mental health AIDS

Summer 2007 Newsletter / Volume 8, Issue 4

Tailoring Evidence-Based HIV Behavioral Risk-Reduction Interventions to Local Capacity & Target Audience Characteristics

"Men who have sex with men (MSM) are the people most affected by the HIV epidemic
in the United States ... as well as Canada, ... the United Kingdom, ... Australia, ... New Zealand, ... and countries of Latin America and the Caribbean. ... In 2004, almost two of three newly diagnosed AIDS cases among U.S. men were among men infected through sexual contact
with other men ...; nearly half of all newly diagnosed HIV infections among men
in 19 Western European countries resulted from homosexual or bisexual contact. ..."

---- Task Force on Community Preventive Services, 2007, p. S36

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To support the efforts of program planners and implementers serving MSM, Herbst et al. (2007) conducted

a systematic review of the effectiveness and economic efficiency of individual-, group-, and community-level behavioral interventions intended to reduce the risk of acquiring sexually transmitted HIV in adult ... MSM[.] ... Sexual risk behavior and condom use were the outcomes used to assess effectiveness. Intervention effectiveness on biological outcomes could not be assessed because too few studies of adequate quality have been published. The evidence found in ... [the 19 studies that qualified for this] review shows that individual-level, group-level, and community-level HIV behavioral interventions are effective in reducing the odds of unprotected anal intercourse ([UAI;] range 27% to 43% decrease) and increasing the odds of condom use for the group-level approach (by 81%). (p. S38)

These results, in turn, are the foundation upon which recommendations by the independent Task Force on Community Preventive Services have been made on the use of these interventions within domestic (i.e., United States) contexts. In short, the systematic review development team and the Task Force concluded that, "[g]iven the diversity of study and participant characteristics in this body of evidence, ... each recommended intervention should be applicable across a range of settings and MSM populations, assuming that interventions are appropriately adapted to the needs and characteristics of the MSM population of interest" (p. S48).

With that proviso, the Task Force encourages "HIV prevention planners, providers, and funding agencies ... to adapt person-to-person behavioral interventions to the needs and resources of their communities and to setting, participant, and cultural characteristics of their populations" (p. S36).

Make It Work!

As Stall (2007) points out,

[t]he bulk of prevention research done with MSM has been conducted among the general population of MSM, and has not been specifically defined to meet the needs of men at gravest risk for HIV transmission. Groups at highest risk for HIV transmission for which we have as yet not specifically defined interventions include African-American MSM, substance abusing MSM, and Hispanic men, among other identifiable groups. Clearly, research to create and test interventions specifically for these groups is a public health agenda of the highest priority. That said, HIV incidence rates in these groups are so high that a strategy of waiting for interventions with evidence of efficacy for MSM at highest risk to appear in the scientific literature is not tenable. Programs with evidence of efficacy among general populations of MSM should be modified so that they are culturally appropriate and may be welcoming to the highest risk groups of MSM. Ongoing process and uncontrolled outcome evaluations of these services can serve as a stopgap measure of intervention effectiveness until such time that interventions with proven efficacy are developed for these specific populations. (p. S30)

How, then, does one modify an evidence-based behavioral intervention (EBI)?

Action Steps to Follow

"Currently, there is no CDC [Centers for Disease Control and Prevention]-recommended process or set of agreed-upon best practices for adapting EBIs to conditions different from those present in the original research. As a result, there is increasing concern that insufficient guidance may limit the effectiveness of EBIs under these new conditions. To help meet this need, the CDC Division of HIV/AIDS Prevention (DHAP) has developed draft guidance on adaptation procedures" (McKleroy et al., 2006, p. 60).

According to McKleroy and colleagues, "[i]n the broadest sense, adaptation can include deletions or additions, modifications of existing components, changes in the manner or intensity of components, or cultural modifications required by local circumstances[.] ... Adopters ... generally perceive adaptation as necessary to make the innovation more relevant for the target population and agency needs and [believe that adaptation] can aid in gaining community ownership of the program ..." (p. 60).

