Longitudinal effects of SafeTalk, a motivational interviewing-based program to improve safer sex practices among people living with HIV/AIDS

Attitudes About Analytic Treatment Interruption (ATI) in HIV Remission Trials with Different Antiretroviral Therapy (ART) Resumption Criteria

HIV remission trials often require temporary stopping of antiretroviral therapy (ART)-an approach called analytic treatment interruption (ATI). Trial designs resulting in viremia raise risks for participants and sexual partners. We conducted a survey on attitudes about remission trials, comparing ART resumption criteria (lower-risk "time to rebound" and higher-risk "sustained viremia") among participants from an acute HIV cohort in Thailand. Analyses included Wilcoxon-Ranks and multivariate logistic analysis. Most of 408 respondents supported ATI trials, with slightly higher approval of, and willingness to participate in, trials using time to rebound versus sustained viremia criteria. Less than half of respondents anticipated disclosing trial participation to partners and over half indicated uncertainty or unwillingness about whether partners would be willing to use PrEP. Willingness to participate was higher among those who rated higher trial approval, lower anticipated burden, and those expecting to make the decision independently. Our findings support acceptability of ATI trials among most respondents. Participant attitudes and anticipated behaviors, especially related to transmission risk, have implications for future trial design and informed consent.

Tele-counseling based on motivational interviewing to change sexual behavior of women living with HIV: a randomized controlled clinical trial

Sexual transmission accounts for the majority of new HIV infections in Iran. More than 80% of HIV-positive persons are sexually active, and nearly 68% reported never using a condom. The present RCT study was conducted on a group of HIV-positive women using internet-based motivational interviewing. The participants, including 100 HIV-positive women, were randomly assigned to an intervention or control group. The intervention group received five weekly internet-based group motivational interviewing sessions focused on reducing risky behaviors, and the control group received routine care. Follow-ups occurred one month and three months after the end of the intervention. The participants completed demographic information, sexual behaviors, HIV knowledge, condom negotiation skills, and HIV-specific perceived social support scales before, one month, and three months after the intervention. Motivational interviewing was effective in improving knowledge about HIV/AIDS, condom negotiation skills, and HIV-specific perceived social support in the intervention group compared to controls. The intervention significantly increased using condoms in vaginal or anal intercourse in the last three months. Still, it was not effective at consistent condom use in all vaginal and anal sex. Further investigation or a larger RCT needs to confirm the using tele-counseling for women living with HIV.

A Health Belief Model-Based Motivational Interviewing for Medication Adherence and Treatment Success in Pulmonary Tuberculosis Patients

Medication adherence behavior plays a central role in the success of tuberculosis (TB) treatment. Conventional motivation is not optimal in strengthening long-term medication adherence. A motivational interviewing (MI) communication motivation model based on the Health Belief Model (HBM) was designed with the main objective of improving medication adherence and treatment success. This study used an experimental design with a randomized posttest-only control group design. The intervention and control groups consisted of 107 TB patients each, who were selected by random cluster sampling. The study was conducted from November 2020 to June 2021 at 38 public health centers in Bali Province. The HBM-based MI model intervention was given in seven counseling sessions, pill count percentages were used to measure medication adherence, and treatment success was based on sputum examination results. Logistic regression was used to assess the effect of the intervention on medication adherence and treatment success. Logistic regression analysis showed that MI-based HBM and knowledge were the most influential variables for increasing medication adherence and treatment success. Medication adherence was 4.5 times greater (ARR = 4.51, p = 0.018) and treatment success was 3.8 times greater (ARR = 3.81, p < 0.038) in the intervention group compared to the control group, while the secondary outcome of knowledge of other factors together influenced medication adherence and treatment success. The conclusion is that the HBM-based MI communication motivation model creates a patient-centered relationship by overcoming the triggers of treatment barriers originating from the HBM construct, effectively increasing medication adherence and treatment success for TB patients, and it needs further development by involving families in counseling for consistent self-efficacy of patients in long-term treatment.

Randomized controlled trial protocol for project BRIDGE: A telephone-administered motivational interviewing intervention targeting risky sexual behavior in older people living with HIV

PURPOSE

By 2020, 70% of people living with HIV in the United States will be greater than 50 years of age. As many as 37% of sexually active older people living with HIV (OPLWH) engage in HIV transmission sexual behaviors. In spite of repeated calls for secondary prevention interventions to reduce condomless sex in OPLWH, no age-appropriate, evidence-based secondary prevention interventions exist for this group. Furthermore, many OPLWH face barriers to engaging in face-to-face secondary prevention services because of HIV- and age-related stigma, comorbid mental and physical health conditions that complicate travel, or geographic isolation. High rates of depression in OPLWH may further complicate engagement in interventions intended to reduce HIV transmissions. Telephone-administered motivational interviewing may be a feasible and efficacious intervention for this population.

