HIV/AIDS Prevention

1. HIV/AIDS Prevention Danuta Kasprzyk Daniel Montaño Update on Sexually Transmitted Infections (STIs) September 29, 2009

2. Some Definitions… • Efficacy • How well an intervention works under ideal circumstances • Effectiveness • How well an intervention works in the real world • Impact = Effectiveness x Reach

3. Prevention • Prevention works • New paradigms, old practices? • Combination Prevention • The overall combination of prevention practices in a synchronized system of prevention programs • Programs that target multiple levels, groups, and individuals with multiple types of approaches • The combination of behavioural and biomedical approaches

4. Risk reduction info Condom supplies Clinical services Community attachment Workshops Peer communication Community development Support groups Group counseling PolicyStructural intervention Face to face counseling Behavioral Interventions in Relation to Coverage and Intensity (Adapted from Mertens et al. WHO) LowIntensity Mass media campaigns Radio Dramas Social marketing Small media School-based programs HighIntensity High Coverage Low Coverage

5. Prevention • Prevention works • New paradigms, old practices? • Combination Prevention • Behavioral counselling works • Works when combined with STD treatment • Examples of such approaches and programs • Manzwa • Makasa • Project RESPECT

6. JAMA 1998; 280:1161-67

7. HIV Prevention: STD treatment and prevention counseling • Sexually transmitted disease treatment • Project RESPECT (RCT) • 3 arm intervention • Conducted in STD clinics with STD patients • Arms 1-2: Interactive counseling based on behavioral models focusing on constructs (i.e. attitude, norm, self-efficacy) related to behavior change • Short one session counseling (Arm 2) • Three session counseling (Arm 3) • Arm 3: usual care, and usual discussion

9. HIV Prevention: Behavioral Intervention • Behavior change works • Behavioral counseling in STD or primary care clinics works • Community and individual interventions work to change individuals and groups • To encourage consistent condom use • To encourage monogamy • To encourage abstinence or delay of sexual onset • To encourage testing for STDs and HIV BEFORE having sex, then committing to monogamy

10. HIV Prevention: Behavioral Intervention • Increasing knowledge is not enough • Behavioral change works • Motivating behavioral change works among targeted groups such as adolescents, drug users, gay and bisexual men, and heterosexuals • Health and sex education in schools • Early • Explicit • Engaging and interactive, NOT preachy • Abstinence only education does not work

11. Percentage of behavior change among women and men who have heard of AIDS and have ever had sex Data source: Zimbabwe Demographic and Health Survey 1994

12. VCT review: Principal findings • Voluntary Counselling and Testing is another form of prevention intervention • Does it work? • A review done by WHO shows that it is not consistent • Though clear impact on specific risk behaviours for individuals and couples in some studies • Impact generally stronger for those who test positive but not exclusively • Impact generally stronger for those who test and receive counselling as a couple Source: K. O’Reilly, WHO

13. VCT review: Principal findings • Few studies looked for primary biological outcomes; • Even fewer found an effect for one • Strongest of these studies had high rates of previous testing, perhaps muting the effect • Quality and rigor of most studies examined was weak • Negative consequences were rare in general, though a little higher for those couple counselled (though still rare) • No studies reported increase in risk behaviours, even for negatives Source: K. O’Reilly, WHO

14. Prevention with positives in VCT • Voluntary counseling and testing • The largest behavior change occurs among individuals who have just found out they are HIV + • Maintenance of safe sex behavior difficult • 1/3 individuals have unprotected sex after they find out their status • VCT less effective for individuals who find they are HIV negative • May be due to multiple factors (e.g., partner choice) • Weak studies • More research needed

15. What do we know about discordance? • Behaviour change is greater in serodiscordant couples • In SSA, transmission within serodiscordant couples is large component of continuing transmission • In Kenya, estimated at 40% • Zambia: 50-90% of infections occur in stable relationships • With appropriate counselling and testing, this may be reduced • Problem is that only about 10% of individuals coming in for VCT come in with partner • Follow-up services for all those found to have HIV are crucial • Including prevention: counselling, disclosure, partner notification; family planning and PMTCT; psychosocial support and behavioral counselling

16. Prevention with positives • 30-50% of married HIV + people from various studies in Uganda have HIV - spouses • Understanding of HIV Discordance is low • Only 12% of HIV-infected people initiating ART knew that discordance could exist (TASO) • Clients did not understand need for partner testing with low uptake of partner VCT at facilities (3-12%) • During first six months on ART: • Increase of sexual desire among clients, but also increase in safer sexual practices Source: A. Coutinho, TASO, Uganda

17. Prevention with positives • Routine HIV Testing in all medical settings • Opt-out testing • Routine testing: • Ambulatory and primary care clinics, ERs, hospitals • Recommendation: • How often does it occur • Couples testing as requirement before marriage • This is not a requirement anywhere in the world • Why?

