HIV Behavioral Interventions Research Articles

Adaptation and pilot testing of an HIV Behavioral Intervention- Chicos Net (CN) for Gay Latino Men (GLM)

Chicos Net (CN) is a globally oriented research program aimed at preventing HIV transmission, initially developed for Latino MSM (men who have sex with other men) in Toronto, Canada. Later, it was modified to fit the cultural preferences of gay men living in Cali, Colombia. The study aimed to reduce the incidence of HIV infection in these communities. The intervention consisted of four sessions, 12 hours, following a prearranged manual. CN covers a range of subjects, such as deepening knowledge about HIV, investigating the impacts of homophobia, studying migration experiences on international (Canada) and local (Cali, Colombia) rural-to-urban scales, exploring dating, analyzing the repercussions of social isolation, and navigating LGBT environments. The intervention consisted of administering a questionnaire before and after and doing a pre-post t-test. The results demonstrate positive effects in terms of social support and efficacy in negotiating condom use.

Factors associated with voluntary HIV counseling and testing among young students engaging in casual sexual activity: a cross-sectional study from Eastern China

Factors associated with voluntary HIV counseling and testing among young students engaging in casual sexual activity: a cross-sectional study from Eastern China

The Evidence Project: Protocol for Systematic Reviews of Behavioral Interventions and Behavioral Aspects of Biomedical Interventions for HIV Prevention, Treatment, and Health Service Delivery in Low- and Middle-Income Countries.

The Evidence Project conducts systematic reviews and meta-analyses of HIV behavioral interventions, behavioral aspects of biomedical interventions, combination prevention strategies, modes of service delivery, and integrated programs in low- and middle-income countries. Here, we present the overall protocol for our reviews. For each topic, we conduct a comprehensive search of five online databases, complemented by secondary reference searching. Articles are included if they are published in peer-reviewed journals and present pre/post or multi-arm data on outcomes of interest. Data are extracted from each included article by two trained coders working independently using standardized coding forms, with differences resolved by consensus. Risk of bias is assessed with the Evidence Project tool. Data are synthesized descriptively, and meta-analysis is conducted when there are similarly measured outcomes across studies. For over 20 years, this approach has allowed us to synthesize literature on the effectiveness of interventions and contribute to the global HIV response.

Childhood Sexual Abuse Moderates the Long-Term Effect of an HIV Prevention Intervention Among Men Who Have Sex With Men With Crystal Methamphetamine Use Disorder

Men who have sex with men (MSM) with a history of childhood sexual abuse (CSA) are more likely to report crystal methamphetamine use and condomless anal intercourse (CAI) than MSM without CSA. MSM with CSA may benefit less in HIV prevention interventions due to long-term psychological effects. Data are from a pilot randomized, controlled trial testing an integrated HIV risk reduction and behavioral activation counseling intervention vs standard of care among MSM with methamphetamine use disorder, which showed effects at reducing CAI. We conducted a secondary analysis (N= 38) to preliminarily assess whether CSA moderated the intervention effects on the two primary outcomes: CAI acts with men whose HIV serostatus was either positive or unknown (1) overall (CAI overall) and (2) while under the influence of methamphetamine (CAI with methamphetamine). At the immediate postintervention assessment, the interaction term between CSA and intervention arm was not statistically significant for either outcome, indicating no moderation effect. However, at the 3-month postintervention assessment, the interaction term was significant for both outcomes. At this time point, for those without CSA, there was a significantly lower number of CAI acts in the intervention condition vs the comparison condition for both outcomes. For those with CSA, however, there was no significant difference between the intervention and comparison conditions for CAI overall, although for the outcome CAI with methamphetamine, the intervention condition had higher levels. Future HIV prevention interventions among MSM with methamphetamine use disorder should consider screening for CSA and addressing CSA-related psychological distress, which may potentially preserve intervention effects.

Intervention Adaptation and Implementation Method for Real-World Constraints and Using New Technologies.

