workers or something
like that. We felt that that just wasn't really the pur-
pose of the RFA and it kind of would be just another
excuse for our providers not to be providing the
messages, and we just felt that it was really important
that our medical providers, and that everyone at our
clinic start talking about prevention. PI
In one location, a mixed intervention design resulted from
physicians identifying both a need to effectively address
HIV prevention, because of the increasing number of pa-
tients presenting with STDs, as well as a need for addi-
tional support services within the clinic. Overall, there was
consensus across sites that certain patients would require
additional services that PCPs simply could not provide
because patients needed and ''deserved'' more intensive or
tailored interventions:
I was really interested [in] trying to design an inter-
vention that got at some of the underlying issues in-
stead of just walking into a room and telling people to
use condoms, to try to deal with the reality that
condoms may not be safe for some people that, you
know, there's violence or all these other issues that
women are dealing with, and lot of it has to do with
just their social reality and what's going on culturally
and socially. Specialist and Intervention Developer
The mixed sites were similar to other clinics in terms of
pre-intervention prevention activities which were carried
out on a case-by-case basis. Two of the five sites had
formal risk assessments that every new patient was
required to undergo, but only one of the five formally
re-evaluated risks. In some sites, prevention discussions
were happening at the discretion of the providers, e.g.,
during family planning discussions, presence of an STD, or
when a patient brought it up. Providers working in a setting
that served women only were having prevention discus-
sions on a routine basis, because STD risk and family
planning discussions were normative for both patients
and providers during gynecological exams. In contrast,
two clinics focused exclusively on HIV treatment. The
following quote illustrates the biomedical focus of the
The Clinic didn't have a formal intervention program
prior to this. You know, condoms were available,
educational materials are in the waiting room, but
there's nothing on paper, pulled together. So this is
the first opportunity to put prevention into a clinical
setting. They provide magnificent treatment and care,
but there's nothing warm and fuzzy about it. You go
in there and you're getting the best care. And that's
what they're there to do, and that's what they do
really well. There's no support groups. There's
nothing for the individual to meet their other than
clinical needs. PI
Prevention Concept, Intervention Content and Tools:
Provider + Specialist Interventions
The single unifying theme among the mixed sites on the
concept of HIV prevention was that patients would most
benefit from a two-prong intervention that included a
message delivered by a provider followed by a lengthier
visit with a specialist. Both components followed the
structure of risk assessment followed by prevention mes-
saging or counseling of the provider- or specialist-deliv-
ered interventions. The specialist components were diverse
in content and form, but consisted overall of discussions
based on either a formalized curriculum, a broader patient-
directed counseling session with a health educator, or, in
one case, a social worker—again, much like the specialist-
only interventions.
AIDS Behav
Page 9
Overall, these interventions were not always conceptu-
alized as collaborations among provider, specialist and
patient. There were few formal tools created to coordinate
the counseling received by patients in the mixed inter-
ventions. Communication between the specialists and the
providers, when it occurred, was typically informal. The
intent and structure of these interventions was not neces-
sarily designed to improve the relationship and interaction
between specialist and provider staff.
Implementation Challenges Encountered
Incumbent upon those implementing a mixed model was
attending to a diverse set of actors, e.g., clinic staff, PCP
and specialists. With that came the real possibility for
criticisms and resistance that could potentially dilute the
power and scope of the interventions. Some clinics were
more prepared and willing to make the significant changes
required of them—working to smooth patient flow,
changing the standard of care procedures, facilitating the
enrollment of patients into the specialist intervention—than
others. The challenges we lay out below were resolved to
varying degrees among the five sites and were highly
dependent on the support of clinic leadership as well as a
willingness on the part of clinic staff to cope with the added
burden of running an intervention demonstration project in
a busy clinical setting.
Dually burdened: Notably, mixed interventions were
perhaps the most difficult to design and implement, pri-
marily because they were ambitious in scope as compared
to the provider-, specialist- or peer-delivered models.
Mixed models required the development of two different
interventions and the training of two distinct types of
interventionists. Implementation
were numerous—making sure the providers accepted the
intervention, understood their role, and were well trained;
specialists required integration into either the clinic itself
because they were newly hired or integration into their new
role as an interventionist. A project director provided in-
sight into the response of clinic staff members to the
intervention project:
preparation activities
Again, I think that from a clinic-wide perspective,
they're just anxious about the change and patients'
acceptability of it and whether or not it just causes
more chaos because there's already enough of that on
a daily basis in a clinic because it is such a hectic
place. Project Director
PCP resistance and clinic readiness for change: All sites
encountered some level of provider resistance to integrat-
ing prevention and care primarily with respect to the fea-
sibility of implementing an intervention in a busy routine
clinical encounter. Provider concerns were related to clinic
flow, lack of time, and discomfort with talking about sex.