In developing its draft adaptation guidance,

[t]he CDC strived to develop guidelines that would assist HIV programs adopt EBIs that fit their local needs while at the same time retaining fidelity to the core elements1 thought most likely to make the intervention effective at reducing HIV risk behaviors. The CDC has narrowed the definition of adaptation2 to mean the process of modifying key characteristics3 of an intervention, recommended activities and delivery methods, without competing with or contradicting the core elements, theory, and internal logic4 of the intervention thought most likely to produce the intervention's main effects. Key characteristics are adapted to fit the risk factors,5 behavioral determinants,6 and risk behaviors7 of the target population and the unique circumstances of the agency and other stakeholders. (pp. 62-63)

An additional consideration in adapting an EBI is "the need for cultural proficiency[,8 which] ... emphasizes the importance of the implementers' practical experience with the target population and agency capacity, while still emphasizing maintaining fidelity to the core elements, theory, and internal logic of the original intervention" (p. 64).

Presently, the CDC's draft adaptation guidance consists of the following five-step process:

The first action step, assess, involves assessing the target population, the EBIs being considered for implementation,9 and the agency's capacity to implement the intervention.

The second, select, is determining whether to adopt the intervention without adaptation, implement the intervention with adaptation, or choose another intervention and repeating the assess action step before moving forward.

The third action step, prepare, ... involves actually adapting the intervention materials, pre-testing the adapted materials with the target population, and increasing agency capacity and developing collaborative partnerships when necessary to implement the intervention.

The fourth action step, pilot, is pilot testing the adapted intervention or its components if it is not feasible to pilot the entire intervention and developing an implementation plan.

The fifth, implement, is conducting the entire adapted intervention with minor revision as needed.

Additionally, the guidance includes feedback loops and checkpoints to ensure each action step is addressed adequately, and to provide an opportunity to revisit earlier action steps should difficulties occur. Process monitoring and evaluation, and routine supervision and quality assurance are also important considerations for the guidance. Credible evidence collected during the adaptation process should be evaluated to determine the success of the adaptation process as well as the effectiveness of the adapted intervention.

Although these five action steps are presented ... in a linear fashion, it is important to note that prevention program activities are not necessarily sequential or mutually exclusive ... . Many of the action steps and activities are interconnected and will be conducted simultaneously rather than sequentially. (pp. 63-64)

Readers desiring a more detailed presentation of the draft adaptation guidance are referred to the paper by McKleroy and colleagues, which lays out the many components of each of these action steps. Solomon, Card, and Malow (2006) also offer tips "on how to adapt an HIV prevention program proven efficacious ... to meet the needs of groups that differ culturally from those with whom the program was initially validated" (p. 163).

At this time,

[t]he draft adaptation guidance is being piloted with five CBOs [community-based organizations] funded through the Adopting and Demonstrating the Adaptation of Prevention Techniques (ADAPT) project. These CBOs are using the guidance to adapt HIV prevention interventions for seropositive men of color who have sex with other men. The interventions being adapted are Community PROMISE (Peers Reaching Out and Modeling Intervention Strategies for Everyone) (CDC AIDS Community Demonstration Projects Research Group, 1999), Healthy Relationships (Kalichman et al., 2001), and Popular Opinion Leader (Kelly et al., 1991). To further evaluate the utility of the draft adaptation guidance, the sites will conduct outcome monitoring on the adapted interventions. Detailed process monitoring and evaluation of the adaptation guidance will be conducted. After the 2-year pilot is completed, the panel of experts will be reconvened and findings from the project will be presented. The panel's feedback and lessons learned by the implementing CBOs will be documented and adaptation guidance will be revised and disseminated. (p. 71)

What Really Matters?

Kalichman et al. (2007) report on the process effects of modifying two key implementation characteristics of "Healthy Relationships" (mentioned above), which "was among the first interventions to demonstrate efficacy for reducing HIV transmission risks using cognitive and behavioral strategies tailored for HIV positive persons" (p. 146).

