Talk in hiv prevention interventions

HIV Prevention Intervention
Methods Based in
Scientific Evidence
Cherrie B. Boyer, PhD
University of California, San Francisco
Department of Pediatrics
Division of Adolescent and Young Adult Medicine

Causes/Contributors of HIV Risk
Racism, Stigma, Poverty, Gender Inequality, Migration
Structural Level
Resource Availability
Physical Environment
Organizational Systems
Laws/Policies
Macro Level
Community Level
Community Norms
Social Networks
Social Capital/Collective
Efficacy
Relationships
Individual Level
Behavior
Attitudes
Knowledge
Perceptions
Biology
Individual Susceptibility
Adapted from Wohlfeiler, D., California STD/HIV Prevention Training Center, Buying Upstream: Stopping the AIDS
Epidemic at the Source (PPT), 2006

Combination HIV Prevention: Tailoring and Coordinating
Biomedical, Behavioural and Structural Strategies
to Reduce New HIV Infections A UNAIDS Discussion
Paper UNAIDS, 2010

Types of Interventions
Impact Types of Interventions
Individual &
Small Group
Examples
One-on-one counseling, school-based education
Community-Level
Structural-Level
Socioeconomic Factors
Peer education program to alter risk taking
behavior
Policies, practices, laws, systems
Racism, poverty, sexism
Smallest
Impact
Largest
Impact
.
Adapted from: Frieden TR. Am J Public Health. 2010;100:590-595

HIV Prevention is Working
• UNAIDS 2010 Report on the global AIDS
epidemic confirms that the decline in new HIV
infections over the past 10 years is linked with
changes in behavior and social norms together
with increased knowledge of HIV
• Despite this, two new HIV infections occurring
for every individual started on antiretroviral
treatment demonstrates that effective HIV
prevention remains an urgent global health
priority UNAIDS, 2010

Types of HIV Prevention Interventions
• Individual-level interventions include health
education and risk-reduction counseling
provided to one individual at a time
– Assist clients in making plans for behavior change
and ongoing assessments of their own behavior
– Facilitate linkages to services in both clinic and
community settings (e.g., substance abuse
treatment settings) in support of behaviors and
practices that prevent HIV transmission
http://www.doh.wa.gov/HIVAIDS/Prevention/Interventions/InterventionTypes

• Group level interventions include health
education and risk reduction counseling that
shifts the delivery of service from the
individual to groups of varying size
– Use peer and non-peer models involving a wide
range of skills, information, and education
– Include skills building over multiple sessions

• Outreach interventions include HIV/AIDS
educational interventions by peer or
paraprofessional educators face-to-face with
individuals in neighborhood settings or venues
where they typically congregate
– Include distribution of condoms, bleach, sexual
responsibility kits, and educational materials
– Encourage those at high risk to learn their HIV
status

• Comprehensive Risk Counseling & Services
include individualized client-centered
counseling for adopting and maintaining HIV
risk-reduction behavior
– Designed for HIV-positive and HIV-negative
individuals who are at high risk for HIV and STDs
and struggle with issues such as substance
use/abuse, physical and mental health, and social
and cultural factors that affect HIV risk

• Partner Services is a systematic approach to
notify sex and needle-sharing partners of HIV-infected
persons of their possible exposure to
HIV so they can avoid infection or, if already
infected prevent transmission to others
– Helps partners gain access to individualized
counseling, HIV testing, medical evaluation,
treatment, and other prevention services

• Health Communication/Public Information
include delivery of HIV prevention messages
using one or more modalities to target
audiences to build support for safe behavior,
support personal risk-reduction efforts, and/or
inform persons at risk for infection how to
obtain health and social services

• Electronic Media include information that is
electronically conveyed to large groups of
people, including use of television, radio, and
more recently social media (e.g., Internet,
Facebook, text messaging), which reach a
large-scale audiences (e.g., city, state,
national)

• Print Media is designed to reach a large-scale
or nationwide audience, using newspapers,
magazines, pamphlets, and “environmental
media” such as billboards and transportation
signage

• Hotline Telephone Services (local or toll free),
offer up-to-date information and referral to
local services, e.g., counseling/testing and
support services