In one case, providers felt the project was ''put upon
them'' because it was neither a provider-initiated project
nor did the PI seek out input on the intervention design or
implementation from the PCP:
Providers are very resistant to change. Our providers
already have a huge amount of responsibility. We
used to have 30 and 60-min appointments. Now
they're 40 and 20 min. They have a bunch of addi-
tional responsibilities and now we're adding more to
their plate. And they get frustrated because there is
really not a process in clinic where they are
approached and asked for their input on addition of
responsibilities. It basically is decided and delegated
that this is what's gonna happen and this is what you
will do, which, as you know, doesn't engender a
bunch of support and high morale. It's basically like,
okay, well, we just have to do it because we've been
told to do it. So, there's a barrier there, because it
wasn't something that they initiated. Again, I think a
lot of the providers probably see that the project
would be a really great program. I think that they get
a bit turned off as soon as they hear that there's more
work for them. And I really have tried to be careful
about letting 'em know, it's really not so much more
work. You're looking at a four-question, we're giving
you the information so that you know immediately
where [and] what to base your prevention interven-
tion message on. Chances are good that if you even
get a 30-s prevention intervention message in with
your clients, that is something. Project Director
In one location, the PI (a non-MD) appeared to have no
power to persuade the providers to participate in the
intervention; the trainings were poorly attended; and pro-
viders generally expressed reluctance in engaging in pre-
department charged to address this issue. In both cases, it
was not clear that the providers would deliver their portion
of the intervention.
Unstable work force and structural upheaval: Staff
turnover (unrelated to the project) posed a significant
challenge among 3 of the 5 hybrid interventions. One site
faced a complete turnover in provider staff, a turnover in
PIs while the entire organization of the clinic was simul-
taneously undergoing massive re-structuring. New staff
needed to be hired, trained, and then integrated into the
clinic and research practice.
Overcoming the challenges: Among the mixed inter-
ventions, those most successful in overcoming provider
resistance followed a process of building buy-in through
hosting a series of meetings (including the provision of
food) to educate them about the project and to listen to
they hadapre-existing
AIDS Behav
Page 10
their concerns. One site made plans to train support staff to
alleviate the tension and help foster clinic-wide support for
the intervention. Sites that had endorsement from the clinic
leadership and strong presence of a PI facilitated the uptake
of the prevention interventions.
Peer-Delivered Interventions
Intervention Description and Rationale
The rationale for using peers as interventionists in three
locations varied by site. Two sites perceived that the intent
of the intervention was beyond the scope of what a phy-
sician could achieve during a routine clinic encounter. For
them, using peers was a better fit with their patient popu-
lation because of issues related to stigma and shame, which
prevented many patients from disclosing their HIV status
to sexual partners, family members or friends. Both sites
felt strongly that having peers provide information would
be more effective, and that credibility and trust would be
higher with peers rather than a physician or specialist. The
interventions at these two sites focused on basic educa-
tional information on HIV/AIDS as well as skill-building
around condom demonstration or role-playing condom
negotiation and disclosure of HIV status. The third peer site
rejected the use of physicians as interventionists because
they did not want to burden the physicians with interven-
tion activities. The PI below described his decision to
minimally involve physicians in the intervention:
So knowing the culture of the Clinic, we kind of
thought that trying to train the physicians themselves
or the nurses to deliver prevention intervention would
meet lots of obstacles. We felt that we had to do
something that would involve referring people but
would be as seamless as it possibly could, so that we
would get people while they were in care. PI
HIV prevention did not appear to have a significant prior
presence among the three sites implementing peer-based
interventions. The PIs characterized the level of HIV pre-
vention in a particular way—they unanimously stated that
providers were focused on providing ''good care'' and did
not have time to attend to prevention issues. Furthermore,
in two of the three sites, the PIs felt that prevention was
something that was notably missing and could optimally be
filled by hiring a peer counselor.
Prevention Concept, Intervention Content and Tools: Peer
Similar to the interventions delivered by specialists, the
peer-based interventions were largely patient driven and
conceptually comprehensive. For practical purposes, each
of the peer interventions included a detailed modular
curriculum for the peers to follow. In two of the three
interventions, these curricula were computerized presen-
tations, which the peer would guide the patient through.
This allowed the intervention designers careful control
over the content of the intervention, while having the
benefit of peer delivery and support.
Overlapping content areas among the peer interventions
were few, primarily because each clinic addressed the
needs of a distinct patient population. The clinic working
with urban gay men took care to address complex sexual
issues openly, to not stigmatize HIV-infected gay men's
sexuality, and to provide harm reduction strategies related
to sex. The other two sites, working primarily with ethnic
minorities, provided more educational information about
HIV and ''safer sex.'' Medication adherence was a primary
topic for one intervention; and managing stress was
addressed in yet another. The format and timing of the
peer-based interventions were also distinct (see Table 1).
Each intervention took place near the clinic, but none were
located within the clinic.
Implementation Challenges and Resolutions
Hiring, training, and supervising: The challenges of
implementing peer-based interventions mainly centered on
staffing and training. Locating and hiring peers was time-
consuming in two of the three projects. Sites needed to
determine who qualified to work as a peer with their patient
population. All three sites hired peers who were current or
former clinic patients even though initially they sought to
hire from the general community. Peer training was
intensive and in most cases needed to extend beyond the
scope of preparing to implement the intervention curricu-
lum to include research and ethical concepts, policies and
procedures. In some cases, this was challenging because
peers identified with their community and were eager to
advocate on their behalf. At times, they described feeling
constrained by having to follow a research protocol and
curriculum. Sites working with disenfranchised patients in
two of the three locations faced unique issues when hiring a
peer. While it was important that the peers could relate to
patients, peers potentially shared the same structural con-
straints that impacted their patients, e.g., poverty and rac-
ism. When hiring and retaining peers, one site struggled
with human resources issues, such as substance use, lack of
experience in the workplace, and balancing work respon-
sibilities with private life. A project director described the
challenges associated attempting to hire someone with a
resource poor background:
The level of chaos in our patient's lives is striking.