Rigorous adaptation methods are needed to revise existing evidence-based behavioral interventions for implementation for new target populations, revised/updated outcomes, new delivery modalities, recent advances, and new technologies. We describe an adaptation method designed to overcome the real-world challenges of having very limited existing expertise, resources, and time. This adaptation method and accompanying visualization tool ("Deconstruction/Reconstruction Matrix") preserves theoretical mechanisms of behavior change, accounts for challenges in utilizing new technologies, and strengthens clinical processes, with an emphasis on safety. The adaptation of an in-person HIV behavioral intervention for sexual and gender diverse men in Kazakhstan to one delivered remotely via telecommunication and social media technologies exemplifies the process and strengths of the method, concomitantly resulting in recommendations for adaptation and implementation of mobile health (mHealth) and digital health interventions. This method allows researchers and clinicians to adapt interventions rapidly and rigorously and to benefit from new technologies.

Recent Incarceration and Other Correlates of Psychological Distress Among African American and Latino Men Who Have Sex with Men.

There is a dearth of research on the intersection of incarceration and psychological distress among men who have sex with men including African American (AAMSM) and Latino MSM (LMSM), populations which bear a large burden of HIV in the U.S. Recent incarceration is an important context to examine psychological distress given the critical implications it has on health outcomes. Using baseline data from the Latino and African American Men's Project (LAAMP), a multi-site randomized HIV behavioral intervention trial, this paper examined the association between previous incarceration within the past three months (i.e., recent incarceration) and psychological distress in the past four weeks, assessed by the Kessler Psychological Distress Scale (K10). Among 1482 AAMSM and LMSM (AAMSM: 911, LMSM: 571), we found 768 (52%) were previously incarcerated, but not in past three months and 138 (9.3%) had been recently incarcerated. After adjusting for race, education, access to resources, current living arrangement, HIV status, and substance use, participants who had been recently incarcerated were more likely to have mild psychological distress i.e., K10 score 20-24 (aRRR:1.43, 95% CI 1.20, 1.71) or severe psychological distress, i.e., K10 score > 30 (aRRR: 1.89, 95% CI 1.22, 2.93) in the past four weeks than those never incarcerated and those previously incarcerated, but not in past three months. Our findings have implications for mental health and HIV prevention services for AAMSM and LMSM with previous incarceration within the past three months.

Inter-partner Agreement of Condom Use and Sexual Positioning in Male Couples

ABSTRACT Accurate, reliable self-reports of sexual behavior are a crucial component of valid HIV risk-estimation and behavioral intervention evaluation, yet this data’s reliability remains understudied. The goal of this study was to describe interpartner agreement on recent receptive anal intercourse (AI) and condomless receptive AI frequencies, among a sample of male couples. We quantified interpartner agreement on self-reported receptive AI and condomless receptive AI (absolute and relative to AI frequency), and position and condom use during a couple’s most recent AI, using cross-sectional data from male partners (US, 2016–2017; N = 718 individuals). Proportional and statistical agreement (intraclass correlation coefficients (ICC), kappa (k)) were assessed. Observed agreement for receptive AI frequency was 49.44% (ICC (95% CI): 0.82(0.79, 0.84)) and for relative receptive frequency, 59.05% (ICC: 0.96 (0.85, 0.96). Agreement on condomless receptive AI was 90.21% (ICC: 0.78 (0.75, 0.82), and for relative condomless receptive AI, 91.15% (ICC: 0.80 (0.77, 0.83). Most recent AI position agreement was 89.42% (k (95% CI): 0.84 (0.80, 0.88)), and condom use, 98.89% (k: 0.82 (0.87, 0.98)). Observed agreement was higher among those who reported consistent positioning and condom use. Further research on self-reported sexual behavior data is needed to improve research validity and intervention effectiveness.

A State of the Science on HIV Prevention Over 40 Years Among Black and Hispanic/Latinx Communities.

