Community-Based HIV Intervention 1
Review of the Literature
While many advances have been made in HIV and AIDS treatment, communities still
need to be proactive in prevention and education. It is imperative that communities work
together to provide culturally-based interventions and work with researchers to implement
evidence-based interventions into community-based organizations and settings. This is
especially true in African American, Latino, injecting drug users (IDUs) and low income
communities. Since there is still no cure for HIV and AIDS, behavior change is the most
effective way to decrease infection of the virus. Community-based organizations need to find
the best prevention interventions that can help change high risk behaviors.
To halt the continuation of HIV, it is important to raise awareness through community
mobilization, education prevention and behavior change in special groups. According to Cai, Li,
and Li’s (2009) article, community-based interventions have been successful in changing risky
behavior and in prevention of HIV. In order to accurately assess the success of interventions
CAI, et al. (2009) believe special attention needs to be paid to socioeconomic and behavioral
aspects at the local level. Community volunteers and leaders as well as religious leaders should
all be included in education programs pertaining to HIV intervention and prevention.
In their research article, CAI, et al. (2009) studied community participation, program
activities and outreach strategies which they believe are necessary for a successful community
education program. One model to prevent HIV transmission was discussed. The PRECEDE-
PROCEED model for community planning and health promotion was adopted and led by public
health professionals. Discussion groups and input from community members and community
based organization assessed information. Twelve areas which accounted for 73% of reported
Community-Based HIV Intervention 2
AIDS cases among African Americans and Latinos aged 18-39 were selected for interventions.
Horizontal outreach to residents, vertical outreach to stakeholders, strategic communications and
infrastructure development were chosen to promote behavioral change.
2,011 surveys were conducted with community residents in the first year, and 2,381
follow-up interviews were done the next year. The results showed that program awareness was
up from 5.4% in 2001 to 6.7% in 2002. Recognition of HIV/AIDS problems increased to 35.3%.
Participation in HIV prevention increased significantly.
The America Responds to AIDS (ARTA) campaign was also studied. ARTA used serial
theme education programs and was based on established theory and practice. Originally
developed as a response to the early AIDS crisis, it has evolved into the development of
objectives to combat HIV/AIDS. ARTA includes state and local health agencies and
community-based organizations. All objectives are based on public need and specific
organizations. Input from all participants was used to implement strategies. The results showed
that community-based interventions which promoted HIV/AIDS awareness and change of risky
behavior did prevent the spread of HIV/AIDS (CAI, et al., 2009).
According to Williams, Wyatt and Wingood, (2010), even though African Americans
only make up 12% of the population, they account for 51% of new HIV/AIDS cases and 48% of
all people currently living with HIV/AIDS. Williams, et al. (2009), believe that since sexual
behaviors are the most common mode of transmission, changing behavior is the key to
prevention. Therefore, they researched different prevention interventions which focused on
behavioral changes in African Americans.
Community-Based HIV Intervention 3
In 1996 the Prevention Research Branch Division of HIV/AIDS Prevention (DHAP)
began the HIV/AIDS Prevention Research Synthesis (PRS) project to review HIV behavioral
prevention research literature to find the most effective preventions. The PRS created a
compendium where community-based organizations (CBO) would implement programs best
suited for their target populations. They found that identifying variables that influence HIV
transmissions and sexual behaviors is critical for interventions to be successful. One of the most
important variables is culture, which needs to be included in interventions. Interventions must
include core cultural and community elements (Williams, et al., 2009).
Previous HIV prevention has generally focused on safe sex with condoms. All ethnic
groups were targeted the same way. According to Williams, et al. (2009), research has shown
that different ethnic groups need to be targeted in ways that are familiar to them. Intervention
presentation strategies use videos, and models of the same race/ethnicity. The person delivering
the message should be a member of the target population and community. Curriculum content
includes cultural concepts into interventions, such as racial pride.
HIV intervention for African Americans needs to address institutional variables, which
operate on either an individual, community and health level. Individual factors include being
poor, lack of health insurance and discrimination. Community and health systems include lack
of services and lack of culturally aware providers which act as barriers. Williams, et al. (2010)
found that while evidenced-based interventions (EBI) may work with study participants, they
often do not achieve the same outcomes in real world settings. Most EBIs are conducted in
university setting and making the transition into the community is challenging.