Somebody gave me contact information [ofa potential
AIDS Behav
Page 11
hire]. This is a great guy, by the way, who we were
ready to hire, and has been a patient here for a long
time. So you know, adherent to medications, doing
well, that sort of thing, but he was moving. He can't
afford a cell phone—he gave me his mother's tele-
phone number, said, if you need to reach me in the
next week to set something up, call my Mom's house.
I call Mom's house. Mom says, I don't have a pen
right now. Can you call me back in twenty minutes?
...Can you just hold the job for him? Project Director
Partnering with peers: One of the greatest advantages to
hiring peers as interventionists was having peers provide
valuable input on the curriculum and offer advice on
recruitment. In order for peers to provide honest feedback
intervention staff had tocultivate a sense ofpartnership with
the peers and work to minimize the power imbalance that
may have prevented the hired peer from providing con-
structive criticism of the project because the job provided
them with needed resources, i.e., a salary. Establishing clear
roles and expectations increased rapport among researchers
and peer-interventionists. At that point, researchers had
built-in community advisors to reflect on the project mate-
rials and provide important feedback on the sensitivity, use
co-PI described the value in partnering with a peer:
And we bring her in every so often to ask her for
advice and we ask her questions. And since she's
worked on other projects, she has a good feel for
some of the issues. She likes it. She really is, she's
really, I think, more representative of peers, of what
you'd find in a regular clinic. And so I really like
having her around because I think it keeps us real.
She will make us stay real. Co-PI
researchers was echoed by the peer below. In this case the
peer described his role as an advisor on the development of
the intervention curriculum:
type of cross-fertilizationbetweenpeer and
So far, my role has been, well, just getting to learn
more about it, more being able to talk about it. And
giving input on the workbook, the modules that we're
creating, trying to give input to that. One of the things
that they want from me is to make sure that this
reflects, because my past work and because I know so
many people in the community, that it's in a language
that's appropriate, that's user-friendly and those types
of things. So, a lot of what I've been doing recently
has been looking at what's already been written and
adapting it and looking at it from that perspective
from—I could very easily be a consumer coming in,
you know. Does this make sense? What is the flow
line here? Is the language they're using too technical
and it's gonna be off putting to people. They're not
gonna respond. So those are the things that primarily
I've been working on, and just trying to get up to
speed on what research is and how it's done. Peer
We found that implementation was most difficult in loca-
tions that utilized providers to deliver the intervention for
two reasons. Successful implementation required changes
in providers' clinical practice as well as a concomitant
willingness on the part of patients to openly and honestly
discuss risk with their providers. Among the specialist and
peer-delivered interventions, patients shouldered the bur-
den to show up to additional appointments and engage in
the prevention counseling process.
In comparing the provider-delivered interventions to the
mixed interventions, we noted that the providers charged to
be the sole interventionists were groomed over a longer
period of time and reported a higher level of acceptability
than the providers in the mixed interventions. This may in
hindsight be perfectly logical, however it illustrates the
conditions needed to fully incorporate providers as partners
in prevention. In focusing on complying with the CDC
guidelines to integrate prevention and care, researchers
may have inadvertently misjudged the level of provider
interest and downplayed or overlooked provider concerns
related to feasibility to implement an intervention that re-
lied heavily on them as key players. Another feature of the
mixed interventions that contributed to implementation
challenges was that they tended to be new collaborations of
behavioral and clinical service providers. The lack of
official authority and personal relationships between the
intervention leaders and the providers contributed to the
implement their portion of the counseling. Comparing
acceptability between the provider-delivered vs. pro-
vider + specialist-delivered interventions illustrated just
how crucial it was to build rapport with providers and
attend to the unique issues that affected their ability to
participate in behavioral interventions.
Common Elements of Successful Implementation
While we do not yet know what the behavioral outcomes of
these interventions will be, we can draw conclusions about
what factors must be taken into consideration in the design
and initial implementation of integrated HIV prevention
programs. We identified the following common elements
that must be in place to successfully implement complex
behavioral interventions in clinical settings:
AIDS Behav
Page 12
Internal Leadership and Authority to Overcome Resistance
and Foster Interest and Motivation on the Part of Clinical
Providers and Clinic Staff
Any model that requires PCPs to deliver some kind of
standardized assessment and counseling demands buy-in
from the providers, as well as someone in a position of
power to enforce the change in clinical practice. Sites
working with providers spent significant amounts of time,
staff, and money to convince the providers that (1) there
was a need for HIV prevention counseling within their
practice, (2) providing behavioral counseling was an
appropriate role for a PCP, and (3) prevention counseling
can be effective and conducted in a short timeframe. Pro-
vider resistance was present in all sites ranging from con-
cerns about clinic flow to ideological objections to
behavioral counseling of any kind. Of foremost importance
was the enthusiastic and public support of the medical
director. At least five of the sites that included providers
had the advantage of the Principal Investigators also being
the medical director, recipient of research funding, or
holding some other position of relative power in the clinic.
These persons were able not only to endorse the inter-
vention, but to enforce a change in the clinic practice.
There were sites that chose not to involve providers as
interventionists because they could not gain their support.
Shared Belief in Importance, Need, Viability, and
Appropriateness of PwP in Clinical Setting
Without these shared beliefs by the majority of clinical
staff and patients, clinic-based PwP may not be feasible.
