AIDS Alert Update: 21st Century Prevention Work

Adapting CDC DEBI list for target audiences is a major issue among CBOs

Translation changes can affect funding

The most recent HIV data show that about 1 million Americans are living with HIV, and the epidemic is becoming more firmly entrenched in the African American community, who now account for 47% of people estimated to be living with HIV.1

Also, about 45% of the people infected with HIV nationwide are men who have sex with men (MSM), while 27% were infected through heterosexual contact, and 22% through injection drug use, according to data presented at the 2005 HIV Prevention Conference, held June 12-15, 2005, in Atlanta. The CDC presented data gathered through 2003.

While the epidemic has moved to the high water point of 1 million people infected, the major ways prevention work is funded and provided has been undergoing major changes.

States are continuing to tighten HIV prevention funding and some are requiring strictly enforced guidelines regarding the use of evidence-based interventions, causing distress among many community-based organizations (CBOs) and concern among HIV prevention researchers.

Researchers and CBO officials across the nation have been scrambling in the past year to find ways to adapt for a wide variety of uses a very narrow list of evidence-based interventions promoted by the CDC.

Commonly called the DEBI list, after the program’s title of Diffusion of Effective Behavioral Interventions, the interventions include 12 HIV prevention projects that were selected from a list of more than 30 prevention programs on a CDC compendium of effective behavioral interventions.

From theory to community

While the federal government and other agencies have invested a great deal in scientifically sound intervention programs for AIDS, there are concerns that the translation of these programs is complicated, says Bart Aoki, PhD, associate director of the Universitywide AIDS Research Program, University of California, Office of the President in Oakland. Aoki spoke about community interventions and translation issues at the CDC’s prevention conference.

"It’s a social and behavioral issue that brings more complexity to the translation of scientifically developed interventions into communities than say would a biomedical device," he says.

"It raises the issue of how are resources that are being invested in research and developed ultimately benefiting the community in general," Aoki says.

Other researchers and CBO officials raise similar questions about the CDC’s DEBI list and how states are including these in prevention funding plans.

For example, in North Carolina, one CBO lost its prevention funding for a DEBI adaptation in the second year because of changes it made to the intervention to make a better fit with the CBO’s target Latino population, 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.

"The CBO is doing amazing outreach with Latinos living with HIV, and they’re leaders in North Carolina in working with the Latino community," he says. "Because they’ve been so successful with outreach they’ve begun to take on some primary prevention responsibilities."

The organization was adapting a DEBI intervention that involves primary care prevention case management, but the CBO’s adaptation fell outside the state’s list of criteria, and so funding was withdrawn, Rhodes explains.

Very few states require CBOs to use only the 12 interventions on the DEBI list, says Charles Collins, PhD, supervisor health scientist and science application team leader for the CDC.

States frequently have one of three requirements for indirectly funded CBOs, and the most common one is for the state to say they should use evidence-based interventions, Collins says.

While the CDC’s intervention compendium list is limited, and the DEBI list is even smaller, there are dozens of HIV prevention interventions that were studied, published, and found significant behavior changes, Collins says.

"Some states go further and say, We suggest you look at the compendium of effective interventions,’" Collins adds. "And some states take it one more step and say, Not only do we want evidence-based interventions, but we also want you to look in the DEBI because prevention materials are available."

DEBI interventions offer users a step-by-step detailed protocol for implementing the intervention, and there are models provided and technical assistance guides, Collins says.

However, CBOs and researchers say the DEBI list is too small to be of use to many at-risk populations without extensive and often expensive adaptations, and few states are providing enough funds for the adaptation process.

For instance, Connecticut changed its HIV prevention funding criteria, strongly encouraging CBOs to use one of the DEBIs.

"Many agencies have relied heavily on the funds from the Connecticut Department of Health, and if an agency didn’t feel they had the resources available to replicate a DEBI, then that would put the agency in a really difficult position," says Ann O’Connell, EDD, an associate professor at the University of Connecticut in Storrs. The University of Connecticut held a conference titled, "Capacity Building for Translation of Effective HIV Prevention Interventions" on May 22-24 in Storrs.

Even when CBOs received funding to use and adapt a DEBI, it often isn’t enough, says Mark Bond-Webster, an outreach worker with Perception Programs in Willimantic, CT. Perception Programs, which was founded in 1970 to provide substance abuse interventions and treatment, established an AIDS/HIV prevention program in 1988, and in the 1990s opened a residential home for people living with HIV/AIDS.

"What we were told when we applied for funding was that although we didn’t absolutely have to use a DEBI, the proposals that would be smiled on most favorably were those that based themselves on DEBIs," he says.

