AIDS Alert Update: 21st Century Prevention Work
DEBI list grows slowly as CBOs adapt models
CDC official explains process
The Diffusion of Effective Behavioral Interventions (DEBI) list of HIV prevention programs that are evidence-based was compiled by the CDC for the purpose of giving states and community organizations detailed models for providing prevention services.
Researchers applaud the focus on evidence-based interventions, but note that it may be difficult for communities to find an ideal model since the list contains only 12 DEBIs, accompanied by more than 30 additional interventions included in a compendium of effective behavioral interventions, also compiled by the CDC.
For instance, there are not any good interventions on the list addressing the HIV prevention needs of new and poor arrivals in the Latino community, says Scott Rhodes, PhD, an assistant professor in the department of public health sciences at Wake Forest University School of Medicine in Winston Salem, NC.
"We don’t have enough for African American men," he explains. "It’s difficult to do prevention research, and it’s difficult to get it funded, so we have huge holes in what we know about HIV prevention."
Although the evidence-based list is limited, help is on the way, says Charles Collins, PhD, supervisor health scientist and science application team leader at the CDC.
One reason it is a slow process is because the evidence-based interventions on the DEBI list are ones for which there are materials available for duplication. Many behavioral interventions had great published results, but no one created materials that could be used by people who wished to replicate the programs, he adds.
"We’re working with 20 behavioral interventions, but they’re in various stages," Collins says. "Some we have diffused for almost two years, and some are still in the materials development stage."
Also, some states, including California, are funding translation projects, targeting different populations, for some of the interventions on the DEBI list.
Although HIV behavioral researchers routinely use the term "translation" in referring to the process of taking a DEBI project and adapting it to be used in a setting and for a population that are different from its original use, the CDC prefers not to use the same term, Collins says.
"We use the terms adaptation and tailoring," he says. "Adaptation and tailoring may involve a language translation, but we believe these interventions have to be adapted for various different target populations and settings and venues."
The DEBI list was started in 2003 following a year of start-up work, Collins says.
It takes some time to add an intervention to the list because each DEBI must first meet criteria to be placed on the CDC compendium, he explains. The criteria include:
- The intervention studied must have had a comparison or control group.
- There has to be statistically significant differences in risk behavior for the intervention group compared with the comparison group.
- There has to have been a behavior change that was sustained for at least 120 days after the intervention ended.
- At least 70% of the people who go through the intervention must be retained for the follow-up.
Once interventions are included in the compendium, they may be selected for the DEBI list based on their relevance for target at-risk populations and their readiness for diffusion, meaning there are materials and guidelines established that could be used by a community-based organization or health department that desires to use and/or adapt the same intervention, Collins notes.
"We look to see if the intervention is culturally competent," he says.
The first compendium was published in November 1999 with 25 interventions, and that list was updated in 2003 with 30 interventions.
"The DEBI interventions have instrumental utility and conceptual utility," Collins says. "Instrumental utility means you learn how to do the intervention as it was designed, but conceptual utility is you learn how important it is to give health messages through multiple channels."
To make an intervention ready for diffusion, it requires meeting with researchers to discuss their vision and beginning a dialogue about how to get their intervention diffused across the country, including what materials would need to be developed, he notes.
While there are perhaps hundreds of evidence-based interventions with published results, even some that meet the compendium criteria are not included on the list because of other issues, including relevance, Collins says. For example, an intervention designed for men who have sex with men (MSM) in 1989 might not be relevant to the population of at-risk MSM in 2005, he explains.
Also, there’s a financial constraint, so the CDC has had to prioritize which interventions to move to the next levels, Collins notes. "There’s a wonderful intervention by Don Des Jarlais, PhD, called Sniffer," he says. "It works with heroin sniffers who have been sniffing for less than 90 days, and it supports them in continuing to sniff heroin rather than to switch to injecting heroin, which protects the person from HIV and hepatitis C."
The reason the CDC has not put this intervention on the list of DEBIs is because there’s a greater need for interventions addressing African American MSM, Collins says. "We don’t have enough money to fund every one of those interventions, so we need to choose those interventions that best fit the HIV epidemic."