As Kalichman and colleagues describe it,

Healthy Relationships is a small group HIV prevention program, designed for men and women living with HIV/AIDS. The intervention ... focuses on building skills for managing HIV status disclosure decisions and skills for practicing safer sex. The intervention consists of three major components focused on (a) decision-making skills for disclosure of HIV status to friends and family, (b) decision-making skills for HIV status disclosure to sex partners, and (c) safer sex negotiation and behavioral self-management skills. The intervention is delivered in multiple small groups using a series of structured interactive activities. A unique feature of the intervention is its use of scenes edited from popular films to depict real-life scenarios used in role playing exercises. (p. 146)

Two key characteristics of the original Healthy Relationships intervention (HR-O) were the formation of groups based on gender and sexual orientation (i.e., separate groups for women, heterosexual men, and MSM) and the co-facilitation of groups by a mental health professional and an HIV-positive peer counselor. To reduce barriers to the implementation of this EBI that have been associated with efforts to match these key characteristics, the intervention was instead delivered to mixed gender groups by facilitators who were neither mental health professionals nor individuals living with HIV.

"Process measures from the altered Healthy Relationships intervention (HR-A) were compared to the same measures taken in the HR-O trial. Intervention completion rates were better in the HR-A model (84%) than HR-O (70%). Results showed that HR-A was comparable to HR-O in social support, group cohesion, and group openness. Facilitators in HR-A were viewed somewhat more positive[ly] than in HR-O" (p. 145). In short, the investigators "found no empirical basis for conducting separate groups by gender or for constraining the facilitators in terms of their professional and HIV statuses" (p. 145).

Kalichman and colleagues emphasize that this study focuses on process measures alone and that outcomes were not investigated. "Although the content of the intervention required minimal changes, it is possible that the intervention outcomes may vary as a function of group composition and facilitator characteristics. Future research is required to examine differential outcomes resulting from altering the Key Characteristics of this and other ... interventions" (p. 152).

Ends Justify Modified Means

One of the EBIs included in Herbst and colleagues' systematic review was an individual-level intervention studied by Dilley et al. (2002). In brief, Dilley and colleagues conducted a randomized, controlled trial at an anonymous-HIV-testing site involving 248 HIV-negative MSM who had engaged in at least one act of UAI with a nonprimary partner of different or unknown status and had sought repeat testing. The study was conducted to assess the impact on high-risk behavior of a single-session, cognitive-behavioral counseling intervention “focusing on self-justifications (thoughts, attitudes, or beliefs that allow[ed] the participant to engage in high-risk sexual behaviors) at most recent ... UAI” (p. 177).

Dilley and colleagues found that “[t]hree prevention strategies significantly decreased risky UAI among MSM, when added to standard client-centered HIV counseling and testing: a 90-day sexual diary, a novel counseling session focusing on self-justifications for UAI, or both. Further, the effects of these three interventions persisted to 12 months. In contrast, standard counseling alone appeared to have, at best, only a small, short-term primary prevention effect in this population of MSM who have tested several times previously” (p. 183). The investigators concluded that a single-session counseling intervention designed to reevaluate self-justifications operating during recent high-risk behavior, when employed between pretest and posttest counseling sessions, may help to decrease sexual risk behavior.

More recently, Dilley et al. (2007) repeated this study, substituting paraprofessional counselors for the licensed mental health professionals utilized in the original study. In this more recent study, paraprofessional counselors conducted the brief, personalized cognitive counseling (PCC) intervention during HIV voluntary counseling and testing.

The paraprofessional counselors ... were bachelor's level-trained and California-certified HIV test counselors with a minimum of 1 year of HIV test counseling experience. Before the start of the study, they received 4 hours of didactic training on the principles of cognitive behavioral interventions and instruction on implementing the PCC, completed 4 supervised role plays of PCC sessions, and reviewed audiotapes of those role plays with the investigators to refine their technique. During the study, they received regular supervision by one of the investigators, and audiotapes of the sessions were reviewed for adherence to protocol. (p. 571)

In this study, "HIV-negative ... MSM ... were randomly allocated to PCC or usual counseling (UC) ... . The primary outcome was the number of episodes of ... UAI ... with any nonprimary partner of nonconcordant HIV serostatus in the preceding 90 days, measured at baseline, 6 months, and 12 months" (p. 569). This time, Dilley and colleagues found that