METHODS

This randomized controlled trial will test the efficacy of a 5-session telephone-administered motivational interviewing plus behavioral skills training (teleMI+BST) intervention versus a 5-session telephone-administered coping effectiveness training (teleCET) control intervention to reduce condomless sex in OPLWH. A diverse sample of 336 OPLWH will be recruited across the U.S. The primary analysis will test the efficacy of teleMI+BST to reduce occasions of non-condom protected anal and vaginal intercourse with HIV serodiscordant sex partners. Secondary analyses will examine the efficacy of teleMI+BST to reduce depressive symptoms in mildly depressed OPLWH.

CONCLUSION

This is the first large-scale RCT intended to reduce HIV sexual transmission risk behavior in OPLWH and will add to the literature on secondary prevention telehealth interventions for people living with HIV. ClinicalTrials.gov Identifier: NCT03004170. This trial has been conducted by the approval of the Institutional Review Board. Participants provided verbal consent to participate in this trial.

Sustained Sexual Behavior Change After Acute HIV Diagnosis in Malawi

BACKGROUND

Identification of acute HIV infection (AHI) allows for important opportunities for HIV prevention through behavior change and biomedical intervention. Here, we evaluate changes in sexual risk behaviors among persons with AHI enrolled in a combined behavioral and biomedical intervention designed to reduce onward transmission of HIV.

METHODS

Participants were randomized to standard HIV counseling, a multisession behavioral intervention, or a multisession behavioral intervention plus antiretrovirals. Sexual behaviors were assessed periodically over 1 year.

RESULTS

Four weeks after diagnosis, the predicted probability of reporting multiple sexual partners decreased from 24% to 9%, and the probability of reporting unprotected sex decreased from 71% to 27%. These declines in sexual risk behaviors were sustained over follow-up irrespective of study arm.

CONCLUSIONS

Diagnosis of AHI alone may be sufficient to achieve immediate and sustained behavior change during this highly infectious period.

Developing a Safer Conception Intervention for Men Living with HIV in South Africa

Within sexual partnerships, men make many decisions about sexual behavior, reproductive goals, and HIV prevention. There are increasing calls to involve men in reproductive health and HIV prevention. This paper describes the process of creating and evaluating the acceptability of a safer conception intervention for men living with HIV who want to have children with partners at risk for acquiring HIV in KwaZulu-Natal, South Africa. Based on formative work conducted with men and women living with HIV, their partners, and providers, we developed an intervention based on principles of cognitive-behavioral therapy to support men in the adoption of HIV risk-reduction behaviors such as HIV-serostatus disclosure and uptake of and adherence to antiretroviral therapy. Structured group discussions were used to explore intervention acceptability and feasibility. Our work demonstrates that men are eager for reproductive health services, but face unique barriers to accessing them.

Randomized Controlled Pilot Study of Antiretrovirals and a Behavioral Intervention for Persons With Acute HIV Infection: Opportunity for Interrupting Transmission

BACKGROUND

Persons with acute HIV infection (AHI) have heightened transmission risk. We evaluated potential transmission reduction using behavioral and biomedical interventions in a randomized controlled pilot study in Malawi.

METHODS

Persons were randomized 1:2:2 to standard counseling (SC), 5-session behavioral intervention (BI), or behavioral intervention plus 12 weeks of antiretrovirals (ARVs; BIA). All were followed for 26-52 weeks and, regardless of arm, referred for treatment according to Malawi-ARV guidelines. Participants were asked to refer partners for testing.

RESULTS

Among 46 persons (9 SC, 18 BI, 19 BIA), the average age was 28; 61% were male. The median viral load (VL) was 5.9 log copies/mL at enrollment. 67% (10/15) of BIA participants were suppressed (<1000 copies/mL) at week 12 vs 25% BI and 50% SC (P = .07). Although the mean number of reported condomless sexual acts in the past week decreased from baseline across all arms (1.5 vs 0.3 acts), 36% experienced incident sexually transmitted infection by 52 weeks (12% SC, 28% BI, 18% BIA). Forty-one percent (19/46) of participants referred partners (44% SC, 44% BI, 37% BIA); 15 of the partners were HIV-infected.