Perception Programs fared very well during the latest funding round, receiving $130,000 in funds to implement two different DEBIs, the Mpowerment intervention and the Community Promise intervention. (See list and description of DEBIs, at bottom.)

And while the CBO’s bottom line looks a great deal better than its brethren CBOs, some of whom saw significant funding cuts, the reality is that $130,000 isn’t enough money to do these interventions well, Bond-Webster says.

The CBO had requested $95,000 per DEBI in funding, and essentially has received enough money to pay for 1.5 DEBIs, which are directed toward different populations, he adds.

"When you read the DEBIs, they give minimum staffing requirements, and we cannot afford, even with the increased funding, to employ the people necessary for the DEBIs," Bond-Webster says.

And that’s not even counting how much it might cost to adapt the DEBIs to the CBO’s target populations. For example, the Mpowerment intervention was designed for young men who have sex with men, and Bond-Webster says he hopes to adapt it for use with both young and older men.

Creativity leads to funding cuts?

Both the lack of flexibility in state’s funding decisions and the lack of adequate funds itself are huge problems, says George Ayala, PhD, director of the Institute for Gay Men’s Health at the David Geffen Center in Los Angeles.

"Health departments end up being very rigid in interpretation of evidence-based interventions, so there’s an expectation that organizations follow manualized interventions verbatim and allow no room for creativity or real-life decisions, adjustments, and changes to the intervention, Ayala says.

Policy-makers want to keep the recipe the same, so they recommend strict modeling of the DEBIs when what’s needed are translational sciences, says Blair T. Johnson, PhD, a professor of psychology and member of the executive committee of the Center for Health/HIV Intervention and Prevention at the University of Connecticut in Storrs.

Instead of making CBOs focus on a dozen DEBIs, the CDC should come up with guidelines based on what has worked among 300 studies, he suggests.

"Something like this blended with a more qualitative strategy of the CDC models may well lead to greater prevention," Johnson says.

Collins says he used to believe this approach was best, but became disillusioned after seeing how the CDC spent years teaching CBOs the four ways to increase self-efficacies and finding out that the models were too complex and needed to be turned into something concrete before the organizations could adapt them.

For instance, the SISTA intervention, which is on the DEBI list targeting African American women, provides information on how to increase the female partner’s assertive sexual negotiation skills by decreasing feelings of threat in a male partner, Collins explains.

"We could teach CBOs the difference between assertive and aggressive, but why have them work out all of the thousands of details of how to turn this into an intervention, when they could come to a SISTA intervention and see the process," he says.

"Frankly, I think the biggest problem is funding," says Susan Kegeles, PhD, a professor at the University of California-San Francisco.

"It’s difficult for organizations, even with the 12 interventions to use, when they don’t have enough money to do the interventions," she says. "And they’re told to focus on testing, focus on prevention for positives, and there’s just not enough money."

The bottom line is the federal government, which has cut or flat-funded CDC prevention funding in recent years, should not be pulling back funding from HIV prevention programs, Kegeles says.

Collins says the use of evidence-based interventions, once it becomes widespread will result in lower HIV infection rates even if funding remains the same.

"Several years ago, there were several researchers and surveys that came out and indicated approximately 70% of HIV prevention efforts in this country were street outreach where an individual on his first day of work, first hour of work, would know the intervention because all they had to do is walk down a street and try to put a condom in people’s hands," he recalls.

"We had strong notions that even though 30% may have been involved in fairly creative interventions, the vast majority were doing a simple intervention with dubious effects," Collins says. "And so the other issue is that the number of new infections in this country has hovered at the 40,000 range for five years, and we have got to increase the prevention and science-based prevention so we can stop new infections."

Now that the CDC recommends that states and cities fund evidence-based interventions instead of unscientific street outreach, there should be improvements, even if funding levels remain the same, he adds.

However, implementing evidence-based interventions costs a great deal more than community outreach prevention, researchers say.

Cost effectiveness studies show that even for the DEBI programs that are not very expensive, the cost of implementing them exceeds the typical prevention funding budget for many CBOs, says Robin Lin Miller, PhD, an associate professor at Michigan State University in East Lansing.

Many CBOs are expected to serve all different at-risk populations within a geographic region, but if they implement a DEBI, they only may have enough money to serve one segment of the population they intend to reach, she adds.

So an organization may shift its relationships to the one population, and there is no research to indicate whether this is beneficial or harmful and how CBOs could manage this change, Miller notes.

