Dissemination of Effective Behavioral Interventions in Rural America with Preview of the New DEBIs

1. Dissemination of Effective Behavioral Interventions in Rural Americawith Preview of the New DEBIs Charles B. Collins, Jr., PhD Science Application Team, Capacity Building Branch Division of HIV/AIDS Prevention National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention New York City 2009

2. The Procedural Guidance for Selected Strategies and Interventions for Community Based Organizations www.cdc.gov/hiv/topics/prev_prog/AHP/resources/guidelines/pro_guidance.htm Disseminating Effective Behavioral Interventions (DEBI) Project www.effectiveinterventions.org Implementing Prevention Strategies

3. These interventions all had rigorous evaluations that demonstrated that the intervention caused a reduction in HIV transmission risk behaviors through use of a control or comparison group. Behavior change had to occur, not just intention to change or attitude change. Behavior change had to be sustained a minimum of 120 days after the intervention. A minimum of 70% of the intervention and control clients must be located for follow-up. For more information on criteria: www.cdc.gov/hiv/topics/research/prs/efficacy_criteria.htm How were the DEBIs selected?

4. Community PROMISE D-Up Focus on Youth/IMPACT Healthy Relationships Holistic Health Recovery Many Men, Many VOICES Modelo Intervencion Psichomedica Partnership for Health Mpowerment Popular Opinion Leader Real AIDS Prevention Project RESPECT Safety Counts SISTA Street Smart VOICES/VOCES DEBIs: Currently Being Diffused

5. Ready in 2010 Sister to Sister Start Connect Ready July 2009 SIHLE WILLOW CLEAR DEBIs: Development In Progress

6. Intervention selection is challenging for rural HIV prevention providers in regard to race/ethnicity and transmission groups. Each community must identify the rural target populations in need of services. EBI Challenges

7. Prevention providers must decide whether an individual, group, or community level intervention is best. Because many rural prevention providers indicate it is difficult to convene a group and community level interventions are generally more expensive, many rural providers select an individual level EBI. EBI Challenges

8. Public health and social service infrastructure is less extensive in rural as compared to urban settings. Since many EBIs are delivered through the public health/social service system recruitment and retention of at-risk persons is challenging. EBI Challenges

9. Recruitment and retention of at-risk persons into interventions is more challenging when there is greater distances to travel for services. People will travel to engage in risk behaviors but they are less likely to travel to engage in prevention activities. EBI Challenges

10. Evidence-based interventions are generally more expensive than health education/public awareness campaigns. EBI Challenges

11. Traditional street outreach strategies do not work as well in rural communities because it is difficult to travel on foot and high-risk individuals may be more hidden. Therefore lay health advisors, community health advisors, or promotores may be more appropriate strategies. EBI Challenges

12. The CDC asks the 65 Health Departments to fund and implement strategies with evidence of efficacy. Health Departments can determine the mix of strategies to meet the HIV prevention needs of their jurisdiction. Cooperative Agreements between the CDC and the 65 Health Departments

13. Mix of Strategies

14. Current DEBIsand DEBIs Coming Soon

15. DEBIs for All At-risk Populations

16. An individual level intervention Uses multiple interactive individual risk reduction counseling Demonstrated that client-centered risk reduction counseling was effective at changing HIV risk behavior RESPECT

17. A community-level intervention Promotes consistent HIV prevention through: Community mobilization Role model stories Distribution of small-media materials and risk reduction supplies, such as condoms and bleach Community PROMISE

18. DEBIs for MSM

19. Community level intervention Involves identifying, enlisting, and training key opinion leaders to encourage safer sexual norms and behaviors within their social networks through risk-reduction conversations Found to be effective with men who have sex with other men who lived in mid-sized cities. Can be adapted to work with low income minority women (Sikema) or in large cities with gay men (Miller) Popular Opinion Leader

20. A group level intervention Targets young MSM and bisexual men Recruit a core group of young gay men to design and carry out project activities Uses a combination of informal and formal outreach, discussion groups, creation of safe spaces, social opportunities, and social marketing to reach a broad range of young gay men with HIV prevention, safer sex, and risk reduction messages Mpowerment

21. A group level intervention Targets MSM of color Based on Kelly’s “Partners in Prevention” and Peterson’s “Brother to Brother” Addresses factors that influence the behavior of black MSM: cultural, social, and religious norms; interactions between HIV and other sexually transmitted diseases; sexual relationship dynamics; and the social influences that racism and homophobia have on HIV risk behaviors Highly interactive and experiential sessions Many Men, Many Voices

22. A community level intervention Designed for African American MSM A cultural adaptation of the Popular Opinion Leader Model tested by the CDC in North Carolina Designed to promote social norms of condom use and assist Black MSM to recognize and handle risk related racial and sexual bias Finds and enlists opinion leaders whose advice is respected and trusted by their peers Opinion leaders are trained to change risky sexual norms of their friends and acquaintances in their own social networks. D-UP

23. DEBIs for Women

24. A community level intervention Designed for heterosexual women who live in high HIV prevalence areas. Conduct community outreach using peer volunteers who distribute printed “role model” stories about community members' safer-sex decisions as well as paid outreach workers who “stage” contacts and conduct women-only workshops. Real AIDS Prevention Program

25. A group level intervention Designed for heterosexual African American women, ages of 18-29 Gender and culturally specific Sessions focus on ethnic and gender pride, HIV knowledge, and skills training around sexual risk reduction behaviors, communication, and decision making. SISTASisters Informing Sisters on Topics about AIDS