CONCLUSIONS

Diagnosis of AHI facilitates behavioral and biomedical risk reduction strategies during a high-transmission period that begins years before people are typically identified and started on ARVs. Sexually transmitted infection incidence in this cohort suggests ongoing risk behaviors, reinforcing the importance of early intervention with ARVs to reduce transmission. Early diagnosis coupled with standard AHI counseling and early ARV referral quickly suppresses viremia, may effectively change behavior, and could have tremendous public health benefit in reducing onward transmission.

Adaptation and delivery of a motivational interviewing-based counseling program for persons acutely infected with HIV in Malawi: Implementation and lessons learned

OBJECTIVE

Individuals diagnosed with acute HIV infection (AHI) are highly infectious and require immediate HIV prevention efforts to minimize their likelihood of transmitting HIV to others. We sought to explore the relevance of Motivational Interviewing (MI), an evidence-based counseling method, for Malawians with AHI.

METHODS

We designed a MI-based intervention called "Uphungu Wanga" to support risk reduction efforts immediately after AHI diagnosis. It was adapted from Options and SafeTalk interventions, and refined through formative research and input from Malawian team members and training participants. We conducted qualitative interviews with counselors and participants to explore the relevance of MI in this context.

RESULTS

Intervention adaptation required careful consideration of Malawian cultural context and the needs of people with AHI. Uphungu Wanga's content was relevant and key MI techniques of topic selection and goal setting were viewed positively by counselors and participants. However, rating levels of importance and confidence did not appear to help participants to explore behavior change as intended.

CONCLUSION

Uphungu Wanga may have provided some added benefits beyond "brief education" standard of care counseling for Malawians with AHI.

PRACTICE IMPLICATIONS

MI techniques of topic selection and goal setting may enhance prevention education and counseling for Malawians with AHI.

HIV/STI Prevention Interventions: A Systematic Review and Meta-analysis

Behavioral interventions can prevent the transmission of HIV and sexually transmitted infections. This systematic review and meta-analysis assesses the effectiveness and quality of available evidence of HIV prevention interventions for people living with HIV in high-income settings. Searches were conducted in MEDLINE, EMBASE, PsycINFO, and CDC Compendium of Effective Interventions. Interventions published between January, 1998 and September, 2015 were included. Quality of evidence was assessed using the Grading of Recommendations Assessment, Development and Evaluation (GRADE). Forty-six articles and 63 datasets involving 14,096 individuals met inclusion criteria. Included articles were grouped by intervention type, comparison group and outcome. Few of these had high or moderate quality of evidence and statistically significant effects. One intervention type, group-level health education interventions, were effective in reducing HIV/STI incidence when compared to attention controls. A second intervention type, comprehensive risk counseling and services, was effective in reducing sexual risk behaviors when compared to both active and attention controls. All other intervention types showed no statistically significant effect or had low or very low quality of evidence. Given that the majority of interventions produced low or very low quality of evidence, researchers should commit to rigorous evaluation and high quality reporting of HIV intervention studies.

Number of Psychosocial Strengths Predicts Reduced HIV Sexual Risk Behaviors Above and Beyond Syndemic Problems Among Gay and Bisexual Men

Syndemics research shows the additive effect of psychosocial problems on high-risk sexual behavior among gay and bisexual men (GBM). Psychosocial strengths may predict less engagement in high-risk sexual behavior. In a study of 470 ethnically diverse HIV-negative GBM, regression models were computed using number of syndemic psychosocial problems, number of psychosocial strengths, and serodiscordant condomless anal sex (CAS). The number of syndemic psychosocial problems correlated with serodiscordant CAS (RR = 1.51, 95% CI 1.18-1.92; p = 0.001). When adding the number of psychosocial strengths to the model, the effect of syndemic psychosocial problems became non-significant, but the number of strengths-based factors remained significant (RR = 0.67, 95% CI 0.53-0.86; p = 0.002). Psychosocial strengths may operate additively in the same way as syndemic psychosocial problems, but in the opposite direction. Consistent with theories of resilience, psychosocial strengths may be an important set of variables predicting sexual risk behavior that is largely missing from the current HIV behavioral literature.

Randomized Controlled Trial of an Intervention to Maintain Suppression of HIV Viremia After Prison Release: The imPACT Trial

BACKGROUND

HIV-infected individuals transitioning from incarceration to the community are at risk for loss of viral suppression. We compared the effects of imPACT, a multidimensional intervention to promote care engagement after release, to standard care on sustaining viral suppression after community re-entry.

