The impact of HIV interventions: What have we left out?

1. The impact of HIV interventions: What have we left out? Beatrice J. Krauss, Ph.D. Professor of Urban Public Health, the City University of New York School of Public Health at Hunter College, Executive Director, Center for Community and Urban Health Center for Community and Urban Health

2. Acknowledgements Center for Community and Urban Health • Cornell University/Cornell Cooperative Extension • InstitutoMexicano de Investigacion de Familia y Poblacion • University of Miami • Albert Einstein College of Medicine • Lutheran Medical Center • Women’s Housing and Economic Development Corporation • 163rd Street Improvement Association • Our trainers • George Miller: “Give psychology away” • The families of the multicultural Lower East Side of Manhattan, New York City • The Parent/Preadolescent Training for HIV Prevention (PATH) research team • Donald T. Campbell • The work of Marilyn Brewer and Frederick Kanfer • The National Institute of Mental Health, R01 MH 53834 • The World AIDS Foundation • The NGO Committee on HIV/AIDS at the United Nations, New York

3. In this presentation, we will … • Briefly review some of the problems facing behavioral HIV prevention interventions and their dissemination • Examine the ways in which we might expand HIV prevention intervention effects by slightly changing our research paradigm • Briefly explore expanded impact on communities through a change in the ways we measure causes and outcomes • Talk about the social organization of science required to expand impact Center for Community and Urban Health

4. The “translation” to practice problem Center for Community and Urban Health

5. The cost-benefit problem • For the simple secondary prevention intervention of HIV testing, and triage to treatment • For populations identified as reaching a CDC risk threshold • $36,000 per quality-adjusted life year for one-time screening • $50,000 for testing every five years • $63,000 for testing every three years • For the general US population • $113,000 for one-time screening (Paltiel et al., 2005) • Cost of counselling HIV- vs. HIV+ clients • $28 vs $104 (Holtgrave, 2007) • However, 20-40% of HIV may be transmitted during the acute phase when less expensive tests do not detect HIV Center for Community and Urban Health

6. The mini-epidemic problem • The following slides were generously provided by Don Des Jarlais • They represent his global meta-analysis of minority vs. majority rates of HIV among injection drug users and reflect on large scale what we see on small scale in NYC Center for Community and Urban Health

7. 1 OR Center for Community and Urban Health

8. 1OR Center for Community and Urban Health

9. Summary of Findings • Both internationally and in the US, minority groups are at higher risk of HIV infection compared to majority groups. • Great heterogeneity (I-squared = 84.9%) and Gaussian distribution of ORs suggest multiple, complex causes of disparities. • Not likely to be a single, “simple” solution to these disparities, and Don added • Many of the “root causes” of disparities preceded the arrival of HIV Center for Community and Urban Health

10. The silo problem Center for Community and Urban Health

11. BUT … Center for Community and Urban Health

12. We are not alone … • Risk Factors include • Mental Disorder… • Substance Abuse… • Psychosocial Factors. Environmental or family stress, especially a history of neglect or physical, emotional, or sexual abuse… Additionally, hopelessness, impulsivity, aggressive behavior, and agitation are psychological characteristics associated with increased risk • Gay, lesbian, and bisexual adolescents are at increased risk • Taken from Cheryl King’s testimony before the US Senate on adolescent suicide Center for Community and Urban Health

13. When we promote responsible sexual, relationship, and substance use behavior • Impact on multiple health outcomes, not only HIV • Other sexually transmitted infections • Infant mortality • Partner violence • Accidents • Homicide • Suicide • We have used this “common pathways” argument to promote diet and exercise and its multiple health outcomes Center for Community and Urban Health

14. Results: Illicit Drug Use – Past 90 days Familias Unidas + Path vs ESOL + PATH, ns Familias Unidas + Path vs ESOL+HEART p<.05 Outcome is continuous measure of frequency of drug use in past 90 days Hunter College Center for Community and Urban Health

15. Work on families and risk suggest • Effects in the Miami study were moderated by family communication/parenting practices and extended to smoking as well as illicit drug use • Child sexual risk may be impacted by parent risk, even when parent risk behaviors seem irrelevant, e.g., seatbelt use, smoking Prado, G., Pantin, H., Schwartz, S.J., Feaster, D., Huang, S., Sullivan, S., Tapia, M.I., Sabillon, E., Lopez, B., & Szapocznik, J. (2007). A randomized controlled trial of a parent-centered intervention in preventing substance use and HIV risk behaviors in Hispanic adolescents. Journal of Consulting and Clinical Psychology, 75(6), 914-926. Wilder, E.I. & Watt, T.T.(2002). Risky parental behavior and adolescent sexual activity at first coitus. Milbank Quarterly, 80(3), 481-524. Center for Community and Urban Health

16. And HIV does not occur alone • Syndemics are common: • In a local study of high-risk substance users (N=578) … • 33.4% reported no health problems • 48.9% reported experiencing two or more health conditions • The most prevalent problems were • Dental • HIV • Cardiovascular diseasee • Anemia • Diabetes • Abscesses • Hepatitis • Other STIs Center for Community and Urban Health

