Evidence-based HIV Prevention Interventions Research Articles

Audit Culture: Unintended Consequences of Accountability Practices in Evidence-Based Programs.

Evaluation has become expected within the nonprofit sector, including HIV prevention service delivery through community-based organizations (CBOs). While staff and directors at CBOs may acknowledge the potential contribution of evaluation data to the improvement of agency services, the results of evaluation are often used to demonstrate fiscal prudence, efficiency, and accountability to funders and the public, rather than to produce information for the organization's benefit. We conducted 22 in-depth, semistructured interviews with service providers from four agencies implementing the same evidence-based HIV prevention intervention. We use the lens of "audit culture" to understand how the evaluation and accountability mandates of evidence-based program implementation within HIV prevention service provision affect provider-client relations, staff members' daily work, and organizational focus in natural settings, or contexts without continuous support and implementation monitoring. We conclude with recommendations for improving the use and methods of evaluation within HIV prevention service delivery.

Impact of Human Resources on Implementing an Evidence-Based HIV Prevention Intervention.

Evidence-based interventions (EBIs) often require competent staff, or human resources (HR), for implementation. The empirical evidence characterizing the influence of HR fluctuations on EBI delivery is limited and conflicting. Using the Interactive Systems Framework, we explored staff fluctuation and the subsequent influence on RESPECT, an HIV prevention EBI. We conducted interviews with staff in two waves (n=53, Wave I; n=37, Wave II) in a national sample of organizations delivering RESPECT (N=29). We analyzed interviews qualitatively to describe changes among RESPECT staff and explore the subsequent influences on RESPECT implementation. Organizations reported downsizing, turnover, and expansion of staff positions. Staff changes had multiple influences on RESPECT implementation including clients reached, fidelity to specific RESPECT protocols, and overall sustainability of RESPECT over time. HR fluctuations are common, and our analyses provide an initial characterization of the relationship between HR fluctuation and EBI implementation. Given the prominent influence of HR on EBI implementation, the Interactive Systems Framework is a useful guiding tool for future examinations.

Exploring sexual risk taking among American Indian adolescents through protection motivation theory

ABSTRACTThis paper examines decision-making around sexual behavior among reservation-based American Indian youth. Focus group discussions were conducted with youth ages 13–19 years old. Through these discussions, we explored youth’s knowledge, attitudes and behaviors related to sexual risk taking through the lens of the protection motivation theory to inform the adaptation of an evidence-based HIV prevention intervention. Findings suggest that condom use self-efficacy and HIV prevention knowledge is low, vulnerability to sexually transmitted infections is lacking and alcohol plays a significant role in sexual risk taking in this population. In addition, parental monitoring and peer influence may contribute to or protect against sexual risk taking. Results suggest that future HIV prevention interventions should be delivered to gender-specific peer groups, include a parental component, teach sexual health education and communication skills, integrate substance-use prevention, and work to remove stigma around obtaining and using condoms.

Adapting an Evidence-Based HIV Prevention Intervention Targeting High-Risk Migrant Workers: The Process and Outcome of Formative Research.

Historically, HIV prevention efforts in Nepal have primarily focused on heterosexual transmission, particularly, among female sex workers and their male clients, with little acknowledgment of the contribution of migrant workers to the epidemic. The very few HIV prevention efforts that have been attempted with migrants have been unsuccessful primarily due to stigma, discrimination, and insufficient availability of culturally relevant evidence-based interventions (EBIs). As an initial step toward addressing this unmet need, we conducted formative research aimed at adapting an evidence-based HIV risk-reduction intervention for implementation among migrants in Nepal. Our formative work involved a critical examination of established EBIs and associated published reports complemented by data elicited through structured interviews with members of the target population and key stakeholders. Between July and August, 2014, we conducted structured one-on-one interview with migrants (n = 5) and key stakeholder (e.g., counselors, field workers, and project coordinator; n = 5), which focused on the HIV risk profiles of the migrants and on ways to optimize intervention content, delivery, and placement within the community-based settings. Data analysis followed a thematic analysis approach utilizing several qualitative data analysis techniques, including inductive analysis, cross-case analysis, and analytical coding of textual data. Based on formative research, we adapted the Holistic Health Recovery Program, an EBI, to consist of four 30-min sessions that cover a range of topics relevant to migrants in Nepal. The intervention was adapted with flexibility, so that it could be provided in an individual format, implemented within or outside the community-based organization, and it can be delivered in either consecutive or weekly sessions based on time constraints. This paper provides a detailed description of the formative research process in preparation for the adaptation of an EBI - taking into account both empirical evidence and input from target population and key stakeholders - for use with migrants in Nepal. We hope that this study will help to inform similar work in the future as a growing number of EBIs have become widely available, but may not yet be in optimal form for implementation in real-world community-based settings.