• Presentations/Lectures involve information-only
activities conducted in-group settings
(i.e., “one-shot” education interventions)

• Social Marketing uses techniques adapted
from commercial marketing techniques to
identify specific audiences (population
segments) and their perceived needs, and
then constructs a program of services,
support, and communication to meet those
needs

• Counseling, Testing & Referral are
individualized interventions consisting of pre-test
and post-test counseling aimed at
learning current serostatus
– Increase understanding of HIV infection
– Assess risk of HIV acquisition and transmission
– Negotiate behavior change to reduce HIV risk
– Provide referrals for additional medical,
preventive, and psychosocial needs

• Community-level interventions seek to
improve the risk conditions and behaviors in a
community through focus on the community
as a whole, rather than intervening with
individuals or small groups
– Alter social norms, policies, practices, or
characteristics of the environment through
community mobilization, and community-wide
events

HIV Prevention is Working…
More is Needed
• For over two decades, HIV prevention
interventions have primarily focused on
individual-level behavioral interventions to
increase knowledge, promote positive
attitudes and behavioral intentions to foster
health promoting behavior change such as use
consistent and effective condom
– Have been successful
– Many are not sustainable (beyond 12-24 months)

Structural Interventions Show Promise
• Interventions that are designed to also focus on
broader structural factors that influence individual
behavior, such health polices and practices and
power differentials have been shown to have greater
efficacy
• Structural interventions differ from
individual/community-level interventions that solely
target behavior change by addressing factors that
affect individual behavior, rather than just behavior
alone
Gupta GR et al., Lancet. 2008, 372:764–75

• HIV prevention efforts cannot succeed long term
without addressing the underlying drivers of HIV
risk and vulnerability in different settings
• Structural factors include the physical, social,
cultural, organizational, economic, legal, or policy
features of the environment that affect HIV
infection
– These factors operate at different societal levels and
different distances to influence individual risk and to
shape social vulnerability to infection

• Structural approaches to HIV prevention seek to
change social, economic, political, or environmental
factors determining HIV risk and vulnerability
– They should be implemented in a contextually sensitive
way, in recognition of both the need for situational
relevance and the interaction between different levels of
influence

Comparing Types of Change
Individual-Level Change
 Focus on behavior change
 Focus on relationship
between individual & HIV-related
problems (i.e.,
poor condom use)
 Short-term focus on
program development
 Individual not a decision-maker
 Individual as audience
Structural-Level Change
 Focus on practice/policy
change
 Focus on social, political &
economic context related to
HIV-related problems
 Long-term focus on policy
development/change
 People gain power by acting
collectively
 Individual as advocate
Adapted from The Coalition Impact: Environmental Prevention Strategies. CADCA’s National Coalition Institute

Example of Types of Interventions
for At Risk Young Women
Problem: Young women are being infected by male
sexual partners recently released from local Juvenile
Correctional facilities who are unaware of their
status
• Individual Intervention: Young women are taught
condom negotiation skills (increase individual skills)
• Community Intervention: Launch a media campaign
about the risk of unprotected sex (change norms)
• Structural Intervention: New policy at Department
of Juvenile Justice requiring all arrested individuals
to receive HIV/STI counseling & testing (targets a
system’s practice)

Needle Exchange Programs
(NEPs)
• In 52 cities around the world without NEPs, HIV
infection rates increased by 5.9% per year on
average
• In the 29 cities with NEPs, HIV infection rates
decreased by 5.8% per year
• Research Conclusion: NEPs appear to lead to
lower levels of HIV infection among IDUs
Hurley SF et al., Lancet. 1997;349:1797-1800

100% Condom Use in Brothels
Voluntary strategies AND policy enforcing
100% condom use in brothels in the
Dominican Republic brought about a greater
reduction in STIs in female sex workers than
voluntary strategies alone
Kerrigan D, et al., AIDS 2003;17:415-23

Thinking
‘Up River’
About
Structural
Change

The River Metaphor
Adopted from presentation conducted by the Center for Strengthening Youth Prevention Paradigms, Risk Reduction
Program at the Division of Adolescent Medicine at Children’s Hospital Los Angeles

The River Metaphor
Broken
Bridge
Watch your
step
Cuidado
!