METHODS

This trial randomized 405 HIV-infected inmates being released from prisons in Texas and North Carolina with HIV-1 RNA levels <400 copies/mL to imPACT versus standard care. The imPACT arm received motivational interviewing prerelease and postrelease, referral to care within 5 days of release, and a cellphone for medication text reminders. The standard care arm received routine discharge planning and a cellphone for study staff contact. The primary outcome was the difference between arms in week 24 postrelease viral suppression (HIV-1 RNA <50 copies/mL) using intention-to-treat analysis with multiple imputation of missing data.

RESULTS

The proportion with 24-week HIV-1 RNA <50 copies/mL was 60% and 61% in the imPACT and standard care arms, respectively [odds ratio for suppression 0.95 (95% confidence interval: 0.59 to 1.53)]. By week 6 postrelease, 86% in the imPACT arm versus 75% in the standard care arm attended at least 1 nonemergency clinic visit (P = 0.02). At week 24, 62% in both arms reported not missing any antiretroviral doses in the past 30 days (P > 0.99).

CONCLUSIONS

Higher rates of HIV suppression and medical care engagement than expected based on previous literature were observed among HIV-infected patients with suppressed viremia released from prison. Randomization to a comprehensive intervention to motivate and facilitate HIV care access after prison release did not prevent loss of viral suppression. A better understanding of the factors influencing prison releasees' linkage to community care, medication adherence, and maintenance of viral suppression is needed to inform policy and other strategic approaches to HIV prevention and treatment.

An integrative review of the efficacy of motivational interviewing in HIV management

OBJECTIVE

The purpose of this integrative review is to examine the use of motivational interviewing (MI) to improve health outcomes in persons living with HIV (PLWH).

METHODS

We reviewed the existing literature, using the PRISMA model. The PubMed, Web of Science, Embase, and CINAHL databases were searched for all relevant studies, using the terms HIV, AIDS, and motivational interviewing.

RESULTS

Of 239 articles identified initially, 19 met our criteria for synthesis. These studies were conducted throughout the world, including the U.S., Thailand, and South Africa. In general, studies that used MI, either alone or in conjunction with other interventions, reported improved adherence, decreased depression, and decreased risky sexual behaviors.

CONCLUSION

This review demonstrates a positive relationship between MI-based interventions and behavioral change, which may lead to improved health outcomes in PLWH.

PRACTICE IMPLICATIONS

Motivational interviewing can be an effective method of therapeutic communication for PLWH, who struggle with adherence, depression, and risky sexual behaviors.

Two-Part and Related Regression Models for Longitudinal Data

Statistical models that involve a two-part mixture distribution are applicable in a variety of situations. Frequently, the two parts are a model for the binary response variable and a model for the outcome variable that is conditioned on the binary response. Two common examples are zero-inflated or hurdle models for count data and two-part models for semicontinuous data. Recently, there has been particular interest in the use of these models for the analysis of repeated measures of an outcome variable over time. The aim of this review is to consider motivations for the use of such models in this context and to highlight the central issues that arise with their use. We examine two-part models for semicontinuous and zero-heavy count data, and we also consider models for count data with a two-part random effects distribution.

Does the quality of safetalk motivational interviewing counseling predict sexual behavior outcomes among people living with HIV?

OBJECTIVE

Although past research has demonstrated a link between the quality of motivational interviewing (MI) counseling and client behavior change, this relationship has not been examined in the context of sexual risk behavior among people living with HIV/AIDS. We studied MI quality and unprotected anal/vaginal intercourse (UAVI) in the context of SafeTalk, an evidence-based secondary HIV prevention intervention.

METHODS

We used a structured instrument (the MISC 2.0 coding system) as well as a client-reported instrument to rate intervention sessions on aspects of MI quality. Then we correlated client-reported UAVI with specific counseling behaviors and the proportion of interactions that achieved MI quality benchmarks.

RESULTS/CONCLUSION

Higher MISC-2.0 global ratings and a higher ratio of reflections to questions both significantly predicted fewer UAVI acts at 8-month follow-up. Analysis of client ratings, which was more exploratory, showed that clients who rated their sessions higher in counselor acceptance, client disclosure, and relevance reported higher numbers of UAVIs, whereas clients who selected higher ratings for perceived benefit were more likely to have fewer UAVI episodes.