Integration of Social, Cultural, and Biomedical Strategies into an Existing Couple-Based Behavioral HIV/STI Prevention Intervention: Voices of Latino Male Couples.

IntroductionSuccessful HIV prevention and treatment requires evidence-based approaches that combine biomedical strategies with behavioral interventions that are socially and culturally appropriate for the population or community being prioritized. Although there has been a push for a combination approach, how best to integrate different strategies into existing behavioral HIV prevention interventions remains unclear. The need to develop effective combination approaches is of particular importance for men who have sex with men (MSM), who face a disproportionately high risk of HIV acquisition.Materials and MethodsWe collaborated with Latino male couples and providers to adapt Connect ‘n Unite, an evidence-based intervention for Black male couples, for Latino male couples. We conducted a series of three focus groups, each with two cohorts of couples, and one focus group with providers. A purposive stratified sample of 20 couples (N = 40, divided into two cohorts) and 10 providers provided insights into how to adapt and integrate social, cultural, and biomedical approaches in a couples-based HIV/AIDS behavioral intervention.ResultsThe majority (N = 37) of the couple participants had no prior knowledge of the following new biomedical strategies: non-occupational post-exposure prophylaxis (nPEP); pre-exposure prophylaxis (PrEP); and HIV self-testing kits. After they were introduced to these biomedical interventions, all participants expressed a need for information and empowerment through knowledge and awareness of these interventions. In particular, participants suggested that we provide PrEP and HIV self-testing kits by the middle or end of the intervention. Providers suggested a need to address behavioral, social and structural issues, such as language barriers; and the promotion of client-centered approaches to increase access to, adaptation of, and adherence to biomedical strategies. Corroborating what couple participants suggested, providers agreed that biomedical strategies should be offered after providing information about these tools. Regarding culturally sensitive and responsive approaches, participants identified stigma and discrimination associated with HIV and sexual identity as barriers to care, language barriers and documentation status as further barriers to care, the couple-based approach as ideal to health promotion, and the need to include family topics in the intervention.DiscussionWe successfully adapted an evidence-based behavioral HIV prevention intervention for Latino male couples. The adapted intervention, called Conectando Latinos en Pareja, integrates social, cultural, behavioral and biomedical strategies to address the HIV epidemic among Latino MSM. The study highlights the promise regarding the feasibility of implementing a combination approach to HIV prevention in this population.

Heterosexual Anal Sex Among Men and Women in Substance Abuse Treatment: Secondary Analysis of Two Gender-Specific HIV-Prevention Trials

Receptive anal sex has high human immunodeficiency virus (HIV) transmission risk, and heterosexual substance-abusing individuals report higher anal sex rates compared to their counterparts in the general population. This secondary analysis evaluated the effectiveness of two gender-specific, evidence-based HIV-prevention interventions (Real Men Are Safe, or REMAS, for men; Safer Sex Skill Building, or SSSB, for women) against an HIV education (HIV-Ed) control condition on decreasing unprotected heterosexual anal sex (HAS) among substance abuse treatment-seeking men (n = 171) and women (n = 105). Two variables, engagement in any HAS and engagement in unprotected HAS, were assessed at baseline and three months postintervention. Compared to the control group, women in the gender-specific intervention did not differ on rates of any HAS at follow-up but significantly decreased their rates of unprotected HAS. Men in both the gender-specific and the control interventions reported less HAS and unprotected HAS at three-month follow-up compared to baseline, with no treatment condition effect. The mechanism of action for SSSB compared to REMAS in decreasing unprotected HAS is unclear. More attention to HAS in HIV-prevention interventions for heterosexual men and women in substance abuse treatment is warranted.