Bridging the GAP between
Individual Risk and
Structural Solutions

HIV Prevention Structural Change
Structural changes are new or modified programs, practices or policies that are logically linkable to
HIV transmission and acquisition and can be sustained over time, even when key actors are no
longer involved. These changes may directly or indirectly impact individuals
Logically linkable to HIV
transmission and acquisition:
The structural change
objectives must be logically
linkable to long-term
Key actors:
•Key actors are those who exerted
pressure to make the change happen,
Key actors may continue their
involvement, but the sustainability of
the structural change does not depend
on their continued involvement.
Directly or indirectly impact individuals:
•Some changes directly target individual
behavior, such as a policy requiring
individuals to use condoms in bathhouses
•Other changes directly target a feature of the
environment
objectives
Programs, practices or policies:
•Programs- any program or service
•Practices- the way things are done
•Policies- written or unwritten guidelines
Sustainability:
•Once the change has been achieved,
the effect of the change is likely to
persist, AND
•There is a supporting infrastructure in
place that increases the likelihood that
the change will be maintained
Connect to Protect Study Definitions

Creating Structural
Change:
The Adolescent Trials Network for
HIV/AIDS Interventions

Connect to Protect®
• Community mobilization initiative of the
Adolescent Trials Network for HIV/AIDS
Interventions
– Funded by National Institutes of Health
(NICHD, NIDA, NIMH)
– Conducted in 14 high risk urban communities
• Objective
– To determine whether structural changes,
accomplished through community mobilization,
can lead to decreased risk for HIV transmission

Community-Based Participatory Research
(CBPR)
• Collaborative approach between researchers and
community members
• Community members participate along the
spectrum of research
– Conception, design, conduct, analysis, interpretation,
conclusions
• Bottom-up approach to developing SCO
– Relevant, acceptable and adoptable

Phases of C2P
• Phase I ATN 016a (2002-2004)
– Identification of target community and population
– Selection of community partners
• Phase II ATN 016b (2004-2006)
– Venue-based needs assessment of target youth
– Establishing community coalition
• Phase III ATN 040/040b (2006-2011)
– Community mobilization
– Annual cross-sectional surveys of target youth
• Phase IV ATN 095/105 (2011-2016)
– Emphasizes Root Cause Analysis (greater strategic thinking)
– Intermediate Outcomes/Sustainability Analyses
– Qualitative Surveys of Key Informants

Connect to Protect® Nationwide
Los Angeles
DC
Bronx
Philadelphia
Baltimore
New Orleans
Chicago
Tampa
Miami
Boston
Houston
Memphis
Denver
Detroit

“LGBT youths in Washington area get their
first mentoring program”
Washington Post, June 6, 2012
“City Hall Recognizes LGBT Homeless Youth”
Philadelphia Gay News, Nov. 2011
“Chicago Department of Public Health
and Community Partners Expand HIV
Hotline for Adolescents”
Press Release, July 17, 2012

C2P Definition of
Community Mobilization
• Collaborative problem solving that leads to
reduced health-related or other social
problems
– Sustained efforts over time are essential to
effectiveness of mobilization
– Increased sharing of leadership, on-going
feedback, and continued growth in capacity are
essential elements of sustained effort

C2P Process of
Community Mobilization
• Strategic planning process
– Vision statement
– Mission statement (actionable)
– Objectives (what structural changes, when, and by
whom)
– Strategies
– Action Plan
• Action plan implementation leading to
accomplishment of structural changes
• Continuous planning, evaluation
and feedback

C2P Definition of
Structural Change Objective (SCO)
• New or modified programs, policies, or
practices
– Logically linkable to HIV acquisition and
transmission
– Can be sustained over time, even when key actors
are no longer involved
– Changes may directly or indirectly impact
individuals