Community-Based HIV Intervention 4
To solve this problem, community-based research (CBPR) was proposed. This was a
collaborative approach designed to create structures for participation of communities,
representatives of organizations and researchers to improve health and well-being. The CBPR
combines culturally and practiced-based evidence and indigenous research methods (Williams, et
The flaw to this research is that CBOs have not been formally evaluated and do not have
the scientific basis to adapted supported interventions. Also, if CBOs do not have access and a
good rapport to the target population, interventions may not be accepted or endorsed. For
interventions to be successful, it is essential that community agencies and partners are included
in all stages of development and civic organizations need to be included. Interventions need to
be adapted specifically to fit the community they are to be implemented in. To have successful
prevention of HIV/AIDS in African American communities, all workers need to work together to
develop cultural HIV interventions and work on changing behaviors. Prevention strategies
should also focus on HIV re-infection and transmission to non-infected partners (Williams, etc.
The introduction of Highly Active Anti Retroviral Treatment (HAART) has increased the
life expectancy of people living with HIV and AIDS. However according to a research article by
Raymond (2005), HIV injecting drug users (IDUs) are not yet receiving the full benefit of this
treatment. There are several theories as to why this is. One theory of thought is that
communities do not provide ample interventions for IDUS. IDUs are discriminated against
because by doing drugs they are therefore criminals and not looked upon as favorably as others
suffering from HIV and AIDS (Raymond, 2005).
Community-Based HIV Intervention 5
Biologists believe it is because illicit drugs prey on the immune system. For example, it
has been long believed that cocaine makes HIV replicate at an increased rate. However, clinical
data received from the Women and Infants Transmission Study (WITS) which included a group
of HIV African American and Latino women who were drug users, found a contradiction to this
theory. The results found no difference from non-drug using HIV women in CD4 cell
percentage, HIV viral load, or survival. They did find that drug users experienced more AIDS
opportunistic infections such as tuberculosis and pneumonia (Raymond, 2005).
The Journal of AIDS reported in 2004, that even though AIDS defining illnesses have
decreased with the use of HAART, these decreases were lower in HIV-IDUs. The death of
IDUS is higher than non drug users. It is hypothesized that this may not be necessarily due to
drug use, but rather to less access to HIV treatment. According to Raymond, (2005), HIV
positive IDUs have less access to care, quality of care and adherence. This reflects lack of
system care such as housing and treatment for drug addiction. Because illicit drugs are illegal
IDUs face a stigma and prejudice ranging from disapproval, police harassment, loss of jobs,
custody of children and imprisonment. Communities need to provide HIV drug users with more
substance abuse counseling, treatment, mental health care, housing and support.
Delayed testing and treatment has been found to have extremely negative consequences
for HIV-IDUS. Raymond, (2005) indicates a study in Baltimore which found that HIV-IDUs
who began HAART when their CD4 cell count was over 350, had survival rates comparable to
HIV negative IDUs. Other studies have shown that HIV-IDUs who received HAART responded
as well as HIV non drug users (Raymond, 2005). These results show that HIV-IDU’s need more
community-based programs, hospitals and clinics. Health care workers and staff need to be
Community-Based HIV Intervention 6
familiar with drug users’ needs and harm reduction models. Community-based programs also
need to be linked to hospitals, clinics, substance abuse programs and correctional facilities. The
limits in these studies are that higher deaths among HIV-IDU’s may be from drug use rather than
HIV and AIDS complications.
While HAART treatment for HIV is an effective treatment, getting HIV patients to
adhere to the medication poses challenges (Mocalino, G. E., Hogan, J. W., Mitty, J. A.,
Bazerman, L. B., Delong, A. K., Loewenthal, H., Caliendo, A. M., and Fanigan, T. P., (2007).
In their article, Mocalino, et al. (2007), detail a study on a randomized trial of community-based,
modify directly observed therapy (MDOT) for HIV positive drug users. This study focused on
adherence and benefits of MDOT.
According to Mocalino, et al. (2007), the study was conducted as an open-label,
randomized, single center trial. Participants were selected from HIV primary care clinics, which
were active users of cocaine, heroin and alcohol misuse and were also non-resistant to a once
daily regimen. Participants were randomly chosen to receive either MDOT or standard of care
(SOC) stratified by HAART therapy for a minimum of two weeks. SOC participants could also
receive any adherence interventions and could cross over to the MDOT arm if their therapy
wasn’t working. MDOT participants were given their own prescriptions. An outreach social
worker observed and transported participants every day for the first three months and then lesser
days over the next nine months.