[m]en receiving PCC and UC reported comparable levels of HIV nonconcordant UAI at baseline (mean episodes: 4.2 vs. 4.8, respectively ...). UAI decreased by more than 60% to1.9 episodes at 6 months in the PCC arm ... but was unchanged at 4.3 episodes for the UC arm ... . At 6 months, men receiving PCC reported significantly less risk than those receiving UC ... . Risk reduction in the PCC arm was sustained from 6 to 12 months at 1.9 ..., whereas risk significantly decreased in the UC arm to 2.2 during this interval ... . Significantly more PCC participants were ''very satisfied'' with the counseling experience (78.2%) versus UC participants (59.2%) ... . (p. 569)

Drawing on these findings, Dilley and colleagues conclude that the

PCC approach could be taught to and successfully executed by experienced paraprofessional HIV antibody test counselors. Further, when compared in a randomized controlled trial with usual client-centered risk reduction counseling, the approach had a stronger and more immediate effect at reducing the incidence of UAI among high-risk repeat testing MSM. Additionally, the effect was persistent: the sharp decrease in risk behavior among the PCC group from baseline to 6 months was sustained at 12 months after the intervention, a finding consistent with the long-term effects of the same intervention when conducted by licensed mental health professionals. ... Moreover, the approach seems highly acceptable to this key behavioral risk population. (p. 573)

---- Compiled by Abraham Feingold, Psy.D.

References

Centers for Disease Control and Prevention AIDS Community Demonstration Projects Research Group. (1999). Community-level HIV intervention in 5 cities: Final outcome data from the CDC AIDS Community Demonstration Projects. American Journal of Public Health, 89(3), 336-345.

Centers for Disease Control and Prevention. (1999, revised 2001). HIV/AIDS Prevention Research Synthesis Project. Compendium of HIV prevention interventions with evidence of effectiveness. Atlanta, GA: Author.

Dilley, J.W., Woods, W.J., Loeb, L., Nelson, K., Sheon, N., Mullan, J., Adler, B., Chen, S., & McFarland, W. (2007). Brief cognitive counseling with HIV testing to reduce sexual risk among men who have sex with men: Results from a randomized controlled trial using paraprofessional counselors. Journal of Acquired Immune Deficiency Syndromes, 44(5), 569-577.

Dilley, J.W., Woods, W.J., Sabatino, J., Lihatsh, T., Adler, B., Casey, S., Rinaldi, J., Brand, R., & McFarland, W. (2002). Changing sexual behavior among gay male repeat testers for HIV: A randomized, controlled trial of a single-session intervention. Journal of Acquired Immune Deficiency Syndromes, 30(2), 177-186.

Herbst, J.H., Beeker, C., Mathew, A., McNally, T., Passin, W.F., Kay, L.S., Crepaz, N., Lyles, C.M., Briss, P., Chattopadhyay, S., Johnson, R.L., & the Task Force on Community Preventive Services. (2007). The effectiveness of individual-, group-, and community-level HIV behavioral risk-reduction interventions for adult men who have sex with men: A systematic review. American Journal of Preventive Medicine, 32(4 Suppl.), S38-S67.

Kalichman, S.C., Cherry, C., White, D., Pope, H., Cain, D., & Kalichman, M. (2007). Altering key characteristics of a disseminated effective behavioral intervention for HIV positive adults: The "Healthy Relationships" experience. Journal of Primary Prevention, 28(2), 145-153.

Kalichman, S., Rompa, D., Cage, M., DiFonzo, K., Simpson, D., Austin, J., Luke, W., Buckles, J., Kyomugisha, F., Benotsch, E., Pinkerton, S., & Graham, J. (2001). Effectiveness of an intervention to reduce HIV transmission risks in HIV-positive people. American Journal of Preventive Medicine, 21(2), 84-92.

Kelly, J.A., St. Lawrence, J.S., Diaz, Y.E., Stevenson, L.Y., Hauth, A.C., Brasfield, T.L., Kalichman, S.C., Smith, J.E., & Andrew, M.E. (1991). HIV risk behavior reduction following intervention with key opinion leaders of population: An experimental analysis. American Journal of Public Health, 81(2), 168-171.