We present a state of the science on HIV behavioral prevention interventions in Black and Hispanic/Latinx communities. The purpose of this article is threefold: (a) highlight the early documented underlying social and political barriers that constrained interventions to prevent new HIV infections; (b) address the structural inequities in HIV prevention and treatment; and (c) describe the need for increasing HIV multilevel prevention interventions that support greater HIV testing and pre-exposure prophylaxis uptake. To address HIV prevention, multilevel interventions that address individual, structural, and social level components have demonstrated more sustainable outcomes. Implications for research and clinical practice include (a) updating antiquated curricula in nursing, medicine, and public health that perpetuate racial, structural-level inequities and (b) increasing the pipeline for Black and Hispanic/Latinx persons to pursue research or clinical-focused doctorate degrees.

Mobile Phone Intervention Based on an HIV Risk Prediction Tool for HIV Prevention Among Men Who Have Sex With Men in China: Randomized Controlled Trial

BackgroundeHealth interventions based on risk stratification have not been extensively applied for HIV behavioral interventions among HIV-negative men who have sex with men (MSM).ObjectiveThis study aimed to evaluate the efficacy of a mobile phone intervention based on an HIV risk prediction tool in promoting HIV testing and reducing high-risk behavior among HIV-negative MSM in China.MethodsWe performed a mobile phone–based randomized controlled clinical trial for 12 weeks. A comprehensive intervention package deployed on Jinshuju—an online survey platform—was developed and consisted of 4 components: (1) a validated HIV risk prediction tool that provides information on personalized risk reduction interventions; (2) a map of individualized HIV testing facilities based on their geographic location; (3) a QR code for free resources on HIV prevention, including condoms and HIV self-testing kits; and (4) general resources for HIV health education. MSM participants recruited from WeChat/QQ groups were randomly assigned to the intervention or control group at a 1:1 ratio. The staff sent the QR code for the comprehensive intervention package to MSM in the intervention group over WeChat and sent the QR code only for the resources on HIV health education to those in the control group. At baseline and 12-week follow-up, data on HIV-related risk behavior and HIV testing behavior were collected through the Jinshuju online survey platform.ResultsIn total, 192 MSM were recruited and assigned to the intervention or control group (n=96 each). At week 12, the total clinical trial retention rate was 87.5%. The number of male sexual partners of the MSM in the past 3 months was significantly lower in the intervention group than in the control group (3.51, SD 4.1 vs 6.01, SD 11.4, respectively; mean difference −2.5; 95% CI −5.12 to 0.12; P=.05); the rate of condom use with casual sexual partners was higher in the intervention group than in the control group (87%, n=66/76 vs 70%, n=54/77 respectively; odds ratio 2.81, 95% CI 1.23-6.39; P=.01). The proportion of individuals intending to undergo HIV testing after in the following 30 days was marginally higher in the intervention group than in the control group (90%, n=77/86 vs 79%, n=65/82 respectively; odds ratio 2.20, 95% CI 0.90-5.35; P=.07). The incremental cost-effectiveness ratio of eHealth intervention was US $131.60 on reducing 1 sexual partner and US $19.70 for a 1% increment in condom usage with casual partners.ConclusionsA comprehensive intervention based on an HIV risk prediction tool can reduce the number of male sexual partners among MSM and increase the rate of condom use with casual partners. Hence, this intervention is a very promising preventive strategy for HIV among MSM, especially in areas with a prominent HIV epidemic.Trial RegistrationChinese Clinical Trial Registry ChiCTR1800017268; http://www.chictr.org.cn/showprojen.aspx?proj=29271

Prevalence and correlates of HIV infection among cross-border families in Dehong Dai and Jingpo Autonomous Prefecture