Assessments were conducted at screening, baseline, one month and then every two
months afterward. Assessments consisted of a questionnaire and venipuncture. Participants
Community-Based HIV Intervention 7
were given incentives during assessments. The types of incentives given were not specified in
the article. Of the 87 participants, 43 received SOC and 44 received MDOT (Mocalino, 2007).
The results showed that after one month, SOC participants missed at least one dose
compared to MDOT participants. The three month evaluation showed similar results. HIV
seropositive drug users on MDOT were more likely to achieve HIV PVL suppression than those
receiving SOC. HAART participants on MDOT also were hospitalized less than SOC
participants. Therefore, there was an overall monetary savings on the MDOT arm (Mocalino,
One limitation to the study was that participants consisted of both drugs users and alcohol
abusers, so the effects between the two groups could not be evaluated. Another limitation is the
study’s endpoint was at three months, which means long-term effectiveness could not be
calculated. The overall results showed that MDOT should be included into adherence
interventions whose participants are failing therapy. However, more studies are needed to
specify which populations would benefit the most and also what the long-term benefits would be.
For community-based interventions to be effectively implemented there needs to be
better ways for scientists, researchers, policy makers, analysts and decision makers to discuss
and exchange HIV prevention and interventions. In his article, Holtgrave (2004) discusses his
framework for scientists, analysts and decision makers to better communicate prevention
interventions for HIV through technology transfer which also includes cost effective analysis.
Community-based organizations have faced several barriers in adopting science-based HIV
prevention interventions in the form of workshop-style training, supportive documentation and
on-site technical assistance. According to Holtgrave (2004), these barriers include: lack of
Community-Based HIV Intervention 8
financial, human and resources to deliver intensive HIV prevention interventions; lack of
resources to fund enrollment incentives to participants; high staff turnover; lack of training; lack
of science-based interventions that are specifically adapted to particular communities.
Little research has been conducted on the most effective methods of delivering HIV
prevention intervention technical assistance to community organizations. It is important for
policy makers to know how effective interventions will be and their cost. Scientists working on
HIV prevention and interventions generally do not provide their findings in a format that can be
inputted into programmatic and policy decision making. Holtgrave’s (2004), framework
provides tools of analytic techniques which can be used, such as research synthesis, Meta
analysis and economic evaluation methods. According to Holtgrave (2004), dialogue between
scientists and policy analysts is important. There also needs to be dialogue between policy
analysts and decision makers to discuss problems in interventions. Holtgrave’s (2004),
framework shows the importance of using scientific results in a technological format to help
policy analysts and decision makers to find the best prevention interventions.
Another article by Bauer, Kilbourne, Neuman, Pincus and Stall (2007), discusses the best
strategies to implement evidenced-based interventions for HIV from academic settings to
community-based settings. Although many effective interventions have been developed for HIV
in academic settings, very few have been successfully disseminated into community-based
organizations. Bauer et al. (2007) describe different strategies that can help with this transfer.
The first strategy is to determine when an organization is ready to implement an intervention.
The second strategy is to work with senior leaders and providers to overcome barriers to
Community-Based HIV Intervention 9
At the time of this article, no implementation frameworks had been specified on how to
implement and adapt interventions to fit community-based organizations. Because of this most
community-based organizations do not implement evidence-based interventions. Bauer et al.,
(2007) study and focus on Replicating Effective Programs (REP) which specifically outlines how
to implement evidence-based interventions into community-based settings through a framework
of strategies which include packaging, training, and technical assistance.
The REP framework, developed by the U.S. Centers for Disease Control and Prevention
(CDC) in 1996 is based on literature review and community input. The REP framework has four
phases. These phases consist of identifying the need for interventions for a particular population,
researching whether the intervention has been successful in similar settings, and identifying
barriers to implementation. After these phases have been completed, an intervention package is
drafted along with training and technical assistance plans. According to Bauer et al. (2007), the
REP package is better than other intervention toolkits because it provides specific details and
options for adaptation for different community-based organizations and settings. As of 2007, the
CDC had funded over 500 prevention organizations (Bauer. et al., 2007).
Once implemented, the REP interventions are thoroughly evaluated by collecting data
through interviews of providers and consumers, checking to see that core elements of the
intervention were implemented, patient-level outcomes are assessed and whether the intervention
was effective. After evaluations are completed the REP framework maintains and makes
changes as needed.