''Successful'' sites, defined by the high level of interest
among clinic staff and least amount of friction imple-
menting the intervention, conducted formative research
with clinic staff and patients to determine the acceptability
of different kinds of interventions, and to determine the
risk behaviors that warranted attention. Formative research
included one-on-one interviews, written surveys, focus
groups, consultation with community advisory board, and/
or ongoing feedback sessions with interventionists and
clinic staff during the intervention development phase.
They met with staff to review the need for a PwP-focused
intervention within the clinic. Researchers presented data
on rising STD rates, particularly powerful were data pre-
sented from within their own clinics. They reviewed
studies on rising rates of reported risk behavior among
people with HIV and, where applicable, presented effec-
tiveness data on the intervention models they had selected.
However, at the time these models were developed, very
little effectiveness data for PwP was available, and many
researchers had to ask providers to make a leap of faith to
agree to participate.
Adequate Attention to Creating Flow between Clinic
Practice and Intervention
Establishing the logistics of how, when and where patients
would complete a risk assessment, be referred and sched-
uled, receive the intervention as well as follow up coun-
seling, all without disturbing the clinic flow in over
burdened, facilities was far from a mundane detail. Con-
cerns about disruption to the clinic flow were primary in
the mind of the clinic staff, even if the intervention was to
be delivered by a dedicated staff person in an off-site
location. Specialist, peer and mixed interventions required
greater effort to ensure that staff, protocols and physical
space were in place to accurately channel the patient
through the intervention. In this regard, provider-delivered
interventions were slightly less complicated. Aside from
determining best practices concerning risk assessment
delivery and communication of results to the provider, all
other components then took place in the course of the
regularly scheduled medical visit.
Ongoing Training within the Clinic that can Address
Clinician and Staff Needs as Prevention Programs become
a Regular Part of the Care
Clinics developed and implemented their own trainings or
relied on local AIDS Education and Training Centers
(AETC) or other professionals to deliver training on or off
site. Primary care physicians were the most difficult group
to train since they were often far more numerous than the
specialists or peers for whom attending an off-site training
was feasible. The clinics had to be shut down, or providers
asked to attend after-hours trainings. Few clinics could
afford an entire day dedicated to training providers, even
though most behavioral counseling trainings lasted two to
three days. Principal Investigators all wanted more training
designed specifically for health care providers.
Lessons Learned and Conclusion
This article describes the challenges and resolution of
challenges associated with the implementation of complex
HIV prevention behavioral interventions in clinical set-
tings. We hope to draw attention to the distinct difficulties
associated with provider-delivered interventions vis-a `-vis
the relatively minimal barriers to implementing interven-
tions with specialists and peers. The most problematic as-
pects of implementing the specialist and peer interventions
were recruiting and retaining patients. In these interven-
tions, the burden to show up for sessions separate from the
clinical visit fell to the patient. Whereas in the provider
delivered interventions, the providers had a captive
AIDS Behav
Page 13
audience, the patient would come to see them. However,
we argue that the advantage of providers routinely inter-
vening with patients must be weighed against the disad-
vantages associated with training and motivating providers
to undertake prevention discussions.
The goal of these demonstration projects is to determine
which, if any, of the interventions facilitate HIV risk
reduction. Our preliminary findings illustrate that imple-
mentation of each intervention model was accompanied by
obstacles great and small, as well as opportunities to suc-
cessfully incorporate PwP into care settings. Based on our
research, there is no one model that will both function and
be accepted in every clinic. Successful integration depends
on the complementary fit between the intervention model
and the clinical setting. The importance of assessing the
feasibility of whether or not a clinic has the support of
providers, staff and patients, as well as the financial re-
sources, is the first step in determining the potential success
of implementing an intervention.
As Prevention with Positives increasingly becomes
standard of care in publicly funded HIV care settings,
medical directors will have to make choices about how to
best integrate prevention and care. Different models may
present different outcomes; no one size fits all; and this
article contributes to an understanding of what is poten-
tially gained or lost in selecting one model over another.
Our findings, which focused on the decision-making and
operationalization of interventions in 15 diverse clinics,
provide insight into this complex process of determining an
appropriate intervention based on local clinical environ-
ment and the local patient population. Developing inter-
ventions that resonate with the patient population and the
clinical environment will lead to great willingness from
and meaningful experience for participants.
following people who contributed to this article: The project staff
across 15 sites; our HRSA project officer, Faye Malitz; Tim Lane,
Mallory Johnson and Emily Arnold for their valuable suggestions for
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AIDS Behav


text:
--- 1 ---Just a housekeeping reminder: This coming week, I'll be talking about Company for our Sondheim watch-along party and having some guest posts/featured comments/etc. So check it out on Netflix and let me know if you'd like to link up. --- 2 --- Last week's links were all Olympic-themed, and I've got one more to add in that vein: Flowing Data has links to all of the NYT's best visualizations of track and field history at the Olympics. One of my favorites: looking at the fasted recor … [Read more...]
7 Quick Takes (8/10/12)
A reading from Henry VI, Part 2 4:2:73
Yes, in context, the line has the opposite sentiment to most of the people quoting it.Yvain asked, in good faith, a detailed question about Natural Law theology, but his comment is buried in the wilds of the comment policy discussion, where tempers are rising. So I want to pull it out and give it its own thread, and also take the opportunity to do some of the wacky experimental comment moderation I was talking about yesterday. Here's how it's going to go down:Only make a top-level … [Read more...]