PRACTICE IMPLICATIONS

Further research is needed to determine the best methods of translating information about MI quality into dissemination of effective MI interventions with people living with HIV.

Individuals motivated to participate in adherence, care and treatment (imPACT): development of a multi-component intervention to help HIV-infected recently incarcerated individuals link and adhere to HIV care

Background

Policy-makers promote a seek, test, treat and retain (STTR) strategy to expand HIV testing, support linkage and engagement in care, and enhance the continuous use of antiretroviral therapy for those HIV-infected. This HIV prevention strategy is particularly appropriate in correctional settings where HIV screening and treatment are routinely available yet many HIV-infected individuals have difficulty sustaining sufficient linkage and engagement in care, disease management, and viral suppression after prison release.

Methods/design

Our research team developed Project imPACT (individuals motivated to Participate in Adherence, Care and Treatment), a multi-component approach for HIV-Infected recently incarcerated individuals that specifically targets their care linkage, retention, and medication adherence by addressing multiple barriers to care engagement after release. The ultimate goals of this intervention are to improve the health of HIV-infected individuals recently released from prison and reduce HIV transmission to their communities by maintaining viral suppression. This paper describes the intervention and technology development processes, based on best practices for intervention development and process evaluation. These processes included: 1) identifying the target population; 2) clarifying the theoretical basis for intervention design; 3) describing features of its foundational interventions; 4) conducting formative qualitative research; 5) integrating and adapting foundational interventions to create and refine intervention content based on target audience feedback. These stages along with the final intervention product are described in detail. The intervention is currently being evaluation and a two arm randomized, controlled trial in two US state prison systems.

Discussion

Based on a literature review, qualitative research, integration of proven interventions and behavioral theory, the final imPACT intervention focused on the transition period two to three months before and three months after prison release. It emphasized pre-release readiness, pre- and post-release supportive non-judgmental counseling, linking individuals to a HIV care clinic and technological supports through videos and text messages. This article provides a useful model for how researchers can develop, test, and refine multi-component interventions to address HIV care linkage, retention and adherence.

Clinical trial registration

NCT01629316, first registered 6-4-2012; last updated 6-9-2015.

Feasibility and Acceptability of a Smartphone App for Daily Reports of Substance Use and Antiretroviral Therapy Adherence among HIV-Infected Adults

While substance use is one of the most consistent predictors of poor adherence to antiretroviral therapy (ART), few studies among people living with HIV (PLH) have utilized mobile phone-based assessment of these health behaviors. PLH were recruited from primary care clinics to report ART and substance use using a smartphone application (app) for 14 consecutive days. The app's feasibility as a data collection tool was evaluated quantitatively via surveys and qualitatively via in-depth interviews to assess daily report completion, compliance, and study satisfaction. Overall, 26 participants (M = 49.5 years, 76% male) completed 95.3% of time-based daily reports. Participants reported high satisfaction with the app and expressed future interest in using smartphones to report daily behaviors. High completion rates and participant acceptability suggest that smartphones are a feasible, acceptable method for collecting substance use and ART data among PLH. Potential areas of concern such as sufficient training and assistance for those with limited smartphone experience should be considered for future app-based research studies among PLH.

SafeTalk: Training Peers to Deliver a Motivational Interviewing HIV Prevention Program

As multiple effective interventions emerge to reduce the spread of HIV, there is a need to implement and disseminate such programs cost-effectively, such as by expanding service delivery through integration of peer supporters. The benefits of peer support are well established. However, knowledge about peer counseling initiatives remain limited. This pilot study tested the feasibility, fidelity, and acceptability of a motivational interviewing (MI) counseling training with individuals living with HIV to serve as peer counselors in order to address medication adherence and safer sex. We adapted, SafeTalk, an evidence-based intervention previously delivered by health professionals to reduce risky sexual behaviors among people living with HIV. We trained six peers in a 5-day program (24 hours total) over a 2-month period. We used a combination of training observation, pre-and posttests, debriefing, and the Motivational Interviewing Treatment Integrity (MITI 3.1) scale 3.1 to assess implementation of the training. Results suggest the program was feasible, and there was positive acceptability. However, fidelity to MI was poor. While participants were dedicated and enthusiastic about the training and able to learn some skills and demonstrate the "spirit of MI," they had difficulty with reflecting and moving away from giving direct advice. Training challenges and successes are discussed.

