mental health AIDS

Spring 2006 Newsletter / Volume 7, Issue 3

The Latest Last Word on HIV Prevention Interventions

As readers of the Summer 2005 issue of mental health AIDS may recall, Carballo-Diéguez et al. (2005) conducted a randomized controlled trial involving 180 Latino men who have sex with men (MSM) in New York City. The men were assigned to either an eight-session empowerment intervention tailored to the target population and designed to reduce unprotected anal intercourse (UAI), or a wait-list control group. Participants were assessed at baseline and again at 2, 8, and 14 months after completing the intervention.

“In the course of this longitudinal study," according to Carballo-Diéguez and colleagues, "about a third of a group of Latino MSM who had twice acknowledged having had recent UAI reported no longer engaging in this risky practice at two different assessment occasions. Furthermore, a larger group – about half of the participants – reported going through at least two-month periods in which they had no UAI. However, the changes cannot be attributed to the intervention, since both intervention and control groups modified their behavior to a similar extent” (italics added; p. 325).

Results like these beg the following question: What changes in the use of male condoms can be attributed to an HIV prevention intervention?

The Most Comprehensive Analysis to Date

Albarracín et al. (2005) conducted a meta-analysis of outcomes and mediating mechanisms reported in 17 years' worth of studies involving strategies designed to increase the use of male condoms. This review synthesized findings from 194 research reports published between 1985 and September 2003, encompassing 354 independent HIV prevention intervention groups and 99 independent control groups. The purpose of this meta-analysis was "to test general … premises [incorporated into theoretical models of health behavior change], identify the mediators of effective interventions, and consider the applicability of interventions to populations that vary in demographic and behavioral variables that correlate with marginalization and risk for HIV" (p. 856).

Two Main Conclusions

Albarracín and colleagues identify and later expand upon the two main conclusions that might be drawn from this extensive review. "First, the most effective interventions were those that contained attitudinal arguments, educational information, behavioral skills arguments, and behavioral skills training, whereas the least effective ones were those that attempted to induce fear of HIV. [ 1] Second, the impact of the interventions and the different strategies behind them was contingent on the gender, age, ethnicity, risk group, and past condom use of the target audience ..." (p. 856).

Elements of Effective Interventions

The investigators suggest that the first set of findings have

implications for the way in which intervention content is selected and interventions are framed. To begin with, ... [these] results suggest that HIV practitioners aiming to motivate audiences to increase condom use are more likely to succeed if they avoid aversion- or fear-inducing approaches. ... Further, ... [these] findings permit conclusions about what interventionists should do. Because active interventions are generally more effective, they should be preferred to passive ones. [ 2] If one can implement only a passive intervention, it makes sense to select attitudinal and behavioral skills arguments and also to distribute condoms to the audience. If, however, one is in a position to deliver an active intervention, the presentation of information and behavioral skills arguments in combination with self-management training or HIV counseling and testing seems advisable. [ 3] (p. 882)

Additional Guidance for Framing Interventions

With regard to the second set of findings, Albarracín and colleagues offer additional guidance for the framing of HIV prevention efforts (see Table 1). On the impact of gender on the effectiveness of intervention strategies,

[w]ith the exception of condom provision, which was effective for both males and females, all strategies had different impact for males than for females ... . For example, even when self-management skills training and HIV counseling and testing were effective across genders, these effects were all stronger for females than for males. Further, whereas attitudinal arguments and information were linked to increased condom use among females alone, behavioral skills arguments and training in condom use skills were linked to increased condom use among males alone. Thus, although these findings point to numerous strategies that can be effective for women (e.g., self-management skills training), they suggest that men are the ones who most benefit from condom use skills training approaches. (p. 884)

As for the age of study participants,

[b]ehavioral skills arguments and HIV counseling and testing were associated with increased condom use only among populations with an average age over 21 years. Further, even when self-management skills training was effective regardless of age, the effect was stronger when the audience averaged over 21 years. However, people under 21 were positively influenced by normative arguments that others support condom use. This finding is ... the only instance in which ... [the investigators] found a favorable effect of the use of this type of argument. (p. 884)

With regard to race and ethnicity, "findings suggest that samples with a greater number of people with African backgrounds show more behavior change in general and that this change is attributable to behavioral skills arguments, self-management strategies, and HIV counseling and testing. However, condom provision appears more effective for populations from European backgrounds ..." (p. 885).

When studies involved groups of individuals at high risk for HIV infection, "distributing condoms was more effective when the sample included groups possessing a variety of behavioral risk factors. Providing condoms to participants was effective only when samples included [MSM], ... [injecting] drug users [IDUs], partners of ... [IDUs], and multiple-partner heterosexuals" (p. 885).