17. Distribution of HIV and Conflict in Africa Throughout history, more die from disease than conflict in war Source: Mock, Duale, Brown et al., 2004 Center for Community and Urban Health

18. Understanding, skills and knowledge have different distributive properties than medicines • I give them away and I still have them …. • Since it costs nothing our participants act as peer educators (and so do our staff)… Center for Community and Urban Health

19. What first steps will you take to implement what you learned today? Center for Community and Urban Health

20. A one-hour training, derived from PATH, implemented at a hospital, influenced … Understanding Work. “Better [at] consoling…help[ing] patients. Fear went way...” “More sensitive. Statistics were very significant. Left a big impact…” Community. “Ability to explain to people who treated a woman terribly because they did not know better.” “More aware of body language--what we may be communicating to people with HIV…” Spread of Knowledge Work. “[I]am moreinteractive w[ith] pat[ient]s in the hallways. I answer their questions…” Community. “Pass information to wife and neighbors, educate them if they have any questions …” Safety Habits Work. “I understand now [when to]…wear gloves, mask, gown [based on] chart color and if they ask about it I explain …” Community. “More cautious when dating …” Center for Community and Urban Health

21. A different study suggests that our participants are active learners, even in the control condition Center for Community and Urban Health

22. Figure 1. Women’s self-reported abstinence and consistent male and female condom use by pre-test assessment and interactive intervention at seven weeks post intervention. Center for Community and Urban Health

23. How did taking a pretest affect participants? • Women exposed to pre-tests reported accessing more sources of HIV information than women who did not take pre-tests (<10 vs. 10 sources or greater, Chi-squared (1)=7.2, p<.01) • Some of the pre-test items were designed to challenge current behavior (“Do you and your partner have an agreement about … birth control … safer sex?”) Krauss, B.J., Goldsamt, L., Bula, E., Godfrey, C., Yee, D.S., & Palij, M. (2000). Pre-test assessment as a component of safer sex intervention: A pilot study of brief one-session interventions for women partners of male injection drug users in New York City. Journal of Urban Health, 77(3), 383-395. PMID: 10976612. Included as an effective program in the meta-analysis by Scott-Sheldon, L.A.J., & Johnson, B.T. (2006). Eroticizing creates safer sex: A research synthesis. The Journal of Primary Prevention, 27(6), 619-640. Center for Community and Urban Health

24. Center for Community and Urban Health

25. The model honors … • Community wisdom • Community context • The scientific method and its approach to human biases: Center for Community and Urban Health

26. In an article on the evaluation of prevention research centers • The late Don Campbell suggested (selected points) • Avoiding problem/method monopolies, but encouraging overlapping agendas (overlap without and diversity within) • Splitting large studies into two or more parallel studies • Facilitating reanalysis and meta-analysis • Facilitating self-criticism and redesign (tailored interventions are common in other disciplines) • Legitimizing and facilitating supplementary and dissenting opinion research reports from the research staff and others (like shadow reports at the United Nations) • Guiding long-term follow-up • Examining the construct validity of causes and effects Center for Community and Urban Health

27. Dissenting research staff made us do this Center for Community and Urban Health

28. The challenges • Define common pathways • Measure multiple outcomes • Measure participants’ active learning and formal or informal dissemination • Create interdisciplinary Centers designed to disseminate and change effective interventions over time Center for Community and Urban Health

29. Our own dissemination for PATH • Publications • Professional • Popular • Local • Replication, for example http://www.imifap.org.mx/imifap/portal/cfpages/category.cfm?nodeId=2 • Reaching service providers and policy makers through distance learning (CDC/SIECUS) • Encouraging “shadow reports” or “town meetings” to garner other viewpoints on your work Center for Community and Urban Health

30. Dissemination continued . . . • Education as advocacy • Participation in revision of the NYC K-12 HIV curriculum • Expert panel on millenial goals for youth and HIV for the United Nations • Special Projects Associate for the American Psychological Association for HIV-related issues to the United Nations • Training of Fellows http://www.hunter.cuny.edu/shp/centers/comm_urb/rhisc/fellows.htm • Training of faculty and students Hunter College Center for Community and Urban Health

31. Tracking your own “unanticipated” dissemination • Staff or students or participants who moved on • Use of curricular materials or measures • Citation and use of articles http://www.ce-credit.net/courses/100716/Vicarious-Trauma-Prevention Google yourself—it will make you crazy or happy. Center for Community and Urban Health

32. Final thoughts….. [T]o take a health and human rights analysis—which is to say a societal based analysis—seriously requires uncovering the rights violations, failures of rights realization, and burdens on dignity which constitute the societal roots of health problems. This approach would consider a whole human being made vulnerable to a wide variety of pathogens and unhealthy conditions as a result of how the person is treated by society—expressed and articulated in the language of human rights and dignity. It is difficult to imagine a more fundamental shift of taxonomy and a more extensive reorienting of necessary actions to promote and protect health. (The late Jonathan Mann, quoted in D’Oronzio, 2001). Center for Community and Urban Health