Objective: To study the prevalence and correlations of HIV infection among cross-border couples in the Dehong prefecture. Methods: A cross-sectional mass screening study with questionnaire interview and HIV testing was conducted among 17 594 registered cross-border couples from May 2017 through June 2018. Results: Among 32 400 participants, the overall prevalence of HIV infection was 2.27% (736/32 400), 2.44% (375/15 372) for Chinese citizens, and 2.12% (361/17 028) for foreign spouses. Among all the 13 853 couples with both spouses receiving HIV testing, 13 415(96.84%) were seroconcordant-negative couples, 142(1.03%) were serocondordant-positive couples, and 296(2.13%) were serodiscordant couples, including 167(1.20%) couples with positive husband and negative wife and 129(0.93%) couples with positive wife and negative husband. Multiple logistic regression analyses indicated that HIV infection was associated with drug use and risky sexual behaviors for male spouses. In contrast, HIV infection was associated with risky sexual behaviors for female spouses. Conclusion: The prevalence of HIV among cross-border couples in Dehong prefecture is high, underscoring the urgent need to scale up HIV testing, prevention, and behavioral intervention.

Challenges of and Solutions for Developing Tailored Video Interventions That Integrate Multiple Digital Assets to Promote Engagement and Improve Health Outcomes: Tutorial.

BackgroundVideo is a versatile and popular medium for digital health interventions. As mobile device and app technology advances, it is likely that video-based interventions will become increasingly common. Although clinic waiting rooms are complex and busy environments, they offer the opportunity to facilitate engagement with video-based digital interventions as patients wait to see their providers. However, to increase efficiency in public health, leverage the scalability and low cost of implementing digital interventions, and keep up with rapidly advancing technology and user needs, more design and development guidance is needed for video-based tailored interventions.ObjectiveWe provide a tutorial for digital intervention researchers and developers to efficiently design and develop video-based tailored digital health interventions. We describe the challenges and solutions encountered with Positive Health Check (PHC), a hybrid app used to deliver a brief, interactive, individually tailored video-based HIV behavioral counseling intervention. PHC uses video clips and multimedia digital assets to deliver intervention content, including interactive tailored messages and graphics, a repurposed animated video, and patient and provider handouts generated in real time by PHC.MethodsWe chronicle multiple challenges and solutions for the following: (1) using video as a medium to enhance user engagement, (2) navigating the complexity of linking a database of video clips with other digital assets, and (3) identifying the main steps involved in building an app that will seamlessly deliver to users individually tailored messages, graphics, and handouts.ResultsWe leveraged video to enhance user engagement by featuring “video doctors,” full-screen video, storyboards, and streamlined scripts. We developed an approach to link the database of video clips with other digital assets through script coding and flow diagrams of algorithms to deliver a tailored user experience. We identified the steps to app development by using keyframes to design the integration of video and digital assets, using agile development methods to gather iterative feedback from multidisciplinary teams, and creating an intelligent data-driven back-end solution to tailor message delivery to individual users.ConclusionsVideo-based digital health interventions will continue to play an important role in the future of HIV prevention and treatment, as well as other clinical health practices. However, facilitating the adoption of an HIV video intervention in HIV clinical settings is a work in progress. Our experience in designing and developing PHC presented unique challenges due to the extensive use of a large database of videos tailored individually to each user. Although PHC focuses on promoting the health and well-being of persons with HIV, the challenges and solutions presented in this tutorial are transferable to the design and development of video-based digital health interventions focused on other areas of health.

Evaluating spillover of HIV knowledge from study participants to their network members in a stepped-wedge behavioural intervention in Tanzania

ObjectivesWe aim to describe the social network members of participants of a behavioural intervention, and examine how the effects of the intervention may spillover among network members.DesignSecondary analysis of a...

Feasibility of Assessing Economic and Sexual Risk Behaviors Using Text Message Surveys in African-American Young Adults Experiencing Homelessness and Unemployment: Single-Group Study.