The analysis of study findings specific to these subpopulations offered the following insights:

o "Leaving condom provision aside, samples including [MSM] changed more in response to interventions than other samples ... . However, this group was generally insensitive to the type of intervention strategy that was used, with the exception of greater behavior change in response to condom provision and lesser change in response to attitudinal arguments ..." (p. 885).

o "[A]ttitudinal and behavioral skills arguments work as well when the groups contain … [IDUs] as when they do not, and … condom use skills training, in addition to condom provision, should be [a] strateg[y] … of choice for this population" (p. 885).

o "[I]nterpersonal skills training was associated with successful increases in condom use only when the sample included partners of ... [IDUs]. Because of the predominantly female composition of this sample, this result may not be surprising. After all, interpersonal skills training has been advocated for situations in which using a condom depends on obtaining the agreement of the sexual partner ... . In this regard, female partners of ... [IDUs] probably constitute the single population in which sexual assertiveness is essential to avoid HIV. ... [T]his group also presented increases in condom use when attitudinal arguments were presented. ... [B]ehavioral skills arguments had similar effects when conditions included this group and when they did not" (pp. 885-886).

o With regard to heterosexuals with multiple partners, "[i]n addition to increasing condom use with condom availability, this group manifested behavior change when attitudinal arguments and condom use skills training were provided" (p. 886)

o "... [B]ehavioral skills arguments and self-management skills training were associated with most beneficial effects among higher condom users, even when these effects were also present among low condom users. In addition, ... information, attitudinal arguments, and HIV counseling and testing were associated with favorable effects across the board. Thus, continued efforts to increase testing appear justified, not only for HIV treatment purposes but also for its influence on behavior change" (p. 886).

Designing Population-Specific Interventions

Taken together, these findings can assist clinicians in designing interventions for specific populations.

For example, ... this synthesis supports peer-oriented approaches for adolescents and children but discourages the application of normative arguments for all other groups. As another example, practitioners may strive to make condoms available to groups that reap high benefits from the mere provision of condoms. Thus, funding for HIV prevention among [MSM], ... [IDUs], female partners of ... [IDUs], and multiple-partner heterosexuals must go beyond dispersing two or three condoms at a time to ensuring a continued supply of condoms when individuals leave the intervention setting.

Similarly, the selection of active strategies should be contingent on the characteristics of the target audience ... . Possibly because most men are still in charge of buying, keeping, and applying condoms, men tend to benefit from the condom use skills training to a greater extent than women. Given this fact, practitioners may wish to implement strategies to increase women’s responsibility over condom use (e.g., popularization of the female condom) before expanding programs to teach condom use skills to women. Further, although men and women both benefit from receiving condoms, not all age and ethnic groups do. Specifically, condom provision is influential only for recipients under 21 and for people from European backgrounds. Thus, even when research has yet to uncover the mediating mechanisms driving these differences, this meta-analysis supports consistent decisions whenever possible. (pp. 886-887)

Albarracín and colleagues expect that these recommendations "will be updated as the HIV intervention literature grows in size and allows researchers to understand higher order interactions among different demographic and behavioral risk variables. However, the present results may increase the flexibility of practitioners who want to effectively target specific populations and previously had only general recommendations about how to structure a preventive program" ( p. 887; see also sidebar on "Prevention Interventions Targeting People Living With HIV ").

The Role of Setting & Modality

Finally, the influence of intervention setting and modality was also considered within this meta-analysis.

Perhaps the most important contribution with respect to methods is the finding that the intervention setup moderates the effectiveness of particular intervention strategies. ... First, when interventions are delivered in clinical settings, information, behavioral skills arguments, condom provision, self-management strategies, and HIV counseling and testing seem optimal. Second, when interventions are introduced in schools ..., normative arguments and condom use skills training work particularly well, whereas behavioral skills arguments are substandard relative to nonschool settings. Third, the only effective community interventions in ... [this] meta-analysis were the ones implementing HIV counseling and testing, even when this strategy was still less effective in community than in noncommunity settings.