Finding the right amount of unpleasantness
There's some very helpful feedback on the recent commenting/housekeeping/debate tactics post. I'm going to highlight and briefly respond to a few people, and then hopefully we can get back to content-y posts to practice constructively commenting on!Emily wrote: I'm really wrestling with at what point I need to walk away from even reading comments here. The tone and mix of commenters has really changed a lot recently, and frankly, I think Adam's right. I'm glad you're writing in a measured a … [Read more...]
Clawing out of the Cesspool
Thanks all for the mostly good behavior on the two preceding posts on queer issues. I know I've got a fairly diverse audience, and it can be hard to negotiate different frames of reference without misinterpreting or even just taking offense at the wrong thing (and thereby missing the insult your sparring partner spent a while crafting!).After looking at comment thread in the last post, Adam Lee was pretty put off by what he termed the "cesspool of anti-gay hate" that bubbled up. I can g … [Read more...]
What would someone have to say to you to get you to break up your family?
For your own good at that.This isn't a hypothetical question. There are plenty of examples where we think this kind of intervention is acceptable or even necessary. In decreasing order of urgency: an abusive spouse, two people who bring out the worst in each other, a couple that's stayed together out of inertia, the person you're with at the beginning of a romantic comedy, etc.But no matter how urgent the need for this conversation, most of us would recognize that this is a really trick … [Read more...]
On Value-Neutral Bravery
Back before I went off to awesome, wacky summer camp (a few more things to come on that, by the way), I was writing a series of posts on martyrdom, pacifism, drone strikes and other problems of offering resistance. And it turns out, looking over some of the posts I missed, I wasn't the only Patheos blogger wondering whether you can praise courage regardless of what exactly the person you're admiring is steeling herself to do. I was talking about drone strikes and David French is talking about h … [Read more...]
Welcome Permission to Live to Patheos!
What a get! I just found out from my RSS reader that Melissa of Permission to Live is moving to Patheos. She grew up in a very Quiverful/Patriarchal strain of Christianity and has told the story of her journey in a very brave and beautiful way. Here's an excerpt from her "Why I blog" tab: I find it ironic when I get input from readers and other people within the Christian home school community on how my parents were so extreme. The comment will often go something like this. "Wow, you're paren … [Read more...]

subset: commoncrawl


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ISDN and Linux—Surfing at Warp Speed
A fair amount of confusion lies in this area. A typical question on comp.os.linux.networking is "Do I have to include ISDN support to operate my Bitsurfr ISDN modem?" Nope. An ISDN modem is a serial device that connects to the serial port on your PC, "dials" a phone number and translates ISDN data to RS-232 data. The system sees it as a regular modem. You can set up getty to answer incoming calls, and you can dial out with minicom or pppd. ISDN kernel support is neither required nor used. Note that the term "modem" does not really apply to an ISDN terminal adapter, because "modem" implies an analog device which an ISDN TA is not.
The Motorola Bitsurfr Pro is one such ISDN modem. I will discuss its connection to a Linux system in detail, because it has been around for quite some time and works well. It features a 115Kbps serial port and two POTS jacks. Newer ISDN modems may include a 230Kbps or higher serial port and compression (such as the Farallon Netmodem).
The test system for the Bitsurfr Pro was a Pentium 100 with 32MB of memory running Linux 2.0.28. The connection was provided by UUNET Canada and both a dedicated connection as well as a dial-up connection were tested. Both situations worked well with one or two B channels operating. The following procedure outlines setting up Linux to talk to the Bitsurfr Pro over the serial port and configuring pppd to use it.
Connect the Bitsurfr Pro to the system and the ISDN line.
Configure the serial port with setserial as required (e.g., setserial /dev/cua1 spd_vhi hup_notify). See the Serial HOW-TO for details.
Now the fun part: configuring the Bitsurfr Pro. The Bitsurfr Pro requires a full VT100-compliant terminal emulator to use its local menu. During my testing, I have found only Seyon to work—Minicom did not work for me—run Seyon (i.e., seyon - modems/dev/cua1). Type AT to get the Bitsurfr's attention. Then type AT@MENU. The local menu will appear as shown in Figure 1.
From the NET SWITCH menu, set up the switch type and the SPIDs (i.e., the ISDN phone line numbers). The directory numbers are required only if you intend to dial into the Bitsurfr. The Data SPID and Voice SPID2 should be made the same. Selecting "Port To Configure" selects which SPID to set up. Select "Reset Network Link" after the SPIDs are entered to start the Bitsurfr talking to the ISDN switch. If all goes well, the LS (link status) light will turn solid green. This can take as long as two minutes to occur.
From the CALL SETUP menu, set the B Channel Speed to 64K unless ISDN in your area does not support 64K. Basically, if calls cannot be made, reduce this setting to 56K.
From the PROTOCOLS menu, set "Rate Adaption Protocol" to PPPC.
From the LOAD/SAVE menu, select "Save Total Active Profile" and save it to Profile 0 and Profile 1.
Install pppd.
pppd comes with a sample script in the scripts directory of its source tree. Copy ppp-off to the the /etc/ppp directory; ppp-off is used unchanged.
Refer to Listing 1. Create the scripts as listed in the /etc/ppp directory. These are modified versions of the pppd ppp-on and ppp-on-dialer scripts. The ppp-on script runs pppd and the ppp-on-dialer dials the phone number. The ppp-on-dialer also controls the number of B channels the Bitsurfr uses. Most dial-up ISPs only permit one B channel usage. Check with your ISP for details. For two channels, the Bitsurfr must be told to use MPPP instead of PPP and must be given two phone numbers with the ATD command.