Adapting an Evidence-Based HIV-Prevention Intervention for Women in Domestic Violence Shelters.

Despite the documented intersection of intimate partner violence and HIV, there is a paucity of evidence-based HIV prevention interventions for female survivors of intimate partner violence in the United States. This paper describes the adaptation of an effective HIV prevention intervention, Sisters Informing Sisters about Topics on AIDS (SISTA), for women in domestic violence shelters and the steps taken to improve the adapted intervention's implementation. The adaptation process was guided by the ADAPT-ITT framework and data collected from directors, direct client service providers, and residents of two domestic violence shelters located in urban areas, as well as topical experts. Eleven of 12 shelter staff (92%) reported that HIV interventions had never been implemented at their shelter and 64% reported they had not provided residents with educational brochures about HIV prevention. Changes made to adapt SISTA for this population and enhance the implementation of the intervention included reducing the intervention's duration; adding education about the intersection of intimate partner violence, substance use, and HIV; and adding an HIV risk assessment and safety plan. Next steps will include implementing the adapted intervention and evaluating its perceived acceptability and efficacy, and assessing whether contextual factors influence the intervention's implementation.

Supplemental Material for Adapting an Evidence-Based HIV-Prevention Intervention for Women in Domestic Violence Shelters

Supplemental Material for Adapting an Evidence-Based HIV-Prevention Intervention for Women in Domestic Violence Shelters

A "Common Factors" Approach to Developing Culturally Tailored HIV Prevention Interventions.

The current dominant model of HIV prevention intervention dissemination involves packaging interventions developed in one context, training providers to implement that specific intervention, and evaluating the extent to which providers implement it with fidelity. Research shows that providers rarely implement these programs with fidelity due to perceived incompatibility, resource constraints, and preference for locally generated solutions. In this study, we used the concept of "common factors," or broad constructs shared by most evidence-based HIV prevention interventions, to train service providers to develop their own programs. We recruited eight Ukrainian HIV prevention organizations from regions with HIV epidemics concentrated among people who inject drugs. We trained staff to identify HIV risk behaviors and determinants, construct behavior change logic models, and develop and manualize an intervention. We systematically reviewed each manual to assess intervention format and content and determine whether the program met intervention criteria as taught during training. All agencies developed programs that reflected common factors of effective behavior change HIV prevention interventions. Each agency's program targeted a unique population that reflected local HIV epidemiology. All programs incorporated diverse pedagogical strategies that focused on skill-building, goal-setting, communication, and empowerment. Agencies struggled to limit information dissemination and the overall scope and length of their programs. We conclude that training service providers to develop their own programs based on common elements of effective behavior change interventions can potentially transform existing processes of program development, implementation, and capacity building. Expanding this model will require committed training and support resources.

Facilitators and barriers to effective scale-up of an evidence-based multilevel HIV prevention intervention

BackgroundSince the scale-up of HIV/AIDS prevention evidence-based interventions (EBIs) has not been simple, it is important to examine processes that occur in the translation of the EBIs into practice that affect successful implementation. The goal of this paper is to examine facilitators and barriers to effective implementation that arose among 72 community-based organizations as they moved into practice a multilevel HIV prevention intervention EBI, the Mpowerment Project, for young gay and bisexual men.MethodsCBOs that were implementing the Mpowerment Project participated in this study and were assessed at baseline, and 6-months, 1 year, and 2 years post-baseline. Semi-structured telephone interviews were conducted separately with individuals at each CBO. Study data came from 647 semi-structured interviews and extensive notes and commentaries from technical assistance providers. Framework Analysis guided the analytic process. Barriers and facilitators to implementation was the overarching thematic framework used across all the cases in our analysis.ResultsThirteen themes emerged regarding factors that influence the successful implementation of the MP. These were organized into three overarching themes: HIV Prevention System Factors, Community Factors, and Intervention Factors. The entire HIV Prevention System, including coordinators, supervisors, executive directors, funders, and national HIV prevention policies, all influenced implementation success. Other Prevention System Factors that affected the effective translation of the EBI into practice include Knowledge About Intervention, Belief in the Efficacy of the Intervention, Desire to Change Existing Prevention Approach, Planning for Intervention Before Implementation, Accountability, Appropriateness of Individuals for Coordinator Positions, Evaluation of Intervention, and Organizational Stability. Community Factors included Geography and Sociopolitical Climate. Intervention Factors included Intervention Characteristics and Adaptation Issues.ConclusionsThe entire ecological system in which an EBI occurs affects implementation. It is imperative to focus capacity-building efforts on getting individuals at different levels of the HIV Prevention System into alignment regarding understanding and believing in the program’s goals and methods. For a Prevention Support System to be maximally useful, it must address facilitators or barriers to implementation, address the right people, and use modalities to convey information that are acceptable for users of the system.