BackgroundText messages offer the potential to better evaluate HIV behavioral interventions using repeated longitudinal measures at a lower cost and research burden. However, they have been underused in US minority settings.ObjectiveThis study aims to examine the feasibility of assessing economic and sexual risk behaviors using text message surveys.MethodsWe conducted a single-group study with 17 African-American young adults, aged 18-24 years, who were economically disadvantaged and reported prior unprotected sex. Participants received a text message survey once each week for 5 weeks. The survey contained 14 questions with yes-no and numeric responses on sexual risk behaviors (ie, condomless sex, sex while high or drunk, and sex exchange) and economic behaviors (ie, income, employment, and money spent on HIV services or products). Feasibility measures were the number of participants who responded to the survey in a given week, the number of questions to which a participant responded in each survey, and the number of hours spent from sending a survey to participants to receiving their response in a given week. One discussion group was used to obtain feedback.ResultsOverall, 65% (n=11/17) of the participants responded to at least one text message survey compared with 35% (n=6/17) of the participants who did not respond. The majority (n=7/11, 64%) of the responders were women. The majority (n=4/6, 67%) of nonresponders were men. An average of 7.6 participants (69%) responded in a given week. Response rates among ever responders ranged from 64% to 82% across the study period. The mean number of questions answered each week was 12.6 (SD 2.7; 90% of all questions), ranging from 72% to 100%. An average of 6.4 participants (84%) answered all 14 text message questions in a given week, ranging from 57% to 100%. Participants responded approximately 8.7 hours (SD 10.3) after receiving the survey. Participants were more likely to answer questions related to employment, condomless sex, and discussions with sex partners. Nonresponse or skip was more often used for questions at the end of the survey relating to sex exchange and money spent on HIV prevention services or products. Strengths of the text message survey were convenience, readability, short completion time, having repeated measures over time, and having incentives.ConclusionsLongitudinal text message surveys may be a valuable tool for assessing HIV-related economic and sexual risk behaviors.Trial RegistrationClinicalTrials.gov NCT03237871; https://clinicaltrials.gov/ct2/show/NCT03237871

Recent Partner Violence, Sexual Relationship Power, and STIs among Women Who Use Methamphetamine: Does Type of Sexual Partner Matter?

Methamphetamine use, sexual relationship power (SRP), and partner violence (PV) are associated with increased risk of sexually transmitted infections (STIs) among women. The objective of our study was to examine the association of recent PV and SRP on STIs by partner type among HIV-negative, heterosexual women who use methamphetamine in San Diego, CA. Using baseline survey data from 209 women enrolled in FASTLANE II, an HIV behavioral intervention trial, we conducted logistic regression analyses to examine associations between PV, SRP, and self-reported lifetime STIs (e.g., chlamydia, gonorrhea). Models focused on PV perpetrated within the past 2months by: (1) spouse, live-in, or steady sexual partners and (2) casual or anonymous sexual partners. Seventy-eight percent of women reported lifetime physical PV and 57% reported lifetime sexual PV. In the past 2months, 19.6% reported physical and/or sexual violence by a spouse, live-in, or steady sexual partner, and 7.2% reported physical and/or sexual PV by a casual or anonymous partner. Median SRP score was 2.36 (interquartile range: 2.02-2.68). Twenty-six percent of women reported ever being diagnosed with ≥ 1 STI. While recent physical violence and sexual violence were not associated with STI history among women in steady relationships, women who reported recent sexual violence by casual/anonymous partners were approximately 8 times more likely to ever have an STI compared with those with no history of recent PV by casual/anonymous partners (AOR: 7.70; 95% CI: 1.32, 44.84). SRP was not associated with lifetime STIs among women who reported either partner type. Our findings support a relationship between recent sexual violence perpetrated by casual/anonymous partners and women's STI history. Women who use methamphetamine need help in navigating partner violence experiences. Risk reduction interventions to support this marginalized population are needed.

The Mechanism of Theory-based HIV Behavioral Intervention on Condom Use among Rural-to-urban Migrants in China: The Mediating Roles of HIV Knowledge and Condom Use Self-efficacy