26. A group level intervention based on the SISTA intervention Targets women living with HIV/AIDS Designed to: Enhance coping skills and social support Improve quality of life Increase safer sex Reduce STIs WILLOW(Ready in July 2009)

27. DEBIs for Drug Users

28. A group and individual level intervention Designed for out-of-treatment active injection and non-injection drug users Found to be effective at reducing HIV risks for injecting drug users and crack cocaine smokers Aimed at reducing both high-risk drug use and sexual behaviors Combines outreach, individualized risk assessment and goal setting, group risk reduction sessions, and social events Safety Counts

29. Uses case management and counseling for out-of-treatment active IDUs Motivational interviewing is used to help move IDUs toward safer sex behavior, safer injection behavior, drug treatment, HIV antibody testing, and STD and Hepatitis screening Found to be effective at reducing HIV risks for injecting drug users Training and materials are offered in both English and Spanish. Modelo Intervencion Psichomedica

30. A case-management or CRCS intervention (individual level) Originally designed for HIV-infected young drug users May be used with anyone at high risk for infection or for HIV-infected persons A client-centered program using cognitive behavioral techniques to change behavior Provides clients with the skills necessary to be able to make healthy choices for their lives After the 5 core sessions, the case manager can select from 18 additional optional sessions to continue to assist the client with prevention needs CLEAR(Ready in July 2009)

31. DEBIs for HIV-infected Populations

32. A small-group level intervention Targets men and women living with HIV/AIDS Involves defining stress and reinforce coping skills with HIV-infected people across three life areas: Disclosing to family and friends Disclosing to sexual partners Building healthier and safer relationships Designed to reduce sexual risk behaviors and improve condom negotiation skills Healthy Relationships

33. An individual level intervention A physician provides risk reduction counseling to his/her HIV-infected patients as part of their HIV primary care visits. Health care staff are involved in providing supportive risk reduction counseling after the physician provides counseling. Partnership for Health

34. DEBIs for Heterosexual Adults

35. A group level intervention Designed for heterosexual African American and Hispanic/Latino men and women A single-session, video-based HIV/STD prevention program using a 22 minute film and a 23 minute discussion Designed to encourage condom use and improve condom negotiation skills VOICES/VOCESVideo Opportunities for Innovative Condom Education and Safer Sex

36. DEBIs for Youth

37. A group level intervention A multi-session, skills-building program Designed to help groups of runaway and homeless youth reduce: Unprotected sex Number of sex partners Substance use Addresses improving youths' social skills, assertiveness and coping through exercises on problem solving, identifying triggers, and reducing harmful behaviors Street Smart

38. A group level intervention Designed for African American inner-city youth in the 7th, 8th, and 9th grades (ages 12-15) Focuses on youth who are becoming the age at which many teens in the U.S. become sexually active Uses fun, interactive activities such as games, role plays and discussions to convey prevention knowledge and skills Informed Parents and Children Together (ImPACT) is for their parents and is delivered via a video. Focus on Youth with ImPACT

39. A group level intervention based on the SISTA intervention SIHLESisters Informing, Healing, Living,and Empowering (Pronounced “SEE-lay”) • Designed for young African American girls between the ages of 15 and 18 • Targets young women who are already sexually active with a male sex partner • Teaches how to negotiate safer sex with a male partner, assertive communication skills, and decision-making skills

40. Starter Kits – in depth information to select the intervention and assess agency capacity Sample budgets Fact sheets Logic models Implementation plans Monitoring and fidelity tools and more Intervention Information on DEBI Websitewww.effectiveinterventions.org

41. Training of Facilitators (TOF) – for those implementing the intervention Participants receive the intervention package Held regionally Often co-sponsored or hosted by health departments Register for DEBI Training Website www.effectiveinterventions.org

42. Connect Project Start (HIP-HOP) Sister to Sister REP 7 Interventions that will be ready for July 2010.

43. A couples intervention Designed for heterosexual African American and Latino couples The first DEBI for couples where both the man and woman are together when the intervention is delivered Currently in English but a Spanish version is in development. Connect

44. An individual level intervention for prisoners Best used in prison rather than jails Sessions are delivered to prisoners prior to release from prison and then sessions delivered after the prisoner has been released Agencies with a history of working in prisons and also have a history of working with ex-prisoners would have the capacity to implement START Project START

45. Sister to Sister • An individual level intervention • Designed for African American women seeking medical treatment • Delivered by African American female nurses to women as they wait for the physician to come into the examination room • Can be delivered in 20 minutes

46. This intervention holds promise for rural communities. An HIV Prevention brochure is sent out to an entire zip code. Inside the brochure is a self assessment of HIV risk. The self assessment is mailed back in a self-addressed stamped envelope. In a few weeks a specific newsletter/magazine is delivered which is specifically targeted to the risk behaviors identified by the addressee. Thus the intervention takes place in the privacy of the home. INSIGHTS

47. Core elements are those activities in an intervention which are believed to bring about behavior change. Core Elements

48. These are aspects of an intervention that may enhance delivery but that are not deemed to be responsible for the intervention’s efficacy. Programs have more ability to adapt these components without fear of undermining the intervention. Key Characteristics

49. This means that the intervention is delivered by implementing all the core elements without adding or dropping a core element. Fidelity

50. The major adaptations are those that involve a change in the target audience or venue in which an intervention takes place. Adaptation for rural communities