With respect to the use of audiovisual media and group sessions, using media was linked to an increased impact of attitudinal and behavioral skills arguments but to decreased effects of information and self-management skills training, which seem more effective when more time is spent in a personal interaction with the intervention facilitator. Moreover, even though behavioral skills arguments and condom use skills training were more effective when the intervention entailed individual sessions with the recipients, the inclusion of group sessions improved effectiveness when interventions included attitudinal arguments, information, self-management skills training, and HIV counseling and testing. (pp. 887-888)

Limitations to These Findings

In closing, the investigators acknowledge several limitations to their meta-analysis (see also sidebar on "The Last Word ?" ). "These limitations concern the correlational nature of the results, the validity of condom use reports, the impossibility of analyzing more complex interactions, the selection of behavioral measures, and the generalizability of the current conclusions to the sample of studies and to the population of potential studies on the topic" (p. 888). With regard to the last of these limitations, couched in " discrepancies between … fixed- and random-effects findings" (p. 889) encountered when the data were analyzed using each of these models, Albarracín and colleagues cite the breadth of their analysis ("the most comprehensive to date" [p. 857]) in reasoning that "[t]he current findings from the present meta-analysis are probably the most generalizable to date" (p. 889).

References

Albarracín, D., Gillette, J.C., Earl, A.N., Glasman, L.R., Durantini, M.R., & Ho, M.-H. (2005). A test of major assumptions about behavior change: A comprehensive look at the effects of passive and active HIV-prevention interventions since the beginning of the epidemic. Psychological Bulletin, 131(6), 856-897.

Carballo-Diéguez, A., Dolezal, C., Leu, C.-S., Nieves, L., Díaz, F., Decena, C., & Balan, I. (2005). A randomized controlled trial to test an HIV-prevention intervention for Latino gay and bisexual men: Lessons learned. AIDS Care, 17(3), 314-328.

__________

1 Intervention strategies may include: "(a) attitudinal arguments, such as discussions of the positive implications of using condoms for the health of the partners and for the romantic relationship; (b) normative arguments about support of condom use provided by friends, family members, or partners; (c) factual information (i.e., mechanisms of HIV, HIV transmission, and HIV prevention); (d) arguments designed to model behavioral skills (what to do when partners do not want to use a condom, when recipients or their partners are sexually excited, and when alcohol or drugs are involved); and (e) threat-inducing arguments, such as discussions about the recipients’ personal risk of contracting HIV or other ... [STDs]" (p. 860).

2 "Passive interventions are characterized by the presentation of material to an audience that has minimal participation; they comprise (a) messages to induce procondom attitudes, (b) messages to induce procondom norms, (c) messages to increase relevant knowledge, (d) messages to verbally model skills that promote condom use, and (e) messages to increase perceived threat. Active interventions generally include passive strategies as well, but their main distinguishing feature is the inclusion of client-tailored counseling, HIV testing, and/or activities to increase behavioral skills, such as role-playing of solutions for prototypical conflicts surrounding condom use" (pp. 858-859).

– Compiled by Abraham Feingold, Psy.D.

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Table 1: Intervention Strategies
To Increase Condom Use,
Organized by Demographic and
Behavioral Risk Factors of Target Audience
(Adapted from Albarracín et al., 2005, p. 887)

Key: MSM = men who have sex with men; IDUs = injecting drug users; PIDUs = partners of injecting drug users; MPHs = multiple-partner heterosexuals; LCUs = low condom users; passive strategy; active strategy; ( ) = effectiveness of strategy not ruled out on the basis of this demographic/behavioral risk factor.

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Prevention Interventions Targeting People Living With HIV

Crepaz et al. (2006) recently conducted "a meta-analytic review of HIV interventions for people living with HIV (PLWH) to determine their overall efficacy in reducing HIV risk behaviours and identify intervention characteristics associated with efficacy" (p. 143). "This systematic review synthesizes the available literature on prevention interventions for reducing risky sex and needle-sharing behaviours in PLWH" (p. 144).

Among studies published between 1988 and 2004, Crepaz and colleagues identified 12 controlled trials that "met the stringent selection criteria: randomization or assignment with minimal bias, use of statistical analysis, and assessment of HIV-related behavioural or biologic outcomes at least 3 months after the intervention" (p. 143). "All 12 trials were conducted in the United States and most trials were carried out after 1996 when [highly active antiretroviral therapy (HAART)] became available" (p. 145).

Crepaz and colleagues found that risk reduction interventions targeting PWLH, as a whole, significantly reduced self-reported unprotected sex among PLWH and also decreased the acquisition of sexually transmitted infections (STIs). "This significant intervention effect is robust as it was not affected by the rules used to guide ... [the] meta-analyses. The reduced rates of unprotected sex were observed not only at 3-4 months but also at 6-12 months post-intervention" (p. 152). At the same time, "a relatively large but non-significant intervention effect was observed for needle sharing" (p. 153). The investigators note that "[t]he findings on STI and needle sharing were based on a small set of trials and, therefore, the robustness of these findings needs to be reassessed when additional controlled trials are completed" (p. 153).