Create an options file as in Listing 2. The debug option is useful for initial testing. Watch your syslog for messages from pppd. The name option is required to identify who you are in the chap-secrets file.
Create the chap-secrets and pap-secrets files. The contents should be the same in most cases. Listing 3 shows an example. The chap and pap-secrets should have the same contents and should list every router on the remote end. In the example, most routers on UUNET's Alterdial POP in Toronto (Canada) are listed. To determine the remote router names, when connecting, monitor the syslog. The names are reported as part of the negotiations. This is an easy way to build a router list. Alternatively, call your ISP and ask for this information. ISDN routers do not issue normal login prompts and rely on chap or pap for authentication. Even if a login prompt were issued, it would not appear through the Bitsurfr's PPP support. All routers are listed twice in reverse order in case bi-directional CHAP or PAP is requested. (Cisco routers tend to default to two-way CHAP.) If you have a dedicated connection, you need list only the one router you are dialing in to; otherwise, you have to list all the routers you may hit in your dial-up connection.
Go on-line by running the ppp-on script. If all goes well, you'll get connected. The DTE (data terminal equipment) light will flash while the Bitsurfr is dialing and glow solid green when the ISDN portion of the link is active. The total time from dialing to authentication is about 2 to 8 seconds depending on the load on the remote routers.
Surf's up! Check the routing table to make sure a default route exists (i.e., run netstat -rn). If it does, ping something on the Internet. Your packets should be returned.
For a dial-up connection, you might want to go one step further and install diald, the Linux dialer daemon, to make your Internet connection automatic when Internet traffic is sensed.
There are a few problems that might occur in getting connected with Bitsurfr Pro. Incorrect SPIDs is the most common problem. Check with your telco for the correct format of the SPIDs. Secondly, a typo in the scripts will cause various weirdness. For example, an error in the phone number in the ppp-on-dialer can cause certain grief. Lastly, if the pap-secrets file is not set up correctly, it will cause authentication problems and failed connects. This error type will be noted in the syslog output from pppd when the debug option is enabled. Obviously, a lot of detail is missing from the above instructions; however, after some experimentation, things should start working. Check the PPP HOWTO for more details, as getting the Bitsurfr working is mostly a fight with pppd.
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Meeting the Standards in Primary Mathematics
A Guide to the ITT NC
(If any tax is payable it will be calculated and shown at checkout.)
Preview (read now) Add to my own site Give this ebook to a friend Add to my wishlist Author's page Publisher's page
This book guides readers through the professional standards and requirements to reach Qualified Teacher Status, explaining what trainees need to know. The author discusses the best ways of developing mathematical knowledge and teaching skills, and how to acquire the professional know-how needed to complete the training successfully.
- help readers to understand the Standards related to mathematics teaching
- offer detailed guidance on the primary mathematics curriculum
- help readers prepare for the QTS skills test
- help readers to develop the pedagogical knowledge that you need for effective teaching of mathematics
- help readers prepare for school-based training
- provide ideas, suggestions and further reading to support during their training and their NQT year.
This practical guide to meeting the standards is invaluable for students on primary training courses, lecturers and mentors supporting trainees in mathematics education programmes and newly qualified teachers.less
Taylor and Francis; September 2003
256 pages; ISBN 9781134533152
Read online, or download in secure EPUB or secure PDF format
Title: Meeting the Standards in Primary Mathematics
Author: Tony Brown
256 pages; ISBN 9781134533152
Read online, or download in secure EPUB or secure PDF format
Title: Meeting the Standards in Primary Mathematics
Author: Tony Brown
Buy, download and read Meeting the Standards in Primary Mathematics (eBook) by Tony Brown today!
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A beloved five-day festival of short plays directed and performed by new theatre talent
Develop the skills in creativity and collaboration needed for today's knowledge economy
20th Annual Directors' Theatre Festival is April 22 - 26. Stay Tuned!
Directors' Festival Participation and Fees - Click here
Performance Theatre & Box Office45635 Yale Road (at Airport Rd.)Chilliwack, BCPhone: email@example.com
Mailing Address only33844 King RoadAbbotsford, BCCanada V2S 7M8
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April 22 - 26, 2015
Curated by Festival Founder Ian Fenwick
Schedule and Tickets will be available soon!