18. Behavioral Theory Works • Meta-analysis of 96 data sets on 2 leading theories • Theory of reasoned action • Theory of planned behavior • Tested associations between models’ key variables • Condom use associated with intentions • Intentions associated with • Attitude, Normative influence, Self-efficacy, Perceived control • Attitude associated with specific behavioural beliefs • Norm associated with specific normative beliefs

19. Behavioral Theory Works • Meta-analysis by Albarracin of 354 HIV-prevention interventions • Effective interventions include: • Educational information • Attitudinal arguments • Behavioral skills arguments • Behavioral skills training • Least effective interventions: • Attempt to induce fear • Active (person-to-person contact) interventions more effective than passive (materials distributed)

20. Behavioral Theory Works • Meta-analysis by Albarracin of condom use interventions • More successful achieving immediate knowledge and motivation change than behavior change • Immediate motivation change decays, while behavior change increases over time • More effective if engage audience with activity (e.g. role-playing) • Expert intervention facilitators more effective than lay facilitators

21. Diffusion of Innovation Theory(Rogers, 1985) • New trends (innovations) are introduced by a small segment of opinion leaders in the population • Once they are visibly endorsed and modeled by opinion leaders, new trends (innovations) diffuse through the population, influencing others

22. CPOL Behavioral Intervention • Developed and tested in US in among gay men in gay bars – where HIV prevalence was highest at that time • Uses Community Popular Opinion Leaders • Deliver persuasive messages to peers to encourage behavior change • Opinions and behavior diffuse through community to become norm • Rationale for using CPOL intervention: • Evolves from within community • Reaches large numbers • Few resources • Self-sustaining

23. CPOL intervention Behavioral Interventions in Relation to Coverage and Intensity (Adapted from Mertens et al. WHO) LowIntensity HighIntensity High Coverage Low Coverage

24. Participants who ‘ever had sex’ Overall: 16% had concurrent partners in past 12 months

25. How did we do it? • Identified popular opinion leaders in each growth point (CPOLs) • Recruited about 683 CPOLs to participate in the intervention (15% of target population) • Trained CPOLs as risk reduction behavior change experts to lower risk behavior in each growth point • 4 weekly sessions • Booster/reunion sessions every 3 months thereafter

26. CPOL Training • Session 1: Information • Motivation of CPOLs • Epidemiology of STD/HIV • Risk reduction steps • Building skills with condoms • Session 2: Health promotion • Characteristics of effective health promotion messages • Sensitizing others to threat • Identifying specific changes needed to lower risk • Suggesting strategies for implementing changes using self as example • Personally endorsing the value and benefits of change

27. CPOL Training • Session 3: Effective conversations • Trainers model conversation examples • CPOLs role play initiating conversations • Feedback, rehearsal • Homework: CPOLs identify four individuals for practice conversations in the next week • Session 4: Review of conversation practice • Review outcomes of conversational attempts • Discuss successes • Problem solve difficulties (person, place, content, timing) • Behavioral contract for ten more conversations • Motivate CPOLs – emphasize their important role

28. CPOLs in action

29. How did we do it? • Created environmental cues that help CPOLs initiate conversations about risk reduction • Repeated the baseline survey 12 and 24 months after CPOL cohorts were trained in each growth point to assess changes produced by the CPOLs • Conducted parallel Process Evaluation for additional community monitoring

30. Results: STI Incidence Results: Unprotected sex

31. CPOL Trial Conclusions • Control arm participants received STD testing, HIV and STD prevention counseling, and treatment for treatable STDs • Intervention arm participants received all that, as well as the CPOL intervention • Both arms of the Trial showed a 50% reduction in the risk outcomes selected • The CPOL intervention did not have an additional behavioral effect for the two study outcomes chosen

32. CPOL Intervention Is considered community level intervention Individual Level In practice CPOL Intervention: - Consists of multiple individual conversations - Community change is composite of individuals influencing friends Community Level Change What happens in this process?

33. Identify and Train Opinion Leaders CPOL Model CPOL Conversations Change in Perception Of Normative Behavior Behavior Change In Community

34. Integrated Behavioral Model, Montaño & Kasprzyk, 2008

35. IBM Goals • Design survey to measure IBM mediators • Conduct qualitative elicitation interviews to identify underlying issues/beliefs for each IBM mediator regarding: • Condom use with different partners, transactional sex, monogamy, talking to partners about sex, sex in context of alcohol use • Develop culturally appropriate IBM mediator measures • Assess how well IBM explains behavioral intentions • Identify specific mediators and their component beliefs for targeted intervention messages

