Designing and delivering a prevention project within an HIV treatment setting: lessons learned from a specialist model

Pre-Exposure Prophylaxis (PrEP) Implementation for Gay, Bisexual, and Other Men Who Have Sex with Men: Implications for Social Work Practice

Social workers have been critical in the response to HIV from its inception, in HIV prevention, support, and advocacy for stigmatized populations including gay, bisexual, and other men who have sex with men (GBM). Recently, social workers have been tasked with working in an era of increasingly biomedicalized HIV prevention, including pre-exposure prophylaxis (PrEP), a safe and highly effective new prevention technology. However, disparities in PrEP access due to structural barriers, including lack of health insurance coverage, and complex decision-making pathways and processes of engagement present substantial challenges for PrEP implementation. Ensuring equitable access to resources and supporting informed decision making are paramount to social work values, yet scant published literature has considered PrEP social work intervention. This article draws on qualitative data from 29 GBM respondents to highlight gaps in PrEP decision-making support and access that may be amenable to social work intervention. Authors describe opportunities for individual, interpersonal, organizational, and structural social work interventions to address multilevel gaps in PrEP implementation. Findings illuminate the complexity of individual experiences and social discourses regarding PrEP and their impact on GBM and raise important issues for social workers to consider in working with GBM clients, service providers, and administrators.

Hospital-based interventions: a systematic review of staff-reported barriers and facilitators to implementation processes

BACKGROUND

Translation of evidence-based interventions into hospital systems can provide immediate and substantial benefits to patient care and outcomes, but successful implementation is often not achieved. Existing literature describes a range of barriers and facilitators to the implementation process. This systematic review identifies and explores relationships between these barriers and facilitators to highlight key domains that need to be addressed by researchers and clinicians seeking to implement hospital-based, patient-focused interventions.

METHODS

We searched MEDLINE, PsychInfo, Embase, Web of Science, and CINAHL using search terms focused specifically on barriers and facilitators to the implementation of patient-focused interventions in hospital settings. To be eligible, papers needed to have collected formal data (qualitative or quantitative) that specifically assessed the implementation process, as experienced by the staff involved.

RESULTS

Of 4239 papers initially retrieved, 43 papers met inclusion criteria. Staff-identified barriers and facilitators to implementation were grouped into three main domains: system, staff, and intervention. Bi-directional associations were evident between these domains, with the strongest links evident between staff and intervention.

CONCLUSIONS

Researchers and health professionals engaged in designing patient-focused interventions need to consider barriers and facilitators across all three identified domains to increase the likelihood of implementation success. The interrelationships between domains are also crucial, as resources in one area can be leveraged to address barriers in others. These findings emphasize the importance of careful intervention design and pre-implementation planning in response to the specific system and staff context in order to increase likelihood of effective and sustainable implementation.

TRIAL REGISTRATION

This review was registered on the PROSPERO database: CRD42017057554  in February 2017.

Behavioral Interventions to Reduce Sexual Risk Behavior in Adults with HIV/AIDS Receiving HIV Care: A Systematic Review

Regular interactions with people living with HIV/AIDS (PLWHA) who are receiving care provide caregivers opportunities to deliver interventions to reduce HIV-related risks. We conducted a systematic review of behavioral interventions for PLWHA (provided at individual level by caregivers at HIV care settings) to determine their efficacy in reducing sexual risk behavior. Conference websites and biomedical literature databases were searched for studies from 1981 to 2013. Randomized and quasi-randomized controlled trials (with standard-of-care control groups), considering at least one of a list of HIV-related behavioral or biological outcomes in PLWHA aged ≥18 receiving HIV care with at least 3-month follow-up were included. No language or publication status restrictions were set. Standardized search, data abstraction, and evaluation methods were used. Five randomized controlled trials were included in the review. We found limited evidence that sexual risk reduction interventions increase condom use consistency in HIV transmission risk acts, and reduce the number of (casual) sexual partners. We still believe that regular interactions between HIV care providers and PLWHA provide valuable opportunities for theory-based sexual risk reduction interventions to restrain the spread of HIV.

Alcohol use, anal sex, and other risky sexual behaviors among HIV-infected women and men

Effective sexual risk reduction strategies for HIV-infected individuals require an understanding of alcohol's influence on specific sexual behaviors. We conducted audio-computer-assisted-self-interviews on 910 patients from two HIV primary care programs. The association between alcohol use and risky sexual behaviors was examined using multivariable logistic regression adjusting for age, education, race/ethnicity and drug use. Frequent/binge drinking was associated with engaging in anal sex and having multiple sex partners among women, engaging in insertive anal sex among gay/bisexual men, and was unrelated to risky sexual behaviors among heterosexual men. Infrequent drinkers did not differ in sexual risk behaviors from abstainers among women or men. Finally, there was no interaction effect between race/ethnicity and alcohol use on the association with sexual risk behaviors. The study has yielded important new findings in several key areas with high relevance to HIV care. Results underscore the importance of routinely screening for alcohol use and risky sexual behaviors in HIV primary care.