Previous studies have suggested HIV knowledge and self-efficacy are important cognitive factors that might influence condom use behaviors. However, data were limited regarding their mediating effects on condom use during behavioral interventions. This study examined the mechanistic roles of these two factors on the effect of a community-based intervention aiming to increase condom use behaviors and intention among young rural-to-urban migrants in China. Data were derived from a community-based HIV behavioral intervention trial among 639 young sexually active rural-to-urban migrants in Beijing, China. Path analyses were used to examine the direct and indirect effects of the intervention program on condom use behaviors and intention over a 12-month follow-up. HIV knowledge and condom use self-efficacy at 6-month follow-up served as mediators in models. Path analyses revealed that intervention program increased condom use behaviors at 12 months through the increase of HIV knowledge at 6 months. Likewise, the intervention program increased condom use intention through the increases of HIV knowledge and condom use self-efficacy. The results suggested HIV knowledge played an important mediating role on the effect of the intervention program on condom use behaviors and intention. Additionally, condom use self-efficacy played an important role in increasing condom use intention. To increase condom use behaviors and intention among migrants, future studies are warranted that focus on improving HIV knowledge and helping migrants overcome cognitive barriers of condom use. Other efforts targeting structural and environmental barriers, such as limited healthcare access due to household registration status, are also needed to increase HIV protective behaviors.

When is Enough, Enough? How the Absence of Dose-Determination Trials Impedes Implementation of HIV Behavioral Interventions

Carefully controlled clinical trials have determined that theory-based behavioral interventions delivered by adherence nurses, professional and paraprofessional counselors, and case managers improve ART adherence and viral suppression. However, there are no studies that empirically inform how much intervention is needed for which patient populations and at what cost. This Editorial raises the issue of how a lack of intervention dosing limits interpretation of trial results and impedes implementation, therefore calling for behavioral intervention dose-finding studies.

Factors associated with obtaining sterile syringes from pharmacies among persons who inject drugs in 20 US cities

BackgroundIncreased access to sterile syringes has been shown to reduce HIV risk among people who inject drugs (PWID). Where syringe services programs (SSPs) are limited, pharmacies are an important sterile syringe source. We assessed factors associated with using pharmacies as the primary source of syringes among PWID from 20 US cities. MethodsPWID ages ≥18 years were recruited for the 2015 National HIV Behavioral Surveillance using respondent-driven sampling. Using generalized estimating equation (GEE) models, we assessed demographic characteristics independently associated with participant-reported primary syringe source: pharmacies vs. SSPs. We calculated associations between primary syringe source and various behavioural outcomes, adjusted for participant characteristics. ResultsPWID who were <30 years old, female, white, and less frequent injectors were more likely have used pharmacies as their primary syringe source. Accessing syringes primarily from pharmacies, as compared to SSPs, was associated with receptive syringe sharing and unsafe syringe disposal; using sterile syringes, recent HIV testing and participation in an HIV behavioural intervention were negatively associated with primary pharmacy use. ConclusionsPharmacies can play an important role in comprehensive HIV prevention among PWID. Linkage to HIV interventions and syringe disposal services at pharmacies could strengthen prevention efforts for PWID who cannot access or choose not to utilize SSPs.

A randomized controlled efficacy trial of behavioral activation for concurrent stimulant use and sexual risk for HIV acquisition among MSM: project IMPACT study protocol

BackgroundIn the United States, problematic stimulant use is a prevalent and difficult to treat problem among men who have sex with men (MSM), as well as a major driver of HIV transmission through the large number of sexual partners and concomitant condomless anal sex (CAS). Evidence-based behavioral studies that address problematic stimulant use in MSM at risk for HIV infection are also lacking. In this paper, we describe the design of a behavioral intervention trial to reduce sexual risk behavior and stimulant use in HIV-uninfected MSM.MethodsThis study, funded by the National Institute on Drug Abuse (NIDA), is a randomized controlled trial (RCT) testing an integrated HIV risk reduction and behavioral activation counseling intervention (IMPACT) for HIV-uninfected, stimulant using MSM in Boston, MA, and Miami, FL. Participants are randomized (2:2:1) to either (1) the IMPACT intervention; (2) a relaxation condition, an active therapy time- and intensity-matched control; or (3) a standard of care risk reduction counseling comparison. At enrollment, all participants receive an HIV test and pre- and post-test counseling. The primary outcome is the difference in the rate of change in the number of self-reported condomless anal sex acts without the protection of consistent Pre-Exposure Prophylaxis (PrEP) use, as well as reductions in stimulant use during the prior 4-months. Major assessments are conducted at baseline, 4-, 8-, and 12-month follow-up visits.DiscussionEffective and sustainable behavioral interventions are sorely needed to reduce HIV acquisition in stimulant using MSM at risk for HIV infection. In this study, we will evaluate the evidence of efficacy of the IMPACT intervention to reduce HIV acquisition in HIV-uninfected, stimulant-using MSM. If found effective, the intervention tested here holds promise for being readily integrated into real-world clinical settings.Trial registrationClinicalTrials.gov number NCT03175159, registered June 5, 2017.