A Pilot Trial of a Sexual Health Counseling Intervention for HIV-Positive Gay and Bisexual Men Who Report Anal Sex without Condoms

Background

Even in the presence of promising biomedical treatment as prevention, HIV incidence among men who have sex with men has not always decreased. Counseling interventions, therefore, continue to play an important role in reducing HIV sexual transmission behaviors among gay and bisexual men and other men who have sex with men. The present study evaluated effects of a small-group counseling intervention on psychosocial outcomes and HIV sexual risk behavior.

Method

HIV-positive (HIV+) peer counselors administered seven 2-hour counseling sessions to groups of 5 to 8 HIV+ gay and bisexual men. The intervention employed information provision, motivational interviewing, and behavioral skills building to reduce sexual transmission risk behaviors.

Results

There was a significant reduction in condomless anal sex (CAS) with HIV-negative and unknown HIV-status partners, from 50.0% at baseline to 28.9% of the sample at 3-month follow-up. Findings were robust even when controlling for whether the participant had an undetectable viral load at baseline. Significant reductions were also found in the two secondary psychosocial outcomes, loneliness and sexual compulsivity.

Conclusions

The findings provide preliminary evidence that this intervention may offer an efficient way of concurrently reducing CAS and mental health problems, such as sexual compulsivity and loneliness, for HIV+ gay and bisexual men.

Trial Registration

ClinicalTrials.gov NCT02546271

HPTN 062: A Pilot Randomized Controlled Trial Exploring the Effect of a Motivational-Interviewing Intervention on Sexual Behavior among Individuals with Acute HIV Infection in Lilongwe, Malawi

Objective

We pilot tested a Motivational Interviewing (MI) –based counseling intervention for individuals with Acute HIV Infection (AHI) to reduce risky sexual behavior in Lilongwe, Malawi.

Methods

Twenty-eight individuals diagnosed with AHI were randomized to receive either brief education alone, or the brief education plus the MI-based intervention, called Uphungu Wanga. Participants in Uphungu Wanga received four sessions delivered on the day of diagnosis, three days later and at weeks 1 and 2 with a booster session at week 8; participants were followed for 24 weeks from diagnosis. An interviewer administered quantitative questionnaire was conducted at baseline and at weeks 2, 4, 8, 12, 16, 20 and 24. Semi-structured qualitative interviews (SSI) were conducted at weeks 2, 8, 12, and 24.

Results

The majority of participants in both arms reported rapid and sustained behavior change following diagnosis with AHI. Very few participants reported having sex without a condom after diagnosis. Participants reported a trend towards fewer sex partners and abstaining from sex during study follow-up. Participants in the MI-based arm provided concrete examples of risk reduction strategies in the SSIs while those in the brief education arm primarily described reducing risk behavior, suggesting that the MI-based group may have acquired more risk reduction skills.

Conclusions

Individuals in both study arms reduced risky sexual behaviors after diagnosis with AHI. We found few major differences between study arms during the 6-month follow up period in self-reported sexual behaviors therefore a MI-based intervention may not be needed to trigger behavior change following AHI. However, comparing the MI-based intervention to repeated brief education sessions made it difficult to assess the potential benefit of an MI-based intervention in a setting where standard counseling often consists of one post-test session. Nevertheless, provision of counseling immediately following diagnosis with HIV to support behavior change should remain a priority.

Trial Registration

ClinicalTrials.gov NCT01197027

A Marginalized Zero-inflated Poisson Regression Model with Random Effects

Public health research often concerns relationships between exposures and correlated count outcomes. When counts exhibit more zeros than expected under Poisson sampling, the zero-inflated Poisson (ZIP) model with random effects may be used. However, the latent class formulation of the ZIP model can make marginal inference on the sampled population challenging. This article presents a marginalized ZIP model with random effects to directly model the mean of the mixture distribution consisting of 'susceptible' individuals and excess zeroes, providing straightforward inference for overall exposure effects. Simulations evaluate finite sample properties, and the new methods are applied to a motivational interviewing-based safer sex intervention trial, designed to reduce the number of unprotected sexual acts.

HIV prevention counseling intervention delivered during routine clinical care reduces HIV risk behavior in HIV-infected South Africans receiving antiretroviral therapy: the Izindlela Zokuphila/Options for Health randomized trial

CONTEXT

Sustainable interventions are needed to minimize HIV risk behavior among people living with HIV (PLWH) in South Africa on antiretroviral therapy (ART), a significant proportion of whom do not achieve viral suppression.

OBJECTIVE

To determine whether a brief lay counselor delivered intervention implemented during routine care can reduce risky sex among PLWH on ART.