Secondary HIV prevention: novel intervention approaches to impact populations most at risk

This paper reviews recent secondary prevention interventions designed to reduce sexual risk behaviors among people living with HIV/AIDS (PLWHA). A summary of findings from previous meta-analyses and narrative reviews of interventions is provided. Next, novel HIV prevention approaches for PLWHA are reviewed. The review reports on the efficacy of interventions delivered in primary care settings or by technology-formats, interventions that also address mental health difficulties, and programs to address particular at-risk populations (eg, men who have sex with men). A critique of recent interventions for people living with HIV/AIDS is provided as well as suggestions for future research.

Group motivational interviewing to promote adherence to antiretroviral medications and risk reduction behaviors in HIV infected women

We present the results of a clinical trial that tested the efficacy of using motivational interviewing (MI) in a group format to promote adherence to antiretroviral medications and risk reduction behaviors (RRB) in 203 predominately African American HIV infected women. It was compared to a group health promotion program. Participants were followed for 9 months. Adherence was measured by MEMS(®); and RRB by self-report. Controlling for recruitment site and years on ART, no significant group by time effects were observed. Attendance (≥7/8 sessions) modified the effects. Higher MI attendees had better adherence at all follow-ups, a borderline significant group by time effect (p = 0.1) for % Doses Taken on Schedule, a significantly larger proportion who reported abstinence at 2 weeks, 6, and 9 months, and always used protection during sex at 6 and 9 months. Though not conclusive, the findings offer some support for using MI in a group format to promote adherence and some risk reduction behaviors when adequate attendance is maintained.

Secondary prevention of HIV in the United States: past, current, and future perspectives

To provide a synopsis of past, current, and potential next-generation approaches to prevention for positives (PfP) interventions in the United States. For a variety of reasons, PfP interventions, with the goals of limiting HIV transmission from people living with HIV/AIDS (PLWHA) to others and protecting the health of PLWHA, did not appear with any frequency in the United States until about 2000. Even today, the number and breadth of evidence-based PfP interventions is very limited. Nevertheless, meta-analytic evidence demonstrates that such interventions can be effective, perhaps even more so than interventions targeting HIV-uninfected individuals. We review early and more recent PfP interventions and suggest that next-generation PfP interventions must involve behavioral and biologic components and target any element that affects HIV risk behavior and/or infectivity. Next-generation PfP interventions should include increased HIV testing to identify additional PLWHA, components to initiate and maintain HIV care, to initiate antiretroviral therapy and promote adherence, and to reduce sexual and injection drug use risk behavior, as well as ancillary treatments and referrals to services. Comprehensive next-generation PfP interventions, including all of these elements and effective linkages among them, are discussed.

Prevention counseling for HIV-infected persons: what every clinician needs to know

The absence of adequate and regular prevention counseling during routine clinical encounters translates into missed opportunities for HIV prevention. HIV care providers have considerably more contact with patients than clinicians in other disciplines. These contacts should be translated into opportunities to provide HIV prevention messages to patients and should be a priority for all clinicians caring for HIV-positive patients. Coincidental preventive care for HIV-positive patients is inherently unproductive because of the absence of reinforcing messages. In a recent meta-analysis, HIV-positive individuals who underwent counseling and testing services reduced high-risk behaviors by about 68%. Prevention counseling should focus on positive reinforcement, harm reduction, education, and support. We strongly recommend regular, brief, targeted prevention counseling as a part of every clinical encounter.

HIV care providers' implementation of routine alcohol reduction support for their patients

Screening and brief intervention (SBI) for alcohol reduction is an important health promoting strategy for patients with HIV, and HIV care providers are optimally situated to support their patients' reduction efforts. We report results from analyses that use data collected from providers (n = 115) in 7 hospital-based HIV care centers in the New York City metropolitan area in 2007 concerning their routine use of 11 alcohol SBI components with their patients. Providers routinely implemented 5 or more of these alcohol SBI components if they (1) had a specific caseload (and were therefore responsible for a smaller number of patients), (2) had greater exposure to information about alcohol's effect on HIV, (3) had been in their present positions for at least 1 year, and (4) had greater self efficacy to support patients' alcohol reduction efforts. Findings suggest the importance of educating all HIV care providers about both the negative impact of excessive alcohol use on patients with HIV and the importance and value of alcohol SBIs. Findings also suggest the value of promoting increased self efficacy for at least some providers in implementing alcohol SBI components, especially through targeted alcohol SBI training.