36. Zichire ethnographers on site at village borehole Typical rural homestead Rural household activities

37. Final IBM Survey • Content analysis yielded lists of items • For each mediator, for each behavior • Measured mediators for each behavior • 5 point scales • Behavioral intention/motivation • Direct attitude: 3 semantic differential items • Indirect attitude: 9-14 behavioral beliefs • Subjective norm: 4-6 normative beliefs • Perceived Control direct: 1 semantic differential item • Self-efficacy direct: 1 item • Self-efficacy indirect: 6-11 self-efficacy beliefs • Condom Stereotypes Scale • Myths – 6 beliefs • Morals – 5 beliefs

38. Integrated Behavioral Model Testing • To determine which mediators are most highly associated with Behavioral Intention • Simple correlations between Behavioral Intention and Mediators • Those most strongly correlated should be the focus of interventions • Strongly correlated mediators should be further explored for design of specific persuasive messages

39. Condom Use with Spouse: Males Experiential Attitude Attitude Instrumental Attitude = .38 Injunctive Norm, others = .36 Intention to Perform the Behavior Intention to Perform the Behavior Injunctive Norm, partner = .45 Injunctive Norm, partner = .45 Perceived Norm Descriptive Norm Perceived Control = .39 Personal Agency Self-Efficacy = .52 Self-Efficacy = .52

40. Condom Use with Steady Partner: Males Experiential Attitude Attitude Instrumental Attitude = .44 Instrumental Attitude = .44 Injunctive Norm, others = .30 Intention to Perform the Behavior Intention to Perform the Behavior Injunctive Norm, partner = .56 Injunctive Norm, partner = .56 Perceived Norm Descriptive Norm Perceived Control = .41 Perceived Control = .41 Personal Agency Self-Efficacy = .61 Self-Efficacy = .61

41. Condom Use with Casual Partner: Males Experiential Attitude Attitude Instrumental Attitude = .38 Injunctive Norm, others = .33 Intention to Perform the Behavior Intention to Perform the Behavior Injunctive Norm, partner = .44 Injunctive Norm, partner = .44 Perceived Norm Descriptive Norm Perceived Control = .41 Perceived Control = .41 Personal Agency Self-Efficacy = .57 Self-Efficacy = .57

42. Condom Use with Commercial Sex Worker Partner: Males Experiential Attitude Attitude Instrumental Attitude = .18 Injunctive Norm, others = .31 Intention to Perform the Behavior Intention to Perform the Behavior Injunctive Norm, partner = . 15 Perceived Norm Descriptive Norm Perceived Control = .23 Personal Agency Self-Efficacy = .43 Self-Efficacy = .43

43. Condom Use with Spouse: Females Experiential Attitude Attitude Instrumental Attitude = .37 Injunctive Norm, others = .34 Intention to Perform the Behavior Intention to Perform the Behavior Injunctive Norm, partner = .46 Injunctive Norm, partner = .46 Perceived Norm Descriptive Norm Perceived Control = .36 Personal Agency Self-Efficacy = .54 Self-Efficacy = .54

44. Condom Use with Steady Partner: Females Experiential Attitude Attitude Instrumental Attitude = .49 Instrumental Attitude = .49 Injunctive Norm, others = .32 Intention to Perform the Behavior Intention to Perform the Behavior Injunctive Norm, partner = .56 Injunctive Norm, partner = .56 Perceived Norm Descriptive Norm Perceived Control = .44 Perceived Control = .44 Personal Agency Self-Efficacy = .70 Self-Efficacy = .70

45. Intervention Targets: Summary

46. Implications for Interventions • Many interventions implicitly target IBM mediators • Mediators’ relationship to behavior seldom systematically identified • Mediators rarely explicitly targeted • Examine mediators that are significantly related • Breakdown to behavioral, normative, perceived control, self-efficacy beliefs • How do you translate this to messages?

47. Participants who ‘ever had sex’ 16% had concurrent partners in the past year

48. Participants who ‘ever had sex’ • Overall: 25% drank in the past 30 days • 11% get drunk 5 or more times a month • Overall: 16% had concurrent partners in past 12 months • 25% men; 7% women • Individuals with concurrent relationships were: • Younger at first sex (17 vs. 18) • Had more total number of partners on average • Drank for a greater number of days per month; 7 days compared to 2 days • More likely to get drunk; 42% compared to 13%

49. Participants with concurrent relationships: • Were significantly more likely to have trichomoniasis gonorrhea, syphilis, and HIV • Had higher HIV prevalence 30% compared to 24% in those who did not have concurrent partners • Not more likely to have HSV2, chlamydia • Overall, condom use rates with main or steady partners are low (only 5-8% used consistently) • Overall, condom use motivations with main or steady partners are also low • But, individuals with concurrent partners are significantly more likely to say if they don’t use condoms with main partners that they are at risk for STD and HIV acquisition

50. Sub-sample Analysis All sexually active men IBM Comparisons for attitudinal, normative, personal agency beliefs Comparisons made between: - those with concurrent partners - to those without concurrent partners