DESIGN

Cluster-randomized 16 HIV clinical care sites in KwaZulu Natal, South Africa, to intervention or standard of care.

SETTING

Publicly funded HIV clinical care sites.

PATIENTS

One thousand eight hundred ninety-one PLWH on ART received the HIV prevention counseling intervention (n = 967) or standard-of-care counseling (n = 924).

INTERVENTION

Lay counselors delivered a brief intervention using motivational interviewing strategies based on the Information-Motivation-Behavioral (IMB) Skills model during routine clinical care.

MAIN OUTCOME MEASURES

Number of sexual events without a condom in the past 4 weeks with partners of any HIV status, and with partners perceived to be HIV negative or HIV-status unknown, assessed at baseline, 6, 12, and 18 months.

RESULTS

Intervention participants reported significantly greater reductions in HIV risk behavior on both primary outcomes, compared with standard-of-care participants. Differences in sexually transmitted infection incidence between arms were not observed.

CONCLUSIONS

Effective behavioral interventions, delivered by lay counselors within the clinical care setting, are consistent with the strategy of linking HIV care and HIV prevention and integrating biomedical and behavioral approaches to stemming the HIV epidemic.

TRIAL REGISTRATION

Not applicable.

HERMITAGE--a randomized controlled trial to reduce sexually transmitted infections and HIV risk behaviors among HIV-infected Russian drinkers

AIMS

This study assessed the effectiveness of HERMITAGE (HIV's Evolution in Russia-Mitigating Infection Transmission and Alcoholism in a Growing Epidemic), an adapted secondary HIV prevention intervention, compared with an attention control condition in decreasing sexually transmitted infections (STIs) and sex and drug risk behaviors among Russian HIV-infected heavy drinkers.

DESIGN

We conducted a single-blinded, two-armed, randomized controlled trial with 12-month follow-up.

SETTING

The study was conducted in St Petersburg, Russia. Participants were recruited from four HIV and addiction clinical sites. The intervention was conducted at Botkin Infectious Disease Hospital.

PARTICIPANTS

HIV-infected individuals with past 6-month risky sex and heavy alcohol consumption (n = 700) were randomized to the HERMITAGE intervention (n = 350) or an attention control condition (n = 350).

INTERVENTION

A Healthy Relationships Intervention stressing disclosure of HIV serostatus and condom use, adapted for a Russian clinical setting with two individual sessions and three small group sessions.

MEASUREMENTS

The primary outcome was incident STI by laboratory test at 12-month follow-up. Secondary outcomes included change in unprotected sex and several alcohol and injection drug use (IDU) variables.

FINDINGS

Participants had the following baseline characteristics: 59.3% male, mean age 30.1, 60.4% past year IDU, 15.4% prevalent STI and mean CD4 cell count 413.3/μl. Assessment occurred among 75 and 71% of participants at 6 and 12 months, respectively. STIs occurred in 20 subjects (8.1%) in the intervention group and 28 subjects (12.0%) in the control group at 12-month follow-up; logistic regression analyses found no significant difference between groups (adjusted odds ratio 0.63; 95% confidence interval = 0.34-1.18; P = 0.15). Both groups decreased unsafe behaviors, although no significant differences were found between groups.

CONCLUSIONS

The HERMITAGE HIV risk reduction intervention does not appear to reduce sexually transmitted infections and HIV risk behaviors in Russian HIV-infected heavy drinkers compared with attention controls.

Systematic assessment of condom use measurement in evaluation of HIV prevention interventions: need for standardization of measures

When evaluating HIV prevention interventions, condom use is a common outcome measure used to assess changes in HIV-related behaviors; however, no widely accepted standards exist for its measurement. Using systematic review data on HIV prevention interventions conducted in low- and middle-income countries, we examined trends in condom use measurement since 1990. We abstracted data from standardized forms on six dimensions of condom use: partner type, temporal period, measurement scale, consistency, controlling for abstinence, and type of sex. Of 215 studies reviewed, 109 studies (51 %) measured condom use as a primary outcome. Outcomes were stratified by partner type in 47 studies (43 %). Assessing condom use at last sex was the most common measurement. Consistency of condom use was assessed in 47 studies (43 %). Developing and utilizing standards for condom use measurement would increase comparability of findings across studies and benefit HIV prevention research. Recommendations include measuring condom use at last sex, frequency of condom use, and number of protected sex acts in studies evaluating the efficacy of behavioral interventions on sexual risk behavior.