Your blues ain't like mine: considering integrative antiracism in HIV prevention research with black men who have sex with men in Canada and the United States.

Evidence-based interventions have been developed and used to prevent HIV infections among black men who have sex with men (MSM) in Canada and the United States; however, the degree to which interventions address racism and other interlocking oppressions that influence HIV vulnerability is not well known. We utilize integrative antiracism to guide a review of HIV prevention intervention studies with black MSM and to determine how racism and religious oppression are addressed in the current intervention evidence base. We searched CINAHL, PsychInfo, MEDLINE and the CDC compendium of evidence-based HIV prevention interventions and identified seventeen interventions. Three interventions targeted black MSM, yet only one intervention addressed racism, religious oppression, cultural assets and religious assets. Most interventions' samples included low numbers of black MSM. More research is needed on interventions that address racism and religious oppression on HIV vulnerability among black MSM. Future research should focus on explicating mechanisms by which multiple oppressions impact HIV vulnerability. We recommend the development and integration of social justice tools for nursing practice that aid in addressing the impacts of racism and other oppressions on HIV vulnerability of black MSM.

Fidelity of implementation of an evidence-based HIV prevention program among Bahamian sixth grade students.

The Bahamian Ministry of Education has elected to implement at a national level in all Bahamian government grade six classes an evidence-based HIV prevention intervention [Focus on Youth in the Caribbean (FOYC)]. This study explores fidelity of implementation of the intervention, factors that may influence implementation fidelity, and the impact of variations in the implementation fidelity on student outcomes. Data were collected in the first wave of national implementation in 2011, involving 35 government primary schools and 110 teachers and 2,811 students. Structural equation modeling was performed to examine the relationships among factors which facilitated or impeded teachers’ implementation of FOYC. Results indicate that teachers taught 16.3 out of 30 core activities, 24.9 out of 46 total activities, and 4.4 out of 8 sessions on average. The strongest predictor of implementation fidelity was teacher comfort level with the FOYC curriculum. Teachers who did not perceive the FOYC intervention to be important for their students or who had attended only part of a FOYC training workshop were more likely to change the curriculum. Increased duration of experience as a teacher (>10 years) was negatively associated with fidelity of implementation. Teacher’s perception of the importance of the FOYC intervention and implementation fidelity had direct positive effects on students’ HIV/AIDS knowledge, reproductive health skills, protective intentions, and self-efficacy. Youth did not appear to benefit from FOYC if two or fewer sessions were delivered. We concluded that an evidence-based HIV prevention intervention can be implemented at a national level. Prior training of teachers in the intervention curriculum, teacher perception of the importance of the intervention, and fewer years as a teacher are associated with implementation fidelity. Implementation fidelity is associated with improved student outcomes.

Where is the Faith? Using a CBPR Approach to Propose Adaptations to an Evidence-Based HIV Prevention Intervention for Adolescents in African American Faith Settings

African American adolescents are at increased risk for HIV/AIDS. Using a community-based participatory research approach, we engaged three black churches in adapting an evidence-based HIV prevention intervention, Focus on Youth (FOY)+ImPACT, for faith settings. To identify potential adaptations to increase FOY's relevance, utility, and efficacy for faith settings, we conducted eight focus groups pre- and post-intervention. Recommendations for maintaining FOY's core elements and enhancing its cultural authenticity include the following: incorporating faith tools, building pastor capacity, strengthening parent-child communication skills, and expanding social support for parents and youth. Engaging faith communities in adapting and implementing evidence-based HIV prevention programs could reduce HIV/AIDS disparities.