REP has shown to be effective in implementing HIV interventions into community-based
settings. The downside to REP is that it had not yet been evaluated for its effectiveness in
Community-Based HIV Intervention 10
reducing HIV/AIDS, patient outcome or costs as of 2007. No studies of the long-term effects of
REP beyond implementations had been done either. More studies that evaluate long-term
outcomes and sustainability of REP needs to be conducted.
As mentioned in other articles, behavioral interventions are the most effective way to
reduce risk and transmission of HIV. However, successfully implementing interventions from
research settings into community-based organizations are often faced with complications. This
is due mostly to the fact that clinical settings often do not have the funding and resources to
deliver, monitor and evaluate community-based interventions. According to an article by
Copenhaven and Lee (2007), AIDS complacency has posed problems to interventions. The
introduction of HIV medications, have made people complacent and the threat of HIV/AIDS is
not necessarily seen as the threat it was once was. Another problem is that targeted individuals
tend to recount prevention information if they view it as redundant.
Analysis of randomized and controlled trials (RCTs) found that IDUs responded better in
community-based interventions when the focus was on sex and drug related risks equally.
Copenhaver and Lee (2007) developed the Community-Friendly Health Recovery Program
(CHRP), which showed successful outcomes with enhanced HIV-knowledge, motivation,
behavioral skills, and reduction in at risk sex and drug behaviors. A study was conducted to
check whether the intervention effects decayed over time and whether the intervention should be
repeated at a follow-point.
The CHRP intervention was conducted at a methadone facility as a manual guided
behavioral intervention which consisted of four 50 minute group sessions. These sessions’
targeted sex and drug related HIV risks and were led by two trained facilitators, using cognitive
Community-Based HIV Intervention 11
remediation strategies. 226 participants participated in the initial intervention, and 62 subjects
participated in a repeated follow-up intervention. Participants did not receive compensation or
any incentives. The follow-up rate was lower than similar interventions where participants
received incentives. No differences were found in regards to pre and post intervention measures
such as HIV knowledge, behavior, attitudes and drug use (Copenhaver and Lee, 2007).
To assess participants’ sex and drug HIV risk behaviors, the Risk Assessment Battery
(RAB) was used. The RAB also assessed participants’ HIV knowledge, motivation and
behavior. The results of the study showed that a positive effect was found for the intervention,
HIV risk group, and sex and drug risk reduction. HIV participants showed greater high HIV risk
improvement at immediate post-intervention. Decay over time was analyzed to see if outcomes
diminished. Results showed no evidence of decay in risk reduction at follow-up. However there
was a gradual decline in some areas in high HIV risk groups. Participants who had children at
home, has less decay (Copenhaven and Lee, 2007). Therefore it is suggested that future
interventions should enhance social support. Also future studies should also analyze the impact
of family and social support on risk reduction outcomes. More decay was noticed in sex-related
risk groups, but follow-up interventions did lessen the decay. The limitations to the study were
that participants did not receive incentives or compensation. Also, this study was limited to one
group, without control groups to compare outcomes. Further studies should have a separate
control group to better track results.
As mentioned in previous articles, the issue of adapting evidence-based interventions into
community-based organizations is not always successful. In their article, Kao, Rosales, and
Veniegas (2009) study how different community organizations adapt HIV prevention
Community-Based HIV Intervention 12
interventions and how these changes affect the core elements of the interventions. The CDC
stresses the importance of keeping core elements of interventions intact when transferring them
from research settings to community-based settings. To ensure this, the CDC released three
versions of HIV prevention intervention guidance to help community agencies in planning and
implementing interventions. These guides outline core elements of evidence-based interventions
and also describe adaptation, resource requirements, recruitment, policies, standards, monitoring
and evaluations for interventions.
To help community-based organizations adapt interventions, the CDC state that agencies
adapting interventions need to conduct formative evaluations to define the target population,
culture behaviors and HIV risk factors. The CDC also encourages agencies to develop
intervention implementation plans, provide leadership, solicit feedback from staff, provide
training, ensure fidelity to core elements and monitor client responsiveness.
Kao, et al. (2009), conducted a study which consisted of interviews with staff who were
implementing evidence-based HIV prevention interventions. Participants were eligible for the
study if they were employed by an organization that provided HIV prevention interventions.
