Sexual Risk Reduction Through Behavioral Intervention with HIV Serodiscordant Couples: Project Eban

1. Sexual Risk Reduction Through Behavioral Intervention with HIV Serodiscordant Couples: Project Eban John B. Jemmott III, PhD University of Pennsylvania Perelman School of Medicine Department of Psychiatry and Annenberg School for Communication

2. Funded by cooperative agreement research grants from NIMH • U10-MH064393 • U10-MH064394 • U10-MH064395 • U10-MH064404 • U10-MH078819 • Dr. Wingood • Dr. Jemmott • Dr. El-Bassel • Dr. Wyatt • Dr. Landis

3. Steering Committee • John B. Jemmott III, PhD, University of Pennsylvania • Nabila El-Bassel, DSW, Columbia University • Gina Wingood, ScD, Emory University • Gail Wyatt, PhD, University of California, Los Angeles • J. Richard Landis, PhD, University of Pennsylvania (Data Coordinating Center) • Willo Pequegnat, PhD, National Institute of Mental Health

4. Advisory Committees • Data Safety and Monitoring Board at NIMH • Community Advisory Boards at Clinical Sites

5. HIV/AIDS and African Americans • President Obama announced plans to concentrate HIV prevention efforts on the highest-risk populations, including gay and bisexual men and African Americans • African Americans represent only 12% of the US population, but 45% of new HIV infections in 2006 • Rates of new infections were 7 times higher among African Americans than White Americans • Heterosexual exposure is the most common HIV transmission category for African American women and second most common for African American men

8. HIV serodiscordant couples • Years of HIV/STD risk reduction research teach that sexual behavior change is not easy, but hard • But to change the sexual behavior of people in long-term relationships is singularly hard • Habit, trust and suspicion make it unlikely partners would even bring up the idea of condom use • Yet it is especially important to promote safer sex practices in a serodiscordant couple • An uninfected person is regularly having sex with an infected person—what an efficient way to spread HIV

9. Objectives • Examine the efficacy of an HIV/STD risk reduction intervention for African American HIV serodiscordant heterosexual couples: • Does it increase condom use? • Does it reduce the incidence of STDs? • Why is it effective or ineffective? • Is it more effective with certain couples or individuals?

10. Design • Multisite Cluster-Randomized Controlled Trial • Groups (the cluster) of 3 to 5 couples were randomized • HIV/STD Prevention vs. Health Control Interventions • Four clinical sites • Atlanta, Georgia • Los Angeles, California • Philadelphia, Pennsylvania • New York City, New York • Assessments before, immediately after, and 6 and 12 months after the intervention

11. Key eligibility criteria • At least 1 partner is African American • A couple for at least 6 months • Plan to remain a couple at least 12 months • At least 18 years of age • One HIV+ and one HIV- • Aware of each other’s HIV status • At least one reported unprotected sex with partner in prior 90 days • No severe physical or sexual abuse in the past year

12. Structure of Interventions • 8 weekly 2-hour sessions • 4 couples sessions and 4 group sessions • 3 to 5 couples per group • Activities included discussions, interactive exercises, role-playing, videos, and games • African American male and female co-facilitators

13. Eban HIV/STD risk reduction intervention • Eban is African concept of “fence” - symbol of safety, security, and love within a family • Couple-focused intervention • Theoretical Framework • Social Cognitive Theory • Ecological Theory • Afrocentric Paradigm

14. Social Cognitive Theory • Albert Bandura • Self-efficacy • Outcome expectancies • Behavioral skills • Practice • Observational learning

15. Ecological Model • UrieBronfenbrenner • Integrates multiple levels of analysis • Ontogenic factors (individual level) • Microsystem factors (couples level) • Exosystem factors (community level)

16. Afrocentric Paradigm: Nguzo Saba (The 7 Principles of Kwanzaa) • MaulanaKarenga • Unity • Self-determination • Collective work and responsibility • Cooperative economics • Purpose • Creativity • Faith

17. Eban HIV/STD risk-reduction intervention (continued) • Couples-focused intervention to enhance: • Beliefs favorable to condom use • Skill and self-efficacy to use condoms • Couples’ communication regarding HIV/STD risk reduction • Peer norms for condom use • The couple’s relationship

18. Eban HIV/STD Intervention Activities Date Night Wheel of Relationship Issues Couple Connection Coupons Safer Sex Jeopardy • Talk and Listen • FENCE • Cherish Activity • Eban Café • Condom-ments

19. FENCE—Address problem-solving skills • Find out what is going on • Explore each other’s feelings • Name and discuss options • Choose the best option to solve the problem • Execute the plan and monitor progress

20. Health Promotion Comparison Intervention • Social cognitive theory • Not couple-focused • Individual-focused intervention designed to: • Increase fruit and vegetable consumption • Reduce fat consumption • Increase physical activity • Increase cancer screening behaviors • Decrease excessive alcohol consumption

21. Self-report outcomes • Audio computer-assisted self-interviewing (ACASI) • Proportion condom-protected intercourse in prior 3 months • Number of unprotected intercourse acts • Consistent condom use • Concurrent partners • Theory-based mediators of condom use • Health behaviors and mediator variables

22. Biological outcome • Urine samples from men • Vaginal swabs from women • Nucleic acid amplification tests for • Chlamydia • Gonorrhea • Trichomonas • STD positive is positive test for any of the 3 STDs

23. Health Promotion (8 weeks) Screen, confirm eligibility, and collect baseline data Follow-up: IPT, 6m, 12m Randomize HIV/STD Risk Reduction (8 weeks) Flow of Participants

24. Selected Sociodemographic Characteristics by Intervention

25. Outcome variables at baseline by Intervention

26. Couples’ attendance at intervention sessions, by condition

27. Percentage of Couples Attending the Data Collection Sessions

28. Number and Percentage Attending the Data Collection Sessions

29. Analysis of the efficacy of the intervention • Primary behavioral outcome was proportion condom-protected sex in the previous 3 months • Primary biological outcome was STD incidence • Efficacy over the 12-month follow-up period • Couple-level analysis • Generalized estimating equations (GEE) • Models control for nesting of groups within interventions and baseline measure of the criterion

30. Proportion condom-protected sex, by assessment period and intervention

31. Percentage testing positive for STD,by assessment period and intervention

32. Percentage reporting consistent condom use, by assessment period and intervention

33. Number of unprotected intercourse acts, by assessment period and intervention

34. Percentage reporting concurrent partnerships,by assessment period and intervention

35. Intervention effects over the 12-month follow-up period adjusted for clustering and baseline

36. Intervention effects on condom-use mediators over the 12-month follow-up period adjusted for clustering and baseline

37. The health promotion intervention Was it efficacious?

38. Effects of health promotion intervention on health behavior over the 12-month follow-up period adjusted for clustering and baseline

39. Comment • First intervention showing efficacy in reducing sexual risk behavior within African American HIV serodiscordant couples • Strengths included randomized control design, high attendance, low attrition, multiple sites • Limitations included lack of random sampling and reliance on self-reports • Strong effects on measures of condom use and unprotected sexual intercourse • No effects on STD incidence

40. HIV serodiscordant couples have high risk of HIV transmission HIV incidence in African Americans is 83.8 per 100,000

41. Future Research • Additional research on couples • Other types of couples (e.g., younger) in other settings (higher prevalence) • Health promotion intervention • Chronic disease prevention in HIV positive individuals

42. Acknowledgments • We thank the project directors, recruiters, data collectors, data coordinators, data analysts, facilitators, supervisors, and laboratory personnel. • We thank the couples for their participation.

43. Thank you!