Where is the Faith? Using a CBPR Approach to Propose Adaptations to an Evidence-Based HIV Prevention Intervention for Adolescents in African American Faith Settings

Where is the Faith? Using a CBPR Approach to Propose Adaptations to an Evidence-Based HIV Prevention Intervention for Adolescents in African American Faith Settings

Incarceration is associated with used syringe lending among active injection drug users with detectable plasma HIV-1 RNA: a longitudinal analysis

BackgroundInformed by recent studies demonstrating the central role of plasma HIV-1 RNA viral load (VL) on HIV transmission, interventions to employ HIV antiretroviral treatment as prevention (TasP) are underway. To optimize these efforts, evidence is needed to identify factors associated with both non-suppressed VL and HIV risk behaviours. Thus, we sought to assess the possible role played by exposure to correctional facilities on VL non-suppression and used syringe lending among HIV-seropositive people who use injection drugs (PWID).MethodsWe used data from the ACCESS study, a community-recruited prospective cohort. We used longitudinal multivariate mixed-effects analyses to estimate the relationship between incarceration and plasma HIV-1 RNA > 500 copies/mL among antiretroviral therapy (ART)-exposed active PWID and, during periods of non-suppression, the relationship between incarceration and used syringe lending.ResultsBetween May 1996 and March 2012, 657 ART-exposed PWID were recruited. Incarceration was independently associated with higher odds of VL non-suppression (Adjusted Odds Ratio [AOR] = 1.54, 95% Confidence Interval [95% CI]: 1.10, 2.16). In a separate multivariate model restricted to periods of VL non-suppression, incarceration was independently associated with lending used syringes (AOR = 1.81, 95% CI: 1.03, 3.18).ConclusionsThe current findings demonstrate that incarceration is associated with used syringe lending among active PWID with detectable plasma HIV-1 RNA. Our results provide a possible pathway for the commonly observed association between incarceration and increased risk of HIV transmission. Our results suggest that alternatives to incarceration of non-violent PWID and evidence-based combination HIV prevention interventions for PWID within correctional facilities are urgently needed.

Feasibility and acceptability of Project Connect: A couples-based HIV-risk reduction intervention among young couples in Johannesburg, South Africa

Given the importance of couples to the transmission of HIV, interventions focusing on both members of a partnership can play an important role in its prevention. We adapted and pilot-tested Project Connect, an evidence-based HIV prevention intervention for couples, to determine its acceptability and feasibility among a sample of young urban South African couples. We recruited couples from a clinic in inner-city Johannesburg to take part in the study. Interviewer-administered questionnaires were conducted at baseline and postintervention; an in-depth interview (IDI) was also conducted postintervention. Of 75 couples screened, 15 were eligible and enrolled. An important reason for ineligibility was a recent history of intimate partner violence (IPV). Couples attended, on average, five of the seven sessions. Overall, the intervention was acceptable and showed signs of potential efficacy. Couples reported enjoying Connect and feeling comfortable with its content. Participants also reported learning important communication and problem-solving skills, which resulted in more effective engagement in HIV prevention behaviors. However, the number of sessions and strict eligibility criteria proved challenging to the feasibility of the study. We recommend future couples' interventions have fewer sessions and enroll couples with a history of IPV.

The influence of social determinants on sexual risk among out-of-school African American female adolescents

Formative research was conducted to understand the social determinants of HIV risk among African American female adolescents as part of a systematic adaptation of an evidence-based behavioral HIV prevention intervention, the Women’s CoOp. Semi-structured in-depth interviews were conducted between November 2008 and April 2009 with 20 African American female adolescents aged 16–18 who reported engaging in sex, using alcohol or other drugs, and dropping out of school. All interviews were audio recorded, transcribed, and coded for key themes and emergent content patterns. The findings indicate that while female adolescents are knowledgeable about HIV and other sexually transmitted infections (STIs), myriad social factors relate to their level of risk. Interpersonal relationships, primarily with older boyfriends and friends, played a pivotal role in their decision-making regarding sex risk behavior, substance use, and educational attainment. A lack of viable employment opportunities, exacerbated by the lack of a high school education, resulted in some young women trading sex to make money. In addition, violence, victimization, and gang involvement are pervasive in their communities. Out-of-school African American female adolescents face a plethora of issues that are directly and indirectly related to their sex risk behaviors and consequently their HIV/STI risk. To reach a vulnerable population disproportionately affected by HIV and other STIs, these factors must be addressed in prevention interventions, when feasible. The findings were incorporated into the intervention adaptation that is currently being tested in a randomized controlled trial.