Lyles, C.M., Kay, L.S., Crepaz, N., Herbst, J.H., Passin, W.F., Kim, A.S., Rama, S.M., Thadiparthi, S., DeLuca, J.B., & Mullins, M.M. (2007). Best-evidence interventions: Findings from a systematic review of HIV behavioral interventions for US populations at high risk, 2000-2004. American Journal of Public Health, 97(1), 133-143.

McKleroy, V.S., Galbraith, J.S., Cummings, B., Jones, P., Harshbarger, C., Collins, C., Gelaude, D., Carey, J.W., & the ADAPT Team. (2006). Adapting evidence-based behavioral interventions for new settings and target populations. AIDS Education & Prevention, 18(Suppl. A), 59-73.

Solomon, J., Card, J.J., & Malow, R.M. (2006). Adapting efficacious interventions: Advancing translational research in HIV prevention. Evaluation & the Health Professions, 29(2), 162-194.

Stall, R. (2007). Opportunities to improve AIDS prevention practice among men who have sex with men [Commentary]. American Journal of Preventive Medicine, 32(4 Suppl.), S29-S30.

Task Force on Community Preventive Services. (2007). Recommendations for use of behavioral interventions to reduce the risk of sexual transmission of HIV among men who have sex with men. American Journal of Preventive Medicine, 32(4 Suppl.), S36-S37.

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 1 "Core elements are required elements that embody the theory and internal logic of the intervention and most likely produce the intervention's main effects. Core elements should be identified through research and program evaluation. Core elements essentially define an intervention and must be kept intact (i.e., with fidelity) when the intervention is being implemented or adapted, in order for it to produce program outcomes similar to those demonstrated in the original research" (p. 62).

 2 "Adaptation is the process of modifying an intervention without competing with or contradicting its core elements or internal logic. An intervention is modified to fit the cultural context in which the intervention will take place, individual determinants of risk behaviors of the target population, and the unique circumstances of the agency and other stakeholders, but the core elements and internal logic are not changed" (p. 62).

 3 "Key characteristics are important, but not essential, attributes of an intervention's recommended activities and delivery methods. They may be modified to be culturally appropriate and fit the risk factors, behavioral determinants, and risk behaviors of the target population and the unique circumstances of the venue, agency, and other stakeholders. Modification of key characteristics should not compete with or contradict the core elements, theory, and internal logic of the intervention" (p. 62).

 4 "Internal logic of an intervention is the explanation of the relationships among intervention activities, behavioral determinants, and the intended outcome(s) of the intervention" (p. 62).

 5 "Risk factors are characteristics of a behavior (including the context in which the behavior occurs) or an individual that increase the likelihood that transmission will occur, but do not in themselves cause transmission (e.g., lifetime number of sex partners, crack use, using old expired-date condoms)" (p. 63).

 6 "Behavioral determinants are theorized determinants of risk behavior given by behavior change theory. Some commonly described behavioral determinants are self-efficacy, skills, knowledge, attitudes, beliefs, cognitions, values, and perceived norms. Behavioral theories explain how behavioral determinants shape risk behavior and, therefore, imply how behavioral determinants can be modified to change risk behaviors. Behavioral determinants are the focus of social-behavioral prevention interventions" (p. 63).

 7 "Risk [b]ehaviors are behaviors that can directly expose individuals to HIV or transmit HIV, if the virus is present (e.g., unprotected sex, sharing unclean needles). Risk behaviors are actual behaviors in which HIV can be transmitted, such that a single instance of the behavior can result in transmission. Risk behaviors derive from behavioral determinants" (p. 63).

 8 "Cultural proficiency is a way of being that enables both individuals and organizations to respond effectively to people who differ from them" (p. 64).

 9 "Examples of such interventions are packaged by REP [CDC's Replicating Effective Programs; http://www.cdc.gov/hiv/topics/prev_prog/rep/index.htm], distributed by DEBI [CDC's Diffusion of Effective Behavioral Interventions project; http://effectiveinterventions.org/], and can be found in the CDC's Compendium of HIV Prevention Interventions with Evidence of Effectiveness (CDC, 1999, revised 2001)" (p. 67); see also Lyles et al., 2007, summarizing the work of the CDC's HIV/AIDS Prevention Research Synthesis Team (http://www.cdc.gov/hiv/topics/research/prs/best-evidence-intervention.htm).

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