Interventions with the following characteristics were found to reduce unprotected sex significantly:

o guided by behavioural theory
o specifically focused on HIV transmission behaviours (more than two-thirds of
sessions)
o provided skills building, such as demonstrating correct condom use, practicing
coping or problem-solving skills, or role-playing safer sex communication with
partners
o delivered to individuals on a one-to-one basis
o delivered by health-care providers or professional counsellors
o delivered in settings where people living with HIV receive services
o delivered in an intensive manner ( >10 intervention sessions, > 20 h)
o delivered over a longer duration ( ≥ 3 months)
o addressed a myriad of issues related to coping with one's serostatus, medication
adherence, and HIV risk behaviours. (p. 152)

Crepaz and colleagues recommend that the "[e]fficacious strategies identified in this review ... be incorporated into community HIV prevention efforts and further evaluated for effectiveness" (p. 143).

Reference

Crepaz, N., Lyles, C.M., Wolitski, R.J., Passin, W.F., Rama, S.M., Herbst, J.H., Purcell, D.W., Malow, R.M., & Stall, R. (2006). Do prevention interventions reduce HIV risk behaviours among people living with HIV? A meta-analytic review of controlled trials. AIDS, 20(2), 143–157.

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The Last Word?

Even the casual reader of medical and social science literature will note the increasingly common use of meta-analysis to synthesize research studies in an attempt to provide "definitive answers" to important research questions.

What Is Meta-Analysis?

In simple terms, "meta-analysis is a statistical technique that enables the results from a number of studies to be combined to determine the average effect of a given technique. ... Study outcomes are translated to a common metric, called an effect size, to allow results to be compared" (Boston, 2002, pp. 1-2).

While amassing and comparing research evidence across multiple studies makes intuitive sense, Streiner (2005) observes that "[m]etaanalysis is predicated on the assumption (or it may be more a belief and hope) that objectivity regarding the criteria used for conducting literature searches, selecting the articles to include or exclude, and abstracting and summarizing the findings would result in unbiased and unequivocal answers. In some hierarchies of evidence, metaanalyses are at the top, trumping even very large randomized controlled trials ... " (p. 829). Nevertheless, investigators conducting meta-analyses on the same topic sometimes arrive at different conclusions!

As Streiner puts it, "[t]he reality is that, despite the claims of true believers, metaanalysis is neither a purely objective, mechanical process nor a panacea for answering all questions. There are 2 major reasons why metaanalyses may differ with regard to the conclusions they draw: methodological considerations and interpretation" (p. 829).

Methodological Considerations

With respect to the first reason, metaanalysis is a complicated process comprising many different phases ... , and each step requires some degree of judgment. Judgment, in turn, implies that equally competent reviewers can make decisions that affect the conclusions that are drawn. Starting at the beginning, the first steps in a metaanalysis consist of posing the questions to be addressed and setting the inclusion criteria. While this may appear at first glance to be simple and straightforward, even subtle differences can lead to a search for and retrieval of different articles. ... During the data abstraction phase, a decision has to be made whether to focus on one outcome measure or to pool the results if several were used in a study. At the point of analysis, the researchers must decide whether to use a fixed-effects model (which assumes that there is one population effect size that each study approximates) or a random-effects model (which allows a range of effect sizes that vary among studies because of sampling, ... research design features, and the like).

... Each question demands an answer, but there are no correct ones; different people can make different decisions and likely provide equally convincing reasons. (Streiner, 2005, pp. 829-830)

Interpretation

"The second reason why conclusions of metaanalyses may differ regards the interpretation they place on the results ... . ... The unfortunate result of the necessity to make decisions at each stage of the process and when interpreting the findings is that there are, and will always be, differences among metaanalyses of the same topic. ... The good news is that metaanalysts will never be out of a job. The bad news is that readers cannot assume that any metaanalysis provides the last word regarding the effectiveness of an intervention, and their own judgments will always play a role" (Streiner, 2005, p. 830).

References

Boston , C. (2002). Effect size and meta-analysis. ERIC Digest. College Park, MD: ERIC Clearinghouse on Assessment and Evaluation.

Streiner, D.L. (2005). I have the answer, now what's the question?: Why metaanalyses do not provide definitive solutions [Editorial]. Canadian Journal of Psychiatry/La Revue Canadienne de Psychiatrie, 50(13), 829-831.

 

 

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