Thirty-four participants who worked in twenty-two different organizations participated in the
study. Twenty-one were female, ten were male and three were transgendered. Participants were
of mixed backgrounds and worked at the agencies from anywhere to six months to over 10 years
(Kao, et al., (2009).
Kao, et al. (2009), stated that semi-structured interviews were conducted with study
participants. The interviews were based upon research on the adoption of evidence-based HIV
prevention programs. Afterwards, the interviews were transcribed, entered electronically and
Community-Based HIV Intervention 13
then coded. The results showed that agency staff adapted activities and delivery methods of
interventions as recommended by the CDC. Most of the study participants said that they used
pilots and made changes after assessing and getting feedback from intervention participants.
Some made changes on cultural issues. For example, if they showed a video about heterosexuals
to homosexuals, participants said that they couldn’t relate to the video. Thus they would change
to a video that showed homosexuals. Other participants often made changes to include
According to Kao, et al. (2009), none of the staff who made changes consulted with a
technical assistance provider or other expert. Seven participants stated that reinvention during
the implementation stage was required by their funders. Some staff reported making changes
during maintenance for quality assurance. These were mostly efforts made to improve activities
and delivery methods. Few of these participants piloted their adaptations before commencing
with full implementation as recommended by the CDC. Also reinventions did sometimes change
the core elements of the interventions which the CDC cautions against.
The results are that continuous measurements of fidelity are needed. Any adaptations to
interventions need to be recorded and these records should be included in periodic reports by
agencies to funders, so that changes can be accessed. This will help the effectiveness of future
prevention interventions (Kao, et al. (2009). Piloting and technical assistance is also important
during the pre-implementation phase. Re-invented interventions should be evaluated to
demonstrate their ability to reduce HIV risk.
The limitations to the study include interview questions that did not address as to specific
program adaptations, or why changes were made. Since there was no program monitoring, or
Community-Based HIV Intervention 14
fidelity assessment, the reliability of the study participants cannot be verified. Also, the study
should have included participants at varying levels in the organizations, to see if the results and
interviews varied by different positions. The article was also confusing, in that in one part Kao,
et al. (2009) stated that all adaptations were within CDC guidelines with most using pilots first.
However, it was later stated that some adaptations were not CDC approved and participants did
not use pilots.
In the final analysis, combining all the information of the reviewed articles shows that
even though treatments such as HAART have been proven effective in prolonging the lives of
people who have HIV and AIDS, community-based interventions still need to be implemented.
It is also important that more research is done to help implement successful evidence-based
prevention interventions into community-based organizations and settings. In order for these
interventions to be successful, they need to focus on behavioral change and be custom tailored to
their specific target populations. This includes incorporating cultural aspects so that participants
are more willing to participate and adhere. Most of the research has shown that community-
based interventions have been successful with lowering high risk behaviors when implemented
Community-Based HIV Intervention 15
Bauer, M. S., Kilbourne, A. M., Neuman, M. S., Pincus, H. A., and Stall, R. (2007).
Implementing evidence-based interventions in health care: application of the replicating
effective programs framework. Implementation Science. 2:42, p42.
CAI, H., Li, Q., Li, Y. (2009). Community-based intervention for AIDS prevention.
International Journal of Health and Science. 2:4, p226.
Copenhaven, M., Lee, I. (2007). Examining the decay of HIV risk reduction outcomes following
a community-friendly intervention targeting injection drug users in treatment. Journal of
Psychoactive Drugs. 39.3, p223.
Holtgrave, D., R. (2004). The role of quantitative policy analysis in HIV prevention technology
Transfer. Public Health Reports. 119.1. P19
Kao, U. H., Rosales, R., and Veniegas, R. C. (2009). Adapting HIV prevention evidence-based
interventions in practice settings and interview study. Implementation Science. 4. P76
Mocalino, G. E., Hogan, J. W., Mitty, J. A., Bazerman, L. B., DeLong, A. K., Loewenthal, H.,
Caliendo, A. M., Fanigan, T. P. (2007). A Randomized clinical trial of community-based
directly observed therapy as an adherence intervention for HAART among substance
users. AIDS. 21.11, p1473-1477.
Raymond, D. (2005). HIV Care and Treatment as Harm Reduction. The Body. Retrieved from
Community-Based HIV Intervention 16
Williams, J. K., Wyatt, G. E., Wingood, G. (2010). The Four Cs of HIV Prevention with African
Americans: Crisis, Condoms, Culture, and Community. CUR HIV/AIDS Rep, 7:185-193
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