Adolescent female school dropouts who use drugs and engage in risky sex: effects of a brief pilot intervention in Cape Town, South Africa

ABSTRACTFemale adolescents from socioeconomically underserved communities in Cape Town, South Africa, who have dropped out of school, use substances, and engage in risky sex behaviour are at risk of HIV. Tailored gender-focused HIV behavioural interventions for this key population are needed to mitigate these risk factors. A pilot trial of a woman-focused risk-reduction intervention for adolescents was conducted (N = 100), with a one-month follow-up appointment. Participants in the intervention group attended two group workshops. Data were examined for significant differences within and between the groups. At baseline, 94% of participants tested positive for cannabis, 17% were HIV-positive and 11% were pregnant. Ninety-two participants returned for 1-month follow-up. At follow-up, the proportion who tested positive for cannabis use decreased significantly in both the intervention (p = 0.07) and control groups (p = 0.04). Impaired sex with any partner (p = 0.02), or with main partner (p = 0.06) decreased among the intervention group. Impaired sex with a main partner was less likely in the intervention group (p = 0.07) in the regression model. In conclusion, findings indicate a need for HIV prevention interventions among out-of-school female adolescents. Intervention acceptability was high, and there were some decreases in sexual risk behaviour among intervention participants which is promising. Future intervention research with this key population involving larger sample sizes and longer follow-up periods will help to determine intervention efficacy.Trial registration: Uniform Trial Number identifier: NCT02677025.

Policy Interventions Shaping HIV Prevention: Providers' Active Role in the HIV Continuum of Care.

The U.S. Centers for Disease Control and Prevention (CDC) Diffusion of Effective Behavioral Interventions project has disseminated HIV behavioral interventions (EBIs) across the United States since the 1990s. In 2011, the CDC launched the High-Impact HIV Prevention (HIP) project, providing EBIs plus high-impact services (HIV testing, primary care, and support services). Providers (nurses, social workers, educators) are unable to consistently make linkages; thus, numerous at-risk individuals are not benefitting from HIP. Research on providers' roles in the HIV Continuum of Care-linking clients to HIV testing, primary care, and support services-is lacking. This article helps fill this gap with evidence that providers exposed to EBIs, whose agencies offer EBIs, more frequently link clients to high-impact services. This is based on diffusion of innovations theory, where individuals in social networks influence one another's adoption of innovations. We hypothesize that providers are exposed to EBIs via training, reading and hearing about EBIs, and/or discussing EBIs with colleagues. We used cross-sectional data from 379 providers from 36 agencies in New York City. We used multilevel ordinal logistic regression models to test associations between provider exposure to EBIs (agency provides EBIs) and frequency of linkages to high-impact services. Providers exposed to greater numbers of EBIs more frequently link clients to HIV, hepatitis C (HEP-C), and sexually transmitted infections testing; to primary care; and to drug treatment and mental health services. Providers link clients most frequently to primary care and HIV testing and least frequently to HEP-C testing and syringe exchange. Findings suggest a dose effect, with exposure to more EBIs resulting in more linkages. Findings show a staged, evidence-based prevention approach that includes exposure to EBIs, leading to providers linking clients to high-impact services. There needs to be emphasis on inspiring providers to engage with high-impact services at the elevated levels needed to end the epidemic.