The core list of DEBIs and their target populations

The Diffusion of Effective Behavioral Interventions (DEBI) list of 12 HIV prevention programs includes the following evidence-based interventions (www.effectiveinterventions.org), selected by the CDC:

  • Healthy Relationships: This five-session, small-group intervention is for men and women living with HIV/AIDS, and is based on Social Cognitive Theory, focusing on developing skills and building self-efficacy and positive expectations about new behaviors through modeling and practicing skills. Staff include group peer facilitators, program coordinators, mental health professional, and program manager, and sites would need video/DVD/TV equipment, as well as incentives and refreshments for participants. Also, sites will need to form a community advisory group, obtain community buy-in, develop a logic model and preliminary implementation plan, and train staff to facilitate the program.
  • HHRP:The Holistic Health Recovery Program (HHRP) contains 12 sessions, manual-guided, group-level intervention for HIV-positive and HIV-negative injection drug users. Based on the Information-Motivation-Behavioral Skills model of HIV prevention behavioral change, HHRP takes a harm reduction approach to behavior change in which abstinence from drug use or sexual risk-taking behavior is one goal along a continuum of risk-reduction strategies.
  • Many Men, Many Voices: Also called 3MV, the intervention has six or seven sessions and is a group level HIV/sexually transmitted disease (STD) prevention intervention for gay men who have sex with men (MSM), including men on the "down low," meaning they do not identify themselves as gay or bisexual but have sex with men. Some factors specific to this population addressed in the intervention include cultural/ societal norms, sexual relationship dynamics, and social influences of racism and homophobia.
  • Mpowerment: Originally designed for young MSM, including acculturated Latino men, this intervention uses informal and formal outreach, discussion groups, creation of safe spaces, social opportunities, and social marketing to reach its target population with HIV prevention, safer sex, and risk reduction messages.
  • Popular Opinion Leader: A community-level intervention, POL involves identifying, enlisting, and training key opinion leaders to encourage safer sexual norms and behaviors within their social networks. It has been adapted for use with a variety of at-risk populations, including inner-city black women and black MSM, and the CDC have promoted it for use with any population.
  • PROMISE: Titled, Peers Reaching Out and Modeling Intervention Strategies, PROMISE is a community-level intervention based on several behavior change theories. Training sites were established in four regions nationwide. PROMISE has been tested with African American, white, and Latino communities, including IDUs and their sex partners, MSM, high-risk youth, female sex workers, and high-risk heterosexuals. The program requires recruitment and training of peer advocates from the target population, and it has role model stories written from interviews with the target population and then distributed to target audiences to help people move toward safer sex or risk reduction.
  • RAPP: A community mobilization program, the Real AIDS Prevention Project is based on the transtheoretical model of behavior change and was designed to reduce HIV risk and unintended pregnancy among women in high-risk communities, chiefly through increasing condom use. This intervention uses peer-led activities, including outreach, one-on-one conversations, brochures, referrals, and condom distribution, along with some small group safer sex discussions and presentations. Community business leaders also may participate in media campaigns.
  • Safety Counts: This HIV prevention intervention is for active IDU and crack cocaine users, and its goal is to reduce both high-risk drug use and sexual behaviors. It has seven sessions, including structured and unstructured psycho-educational activities in group and individual settings, and it works well with the CDC’s Advancing HIV Prevention initiative by strongly encouraging HIV testing. Both HIV-positive and HIV-negative, at-risk populations are addressed.
  • SISTA: Five peer-led group sessions are conducted among sexually-active African American women. The goal is to increase condom use, and the sessions focus on ethnic and gender pride, HIV knowledge, and skills training for sexual risk reduction behaviors and decision making. The intervention is based on the Social Learning theory and the theory of Gender and Power.
  • Street Smart: This multisession, skills-building program originally was designed for use with runaway and homeless youth, ages 11 to 18, populations. It addresses improving their social skills, assertiveness and coping skills, and reducing substance use and harmful behaviors. Individual counseling and trips to community health providers also are provided.
  • TLC: Teens Linked to Care targets youth, ages 13 to 29, living with HIV. The intervention is delivered in small groups, using cognitive-behavioral strategies to change behavior. Participants meet regularly to learn new skills, provide social support, and to socialize. The goal is to help young people identify ways to improve their lives by setting new habits and daily social routines, and it’s based on the Social Action Theory. Low-cost, regional training sessions for TLC will begin in 2006.
  • VOICES/VOCES:Titled, Video Opportunities for Innovative Condom Education & Safer Sex, this group-level, single-session, video-based intervention was designed to increase condom use among heterosexual African American and Latino men and women who visit STD clinics. Staff training is necessary, and the video sessions include either an English or Spanish video on HIV risk behaviors and condom use, followed by a facilitated discussion.

Reference

  1. Estimated HIV prevalence in the United States at the end of 2003. Presented at the 2005 HIV Prevention Conference. Atlanta; June 2005. Abstract presentation: T1-B1101.