Special Report: Research shows targeted HIV prevention succeeds
Research shows targeted HIV prevention succeeds
Here’s what works and what doesn’t
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Systematic reviews of HIV prevention literature for the target populations of African-Americans, Latinos, youths, and men who have sex with men (MSM) in the United States show that those targeted interventions work in reducing HIV risk behaviors. Interventions that succeeded were culturally sensitive, gender-sensitive, of longer duration, and included skills training, according to a project supported by the Surgeon General’s Leadership Campaign on AIDS and the California HealthCare Foundation in Oakland.
"Skills training was definitely shown to be a useful component, and that could mean communication skills or asking a partner to use a condom or teaching skills of how to put a condom on," says Lynae Darbes, PhD, research specialist for the AIDS Research Institute of the University of California - San Francisco. Darbes is the project director of the systematic reviews, which were broader and more detailed than a standard literature review. The reviews incorporated both published and unpublished data, using strict methodological inclusion criteria, including the requirement that there was a control group. Also, all research reviewed involved people of color.
Investigators are continuing to analyze the data and are in the process of combining analyses of interventions into a meta-analysis.
Here are descriptions of some of the stronger research reviewed by Darbes and fellow investigators that pertains to different types of prevention interventions:
• Abstinence education: There was only one abstinence study that met the review’s strict inclusion criteria, Darbes says. In this 1998 randomized control trial, which studied African-American adolescents, one group received safer-sex education, one received abstinence education, and another had the control intervention.1
"They tested the two against the control intervention, and what they found was that the abstinence intervention was successful in terms of people who were in the intervention were less likely than the control group to report having sex in the three months after the intervention," Darbes says. "But that was only the case for those who were not already sexually active."
When investigators checked the abstinence group at six- and 12-month intervals, they found that there was no longer a positive effect. The youths who received abstinence education no longer were less likely to have sex than those who were in the control group. The youths receiving the safer-sex intervention reported a higher frequency of condom use and fewer episodes of sexual intercourse at all follow-up points when compared with the control group and the abstinence-only intervention group, Darbes says. "The safer-sex intervention emphasized that abstinence is the best choice, but that people could reduce pregnancy with condoms and protect against sexually transmitted diseases," Darbes says.
• MSM intervention for African-American men: Again, only one of these studies met the inclusion criteria. The study had a safer-sex intervention that was divided into two groups, as well as a wait-list control group. The safer-sex intervention groups consisted of one group that received three consecutive weekly group meetings that consisted of three-hour sessions, and one safer-sex intervention group that met only once for three hours.2 Intervention material covered skills training about eroticism and condom use and had a strong cultural component in terms of trying to improve positive self-identity for African-American MSM.
Risks declined by 50% after intervention
The triple-session group showed risks declined at the 12-month follow-up by 50%, and that rate was maintained at the 18-month follow-up. Specifically, the triple-session group reduced the frequency of unprotected anal intercourse from 46% at baseline to 20% at the 12-month follow-up.
The single-session group reduced unprotected anal intercourse from 47% to 38% at the 12-month follow-up. The control group had no statistically significant decrease, with a 26% incidence at baseline and 23% at the 12-month follow-up, Darbes says.
"That was a hallmark study," Darbes says. "It was the only published study with African-American MSM, and it demonstrated six years ago that an intervention can have a positive effect and reduce the rates of unprotected anal intercourse."
The intervention strategies included reinforcing and enhancing positive self-identity for members of racial and sexual minority groups. Participants viewed segments of a movie called Tongues Untied that deals with the issues facing gay African-American men. There also were discussions, AIDS education, assertiveness training focused on improving communications skills needed to refuse high-risk activities or initiate safer sex, and role-playing. The interventions were led by two trained African-American facilitators who were homosexual men, Darbes says.
• Heterosexual African-Americans: Investigators reviewed 25 interventions targeting heterosexual African-Americans and found that the most successful programs resulted in increases in condom usage, decreases in STD re-infection rates, and improvements in condom-use skills. The interventions that succeeded were gender-sensitive, separated men and women, involved videos featuring African-American actors, and used role-playing. It also was important to have African-American facilitators. About half of the interventions were unsuccessful. Investigators attributed this to short follow-up periods or a lack of reinforcement mechanisms.
One recent study involved an intervention that used social cognitive theory to influence HIV risk behavior among low-income women in Chicago.3 From two demographically similar communities, 280 women were recruited, with one community serving as the control group. The intervention community was provided with information, skills training, role playing, and modeling, with the goal of increasing self-efficacy and improving positive social norms. Interventions were given in six 90-minute sessions, followed by booster sessions at three, six, and nine months. Women in the treatment community significantly increased protected sexual behavior at the six-month follow-up, but had returned at the nine-month follow-up to their risk behavior levels noted at the three month follow-up.
• Injection drug users (IDUs): Twelve intervention studies targeted African-American IDUs. The programs that worked showed significantly less drug use, and participants were less likely to share needles and were more conscientious about using clean needles. Injection drug use is a major risk factor for HIV among African-Americans, according to a review summary. It accounts for 34% of the cumulative AIDS cases among African-American men and 42% of the cumulative AIDS cases among African-American women.
San Juan study targets Latinos
Among Latinos, injection drug use accounts for 35% of the cumulative AIDS cases among men and 40% of the cumulative AIDS cases among women. Puerto Rico has an AIDS incidence rate that is second only to Washington, DC, among U.S. states and territories, and there have been some large-scale intervention studies conducted there. One notable study involved an intervention for drug users, recruited from neighborhoods with high levels of drug use, shooting galleries, and bars in San Juan. About 80% of the participants were men, and investigators compared a standard intervention of HIV testing and counseling combined with health and drug treatment services to an enhanced intervention in a randomized clinical trial.4
The enhanced intervention included the same components as the standard intervention, plus three additional educational sessions that included risk-reduction strategies and information about HIV test results. Peer educators, who mostly were ex-addicts, were involved in the intervention, and the sessions lasted 30 to 60 minutes.
At a seven-month follow-up, the only significant differences between the two groups were that the enhanced intervention group showed a greater rate of discontinuation of drug injection and a lower rate of sharing "cookers." Among nine risk behaviors, the enhanced risk group decreased the frequency of borrowing needles, and the standard group decreased their number of visits to shooting galleries. Both groups significantly decreased their initiation of borrowing needles and daily drug injection from baseline to follow-up, and both groups also improved their frequency of protective acts, such as bleaching needles and using condoms.
References
1. Jemmott JB, Jemmott LS, Fong GT. Abstinence and safer sex, HIV risk reduction interventions for African-American adolescents: A randomized controlled trial. JAMA 1998; 279:1529-1536.
2. Peterson JL, Coates TJ, Catania J, et al. Evaluation of an HIV risk reduction intervention among African-American homosexual and bisexual men. AIDS 1996; 10:319-325.
3. Dancy BL, Marcantonio R, Norr K. The long-term effectiveness of an HIV prevention intervention for low-income African-American women. AIDS Education and Prevention 2000; 12:113-125.
4. Colon HM, Robles RR, Freeman D, Matos T. Effects of a HIV risk reduction education program among injection drug users in Puerto Rico. Puerto Rican Health Sciences J 1993; 12:27-34.
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