Implementation of HIV Prevention Interventions in Resource Limited Settings: The Partner Project

Evidence-based HIV prevention interventions have been translated to a variety of contexts across sub-Saharan Africa. Non-specialized community health center (CHC) staff members have been successfully engaged to deliver the interventions, which can be integrated into pre-existing HIV service programs in community-based health care delivery sites. This manuscript describes the process of implementing the Partner Project, a couples HIV risk reduction intervention, and examines the ability of CHC staff to achieve risk reduction outcomes comparable to those of the highly-trained research staff. The Partner Project was implemented within the HIV Counseling and Testing program in 6 urban community health clinics in Lusaka, Zambia. One hundred ninety-seven HIV-seroconcordant and -discordant couples were sequentially enrolled to the control group or to receive the intervention from partner research or CHC staff members. Couple members completed assessments on condom use, alcohol use, and intimate partner violence (IPV) at baseline, 6, and 12months follow-up. Sexual barrier use outcomes achieved by the CHC staff were comparable to or better than those achieved by the Partner Project research staff, and both were superior to the control group. A reduction in IPV was observed for the entire sample, although no change in alcohol use was observed. Implementation of HIV prevention interventions at the community level should take advantage of existing resources available within the CHC staff. This is especially relevant in resource limited settings as consideration of the financial and clinical requirements of intervention programs is essential to the achievement of successful program implementation.

Cross-Cultural Adaptation of an Adolescent HIV Prevention Program: Social Validation of Social Contexts and Behavior Among Botswana Adolescents

An evidence-based HIV prevention intervention was adapted for Botswana youth with qualitative interviews, input from an adolescent panel, and social validation. Qualitative interviews were conducted with 40 boys and girls ages 13-19. An adolescent panel then drafted scenarios reflecting social situations described in the interviews that posed risk for HIV. A social validation sample (N = 65) then indicated the prevalence and difficulty of each situation. Youth described informational needs, pressures to use alcohol and drugs, peer pressure for unprotected sex, and intergenerational sex initiations as risk-priming situations. From 17% to 57% of the social validation sample had personally experienced the situations drafted by the adolescent panel. There were no differences in the ratings of boys versus girls, but youth over age 16 more often reported that they had experienced these risky situations. The results were embedded into the intervention. Major changes to the intervention resulted from this three-phase process.

Sustained Institutional Effects of an Evidence-based HIV Prevention Intervention

Limited data are available as to what happens in institutions involved in behavioral intervention trials after the trial has ended. Specifically, do the trainers continue to administer the behavioral intervention that had been the focus of the trial? To address this question, we examined data in grade six schools before a year-long behavioral intervention had been delivered in some schools (and a year-long control condition in others) and data obtained again 6 and 7years later in the same two sets of schools. Data were derived from the baseline surveys of two interventions: (1) national implementation of the evidence-based Focus on Youth in the Caribbean (FOYC) intervention in 2011; and (2) the randomized, controlled trial of the FOYC intervention in 2004/2005. Cross-sectional, longitudinal comparisons and random coefficient regression analysis were conducted to evaluate long-term intervention effects. Results indicate that grade six students in 2011 from schools in which the FOYC intervention had been implemented in 2004/2005 had a higher level of HIV/AIDS knowledge, increased reproductive health skills, increased self-efficacy regarding their ability to prevent HIV infection, and greater intention to use protection if they were to have sex compared to their counterparts from schools where no such training took place. We concluded that new cohorts of students benefited from the extensive training and/or experience in teaching the FOYC curriculum received by teachers, guidance counselors and administrators in schools which had delivered the FOYC intervention as part of a randomized trial several years earlier. The findings suggest that teachers who previously were trained to deliver the FOYC intervention may continue to teach at least some portions of the curriculum to subsequent classes of students attending these schools.