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|The Tantric Buddhism of the Himalayas; its best-known teacher is the Dalai Lama
6 comments
Words for the WestThinley Norbu Rinpoche is a preeminent teacher of the Nyingma lineage of Tibetan Buddhism. His books include The Small Golden Key, Magic Dance, which Shambhala is reissuing this Fall, and White Sail, published by Shambhala in 1992. He presently spends part of each year in the United States and Nepal. The term nihilism figures prominently in your book White Sail. What do you mean by it? More »
3 comments
Awareness ItselfHis Holiness the Twelfth Gyalwang Drukpa is the head of the Drukpa School of Tibetan Buddhism, one of Tibet's great practice lineages, and is a renowned master of the Mahamudra and Dzogchen lineages. He has monasteries and nunneries in India and Nepal, as well as centers in Europe and Mexico. This is his first interview in ten years. Lama Surya Das, a Western Dzogchen teacher, taught English to the Gyalwang Drukpa at His Holiness's monastery in Darjeeling, India, in the early seventies. Lama Surya Das is the founder of the Dzogchen Center and author of numerous books, most recently Letting Go of the Person You Used to Be: Lessons on Change, Loss and Spiritual Transformation. This conversation took place at Lama Surya's hermitage and sanctuary, Dzogchen Osel Ling, outside Austin, Texas, last November. More »
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Old Wine, New BottlesLama Surya Das, the American founder of the Dzogchen Foundation, a lay practice center in Cambridge, Massachusetts, was born Jeffrey Miller in Brooklyn, New York, in 1950. He spent nearly thirty years studying with many of the great spiritual masters of Tibet, including Kalu Rinpoche, Dilgo Khyentse Rinpoche, Gyalwa Karmapa, and Nyoshul Khenpo Rinpoche. A dzogchen lineage holder, Lama Surya Das has twice completed the traditional three-year Vajrayana meditation retreat at Shechen Monastery in Dordogne, France. In addition to leading dzogchen retreats, he is the author of Awakening the Buddha Within and Awakening the Sacred, and has translated into English a selection of Tibetan wisdom tales, published in a collection titled The Snow Lion's Turquoise Mane. This interview was conducted at Lama Surya Das's home in Concord, Massachusetts, by Helen Tworkov. More »
1 comment
First ThoughtWhen we trust with our open heart, whatever occurs, at that very moment that it occurs, can be perceived as fresh and unstained by the clouds of hope and fear. Chogyam Trungpa Rinpoche used the phrase "first thought, best thought" to refer to that first moment of fresh perception, before the colorful and coloring clouds of judgment and personal interpretation take over. "First thought" is "best thought" because it has not yet got covered over by all our opinions and interpretations, our hopes and fears, our likes and dislikes. It is direct perception of the world as it is. More »
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One Blood, Two LineagesRevel: Is Buddhism a religion or a philosophy? You've mentioned the first contact you had with the teacher who made such an enormous impression on you without even speaking. In view of that first experience, are we talking about a conversion in the religious sense, or about some sort of purely philosophical breakthrough? Ricard: It's hard to describe such a meeting. What gave it all its value was that it was nothing to do with abstract speculation; it was a direct experience, something I could see with my own eyes, and that was worth more than a thousand descriptions. More »
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The Return of the SuppressedThe Chinese rejection of the Dalai Lama's choice of the next Panchen Lama, the second most important Tibetan lama, represents the greatest threat to the Tibetan institution of the incarnate lama in its history. It is a long history. With the decline of the Tibetan monarchy in the ninth century, political and religious authority shifted gradually to Buddhist teachers. Because many of these were Buddhist monks who had taken vows of celibacy, the problem of succession eventually arose. In some cases, authority was passed from a monk to his nephew. But by the fourteenth century (and perhaps even earlier) a form of succession had developed in Tibet that, although supported by Mahayana Buddhist doctrine, seems unique in the Buddhist world. This was the institution of the incarnate lama, or tulku (sprul sku). More »


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Contrary to popular belief, fall is still a good time for watering your trees. When it is winter trees are not able to access water, so it is important that you are watering your trees in the fall, especially if rain is scarce.read more
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The weather here in March may be a bit cool, windy, and rainy but don't let that stop you from getting outside to clean up your garden for spring. Here are 5 important things to do now before it does get warm out and becomes too late to don't forget these important garden chores.read more
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Our Gladioli at TBG are scattered throughout the Color Garden and Cottage Garden sections of the Perennial Garden, they come in a wide range of colors and are blooming now as they begin in July and will actually bloom all the way until frost. The flowers make some of the best cut flowers for arranging, […]read more
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Is this a good buy?
I'm looking at a 20'x80' gothic arch greenhouse for sale close to me. It needs new glazing. Along with the frame and end walls there are these extras: 2 propane heaters, 2 exhaust fans, 3 air circulation fans, shade cloth, ground cloth, ground stakes, mist system, drip irrigation system, hydroponic growing system used for tomatoes, grow lights and a complete electrical system. I think he also has 200 hanging pots and some other odds and ends for potting plus some hydroponic nutes that he's going to give me if I buy it. The asking price of $2,200.00 sounds okay to me but I've never bought a greenhouse this big. I'm thinking of covering it with corrugated polycarbonate roofing if I can get a good enough deal on it. Does $2200 sound like too much? Thanks in advance.
I am thinking that a decent sized hydroponic kit already will cost you around $1000.00.
The bare-bones greenhouse frame that size will probably go for at least $1000.00 in the used market.
$2200.00 seems too much for just the frame. But all the extras they are throwing in makes it a great deal.
That will be a monster greenhouse though. 20'x80'? WOW!
Just make sure you have the propane heaters inspected by someone knowledgeable in those matters. You will want to address any leaks or breaches in the system before using it on your property.
The new glazing will cost you a bundle though, but do make sure you buy the best quality available. You know what they say "Buy cheap, Buy every year"
Thanks for your input. I took HVAC training back in my early 20s while working for the state since it was free training and I'm pretty knowledgeable about heating repair thanks to it. About how much do you think it would cost to cover the greenhouse with plastic as opposed to corrugated polycarbonate? I can't find a supplier for either one close to WV so shipping is going to kill me if I buy the polycarbonate panels even though they're lifetime warranted.
Surely there is a Home Depot or Lowe's in WV. I was in HD the other day and they have 8 and 12 feet polycarbonate panels (26 inches wide) in stock. Google SUNTUF. That is the brand HD carries and I recommend that brand. My Suntuf panels are over 10 years old and just now need replacing. I'll do that next Spring. I used the brand Lowe's carries (I don't recall the name) on an extension of the greenhouse and it is only 6 years old and needs replacing.