Structural Changes CORE RISK FACTORS =
Root Cause/
SCO
C2P Logic Model
Number of
partners
Partner selection
(high-risk
vs. low-risk)
Condoms/
clean needles
STI Co-
Infection
Viral load
Reduce chances of
transmitting virus if a
partner is infected
Reduce
incidence
and
prevalence
of HIV
among
YOUR
TARGET
population
Multiple
partners at the
same time
(concurrency)
Reduce chances for
people to have
infected partners
Root Cause/
SCO
Root Cause/
SCO
Root Cause/
SCO
Root Cause/
SCO
Root Cause/
SCO
Root Cause/
Root Cause/
SCO Root Cause/
SCO
Root Cause/
SCO
SCO
Individual Level Outcomes
Long-term Outcome
(Primary Pathways)
Ultimate
Outcome

Vision: HEALTHY YOUTH Mission: To reduce HIV/AIDS among adolescents and young adults through…..
Reduce
incidence
and
prevalence
of HIV
Structural Changes CORE RISK FACTORS =
Individual Level Outcomes
Condoms =
increase
condom use
Long-term
Outcome
Ultimate
Outcome
Reduce the chances of
partner is infected
Tax incentive
for businesses
who provide
condoms
Encourage
Beauty/nail
salons to
provide
condoms
Encourage
clubs to
provide
condoms
Policy that
condoms are
available on
pharmacy
aisles

Root Cause Analysis (RCA)
• Process to reveal underlying issues that
contribute to individual level risk
• Dig below the symptoms to find the
fundamental issues that led to the undesired
consequences
• Identify more targeted and concrete solutions
• More than one root cause contributing to an
issue/problem
Adapted from Wu, A W et al (2008), JAMA, 299, 685–687; Being an effective Coalition using the Strategic Prevention Framework;
National Coalition Institute Champions for Change CADCA & Coalitions Presentation; November 2005

RCA Steps
1. Define the problem factually
– Write a problem statement:
Issue: Homelessness among YMSM
Problem Statement: LGBT youth are at risk for HIV/AIDS
because of unstable housing
2. Gather data and evidence to describe the
problem
– Collect local data via reports, partners, newspaper, etc.
– Use maps – great resource
– Identify stakeholder(s) who can offer insight

RCA Steps (cont.)
3. Identify the reasons associated with the
problem (“But why?”)
– Probe at least 2 layers deep to get at core of problem
4. Brainstorm systems that may intersect with
identified root causes
– What entities/systems have influence over the issue?
– What entities/systems control funding?
– What entities/systems have the broadest reach?

RCA Steps (cont.)
5. Identify stakeholders
– Who has decision making power within targeted
entities/systems?
– Who knows the inner workings of the entity/system?
– How can we engage this stakeholder? Who has
contacts?
6. Initial identification of solutions
– What are some preliminary ideas (structural change
solutions) that come to mind to fix the
problem/address the root cause?
– Who can help develop these ideas and /or facilitate
moving these ideas forward?
– Who to Invite to next working group meeting?

PROBLEM
Being an effective Coalition using the Strategic Prevention Framework;
National Coalition Institute Champions for Change CADCA & Coalitions
Presentation; November 2005
BUT WHY?
BUT
WHY?
BUT
WHY?
BUT
WHY?
BUT
WHY?
BUT
BUT WHY?
WHY?
BUT
WHY?
Identify
Identify root cause
root cause
Identify
root cause

SCO
idea?
Number of
partners
Example 1
BUT
WHY?
BUT
WHY?
Young men
hanging out
at adult
venues
Predatory
behavior
of older
men
Economic
Need YMSM hooking
up with
older men
Lack of
safe spaces
for young
men Partner selection
(high-risk
vs. low-risk)
Multiple partners
at the same time
(concurrency)
No
Lack of
shelter
space
experience
SCO
SCO
idea?
SCO
idea?
SCO idea?
Idea?
SCO
Idea?
SCO
idea?
SCO
SCO idea?
Idea?
No job
to pay rent
Employers
require 2
forms of ID
Job training
Center has
limited hours
SCO
idea?
SCO
idea?
SCO
idea?