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Originally written on Reading Between The Seams | Last updated 11/13/14
Just a few days after St. Louis CardinalsŌĆÖ Jason Motte suffered a forearm/elbow injury resulting in a start on the DL, another team expected to contend for the postseason suffers a bad blow.┬Ā Atlanta Braves All Star set-up man Jonny Venters left todayŌĆÖs game vs. Detroit in Lakeland, Florida.┬Ā Venters was struggling in the outing, allowing 2 hits and 2 walks while retiring only one.┬Ā Venters has exhibited closers stuff with an ERA under 2.00 in 2010 and 2011, but was behind extremely effective firemen Billy Wagner and Craig Kimbrel.┬Ā Venters seemed a little bit off in 2012 scuffling to a 4.24 ERA in the first half of the season, but regaining form down the stretch with a 1.71 ERA, just when the team needed it to make the Wild Card.┬Ā His durability has come into question, as he averaged about an appearance every other game for the 2010-11 seasons, but those issues seemed to be behind him in the second half.┬Ā However, alarms are raised, as he was already shelved for 10 days this Spring with arm discomfort. Not having a healthy Venters for the long haul would be a significant blow to the Braves AL East chances, with the defending Division champ Washington Nationals, and always-strong Philadelphia Phillies lurking. - Dave (@lhd_on_sports) Follow us on Twitter @rbts_baseball The post Jonny Venters the latest reliever to suffer elbow injury appeared first on Reading Between The Seams.
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Trains to/from Riga
During our visit to Riga in December 2014 we decided to take a day trip on the train to the nearby seaside town of Jurmala. The following details were correct as at the time of our journey:Riga – Jurmala (Majori)We visited Riga Central Station on the evening before our intended journey. We familiarised ourselves with the train times and purchased...more
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Waste Ink Counter
Waste Ink Counter
Epson inkjet printers have inside a part of sponge for absorbing and collecting waste inks. It is called waste ink pad.
Ink is collected by waste ink pads during the initial setup of the product, during cleaning cycles and when printing borderless photographs. While printhead cleaning process ink flush through printhead to waste ink pad.
So one time it can be overflowed because it could not absorb ink anymore then the ink will leak from the bottom of the printer.
The printer counts how much ink flow to waste ink pad and stores this number into printer's memory.
This number is called Protection Counter or Waste Ink Counter.
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Printer Reset
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Moves afoot to cancel Visakhapatnam-Digha weekly express
East Coast Railway is said to be toying with the idea of cancelling Visakhapatnam – Digha Weekly Express on the plea of lack of patronage. The ECoR authorities wrote to a ZRUCC (Zonal Railway Users Consultative Committee) member in Visakhapatnam for his comments on the proposal and also on cancellation of two other pairs of trains between Puri and Digha, which were also having poor patronage.
Praja Spandana president C.S. Rao attributes the 'step-motherly' attitude of the ECoR to the indifference of our public representatives. A study of the status of berths booked on these trains shows that Visakhapatnam – Digha has around 90 per cent occupancy right at the originating station whereas the other two pairs of trains have 20 per cent or less occupancy. There is no justification in the placing these trains on the same plank. In another instance of bias, the ECoR authorities instead of cancelling the Puri – Howrah Duronto Express, which had poor patronage, upgraded and converted it into Shatabdi Express with more stops and higher fare. The decision was taken even before the Railway Budget. In contrast, the Visakhapatnam – Koraput, which was announced as 'five times a week' in the budget, was reduced to twice a week.
The Visakhapatnam – Nanded Express is, perhaps, the only 'special train' to have the dubious distinction of being run as a 'special' for the longest period for the last five years. ECoR had proposed to run this train thrice a week, it was announced on its official website in 2007. This train, which was originally from Visakhapatnam to Nizamabad, was extended to Nanded.
Railway Zone Sadhana Samiti convener J.V. Satyanarayana Murthy feels that the situation is because our State lacks the 'lobbying power' in Delhi and at the Railway Board. "ECoR is running a number of trains with poor patronage only because they originate in Puri and Bhubaneswar.
Visakhapatnam is not being given due importance though Waltair Division earns more than half of the total revenue of the zone. De-linking Waltair Division from E CoR is the only solution to end the injustice," he feels.
ECoR upgraded Puri-Howrah Duronto Express despite poor patronage Railway zone Sadhana Samiti seeks delinking of Waltair division from ECoR
ECoR upgraded Puri-Howrah Duronto Express despite poor patronage
Railway zone Sadhana Samiti seeks delinking of Waltair division from ECoR


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Finelite Wins Multiple Product Innovation AwardsMarch 2, 2015
Finelite Wins Multiple Product Innovation Awards from Architectural SSL Magazine Finelite, Inc., a leading manufacturer of high performance lighting systems takes home the award for "Best Renovation/Retrofit" for the Boston Logan International Airport – Terminal B project. Additional awards were given to the […]
MERCURY LIGHTING: DLC QUALIFIED FIXTURESFebruary 20, 2015
Mercury Lighting now offers an array of DLC Qualified fixtures that are made in America and available to ship immediately from New Jersey.
Omnilite Now Representing LEVITONFebruary 4, 2015
Leviton is the smart choice, providing the most comprehensive range of solutions to meet the needs of today's residential, commercial and industrial buildings. Leveraging more than a century of experience, Leviton helps customers create sustainable, intelligent environments through its electrical wiring devices, network and data center connectivity solutions, lighting energy management systems, and security […]


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