BUT WHY?
CAUSE
Lack of testing
sites available
for JJC releases
SCO Solution
By Dec 2007, the Florida
Department of Health,
Division of Disease Control,
Bureau of HIV/AIDS registered
the Department of JJ
as an HIV testing site to identify
and track HIV (+) youth in
local correctional
institutions
PROBLEM
Young women are
being infected by
partners recently
released from local
Juvenile Correctional
Facilities
SCO Solution
Miami-Dade
County Juvenile Service
Department (JAC) also
registered as HIV testing
site to identify and track
HIV positive youth in
correctional
facilities
SCO Solution
Bay Point Alternative
School also registered as
HIV testing site to identify
and track HIV positive
youth in correctional
facilities



CAUSE
Young men released
from the JJC don’t
know their status
Example 2

BUT WHY ELSE?
52
CAUSE
Lack of testing
sites available
for JJC releases
CAUSE
Young men released
know their status
CAUSE
Young men
in the system
do not have
access to services
or resources
Dept of Corrections to
implement policy requiring
all youth being held at
Dept. of Juvenile Justice to
receive HIV/STI prevention
info including where to get
free counseling &
Solution
SCO Solution
testing
Solution #24
Miami-Dade
By Dec 2007, the
Florida Department of Health,
Bureau of HIV/AIDS will have
registered the Department of JJ
local correctional
correctional
facilities
institutions
Solution #25
facilities
PROBLEM
Young women are
being infected by
partners recently
released from local
Facilities



SCO Solution
Dept. of Corrections to
all youth processed at
Juvenile Assessment Center to
free counseling &
testing

AND?
53
CAUSE
Young men
in the system
do not have
access to services
or resources
Solution #4
all youth being held at
Dept. of Juvenile Justice to
free counseling &
testing
CAUSE
Lack of testing
sites available
for JJC releases
CAUSE
Young men released
know their status
Solution
Solution #24
By Dec 2007, the
State Department of Health,
Bureau of HIV/AIDS will have
registered the Department of JJ
correctional
facilities
local correctional
institutions
SCO Solution
facilities
PROBLEM
Young women are
being infected by
partners recently
released from local
Facilities

 
SCO Solution
all youth processed at
Juvenile Assessment Center to
free counseling &
testing
CAUSE
Young men are not
aware of their status
at time of
incarceration
SCO Solution
Dept. of Juvenile Justice
will implement policy
requiring all arrested youth
to receive HIV/STI
counseling and testing

Creating a Package of Upriver SCOs
• Comprehensive solutions require broad and diverse
perspective
• SCOs require linking and leveraging existing
resources rather that creating new ones
• Coalition is an agent of change, NOT a program
implementer
• Include large and long range ideas with some that
are shorter and easier to achieve
• Focus on target population and geographic area to
concentrate effort (remember: effects will be
diffused)

Structural Changes for HIV
X + Y + ? = “Solution”
• Have we considered all of the underlying ‘root’ causes of
high risk behavior among “INSERT TARGET POP” in CITY?
• Does our Action Plan (SCOs active and new) attack the
issues fueling HIV risk behavior among our population of
focus from various angles?
• Does our overall approach add up to a lasting solution to
HIV infection among “INSERT TARGET POP” in CITY?
• Have we invited the key players/stakeholders into our
coalition? Key players and stakeholders include people
who are instrumental in moving our objectives forward as
well as those who can be valuable in adding new and
different objectives into our action plan.

Vision: HEALTHY YOUTH Mission: To reduce HIV/AIDS among adolescents and young adults through…..
?
Number of
partners
Multiple partners
at the same time
(concurrency)
Partner selection
(high-risk
vs. low-risk)
Condoms/
clean needles
STI Co-
Infection
Viral load
Structural
Change Ideas
Intermediate
Outcome
Long-term
Outcome
Ultimate
Outcome
Ex. Increase age
to 21 for
admittance to
clubs
?
?
? Reduce chances of
partner is infected
Reduce
incidence
and
prevalence
of HIV
among
YOUR
TARGET
population
Reduce chances for
people to have
infected partners

“Never doubt that a small group
of thoughtful, committed
citizens could change the
world. Indeed, it's the only
thing that ever has.”
--Margaret Mead

Talk in hiv prevention interventions

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