Examining the role of serostatus disclosure on unprotected sex among people living with HIV

Given the increasing prevalence of HIV, it is important to identify factors associated with safer sex behaviors between people living with HIV and their partners. Utilizing a diverse sample of 242 HIV-infected adults [n=69 men who have sex with men (MSM); n=68 men who have sex with women (MSW); n=105 women who have sex with men (WSM)], we examined the association between serostatus disclosure and unprotected anal or vaginal intercourse (UAVI) and the moderating effect of sexual behavior group on this association. Overall, 88.7% disclosed to their current partner. Approximately 18.8% of MSM, 17.7% of MSW, and 29.5% of WSM reported UAVI. Controlling for age, time since diagnosis, and partner serostatus, we found main effects on UAVI for disclosure and sexual behavior group; specifically, disclosure was inversely related to unprotected sex [AOR=0.09, 95% CI (0.02, 0.43), p<0.001], and MSM were less likely to engage in UAVI relative to WSM [AOR=0.11, 95% CI (0.17, 0.82), p<0.05]. However, the relationship between disclosure and UAVI was not moderated by sexual behavior group. Future strategies that aim to increase disclosure to partners may consider focusing on its value as a means by which to reduce sexual risk behavior.

Sexual risk reduction for HIV-infected persons: a meta-analytic review of "positive prevention" randomized clinical trials

BACKGROUND

Prevention intervention trials have been conducted to reduce risk of sexual transmission among people living with HIV/AIDS (PLWHA), but the findings were inconsistent. We performed a systematic review and meta-analysis to evaluate overall efficacy of prevention interventions on unprotected vaginal or anal intercourse (UVAI) among PLWHA from randomized clinical trials (RCTs).

METHODS

RCTs of prevention interventions among PLWHA published as of February 2012 were identified by systematically searching thirteen electronic databases. The primary outcome was UVAI. The difference of standardized mean difference (SMD) of UVAI between study arms, defined as effect size (ES), was calculated for each study and then pooled across studies using standard meta-analysis with a random effects model.

RESULTS

Lower likelihood of UVAI was observed in the intervention arms compared with the control arms either with any sexual partners (mean ES: -0.22; 95% confidence interval [CI]: -0.32, -0.11) or with HIV-negative or unknown-status sexual partners (mean ES and 95% CI: -0.13 [-0.22, -0.04]). Short-term efficacy of interventions with ≤ 10 months of follow up was significant in reducing UVAI (1-5 months: -0.27 [-0.45, -0.10]; 6-10 months: -0.18 [-0.30, -0.07]), while long-term efficacy of interventions was weaker and might have been due to chance (11-15 months: -0.13 [-0.34, 0.08]; >15 months: -0.05 [-0.43, 0.32]).

CONCLUSIONS

Our meta-analyses confirmed the short-term impact of prevention interventions on reducing self-reported UVAI among PLWHA irrespective of the type of sexual partner, but did not support a definite conclusion on long-term effect. It is suggested that booster intervention sessions are needed to maintain a sustainable reduction of unprotected sex among PLWHA in future risk reduction programs.

A marginalized zero-inflated Poisson regression model with overall exposure effects

The zero-inflated Poisson (ZIP) regression model is often employed in public health research to examine the relationships between exposures of interest and a count outcome exhibiting many zeros, in excess of the amount expected under sampling from a Poisson distribution. The regression coefficients of the ZIP model have latent class interpretations, which correspond to a susceptible subpopulation at risk for the condition with counts generated from a Poisson distribution and a non-susceptible subpopulation that provides the extra or excess zeros. The ZIP model parameters, however, are not well suited for inference targeted at marginal means, specifically, in quantifying the effect of an explanatory variable in the overall mixture population. We develop a marginalized ZIP model approach for independent responses to model the population mean count directly, allowing straightforward inference for overall exposure effects and empirical robust variance estimation for overall log-incidence density ratios. Through simulation studies, the performance of maximum likelihood estimation of the marginalized ZIP model is assessed and compared with other methods of estimating overall exposure effects. The marginalized ZIP model is applied to a recent study of a motivational interviewing-based safer sex counseling intervention, designed to reduce unprotected sexual act counts.

HPTN 062: a feasibility and acceptability pilot intervention to reduce HIV transmission risk behaviors among individuals with acute and early HIV infection in Lilongwe, Malawi

Acute HIV infection (AHI) is a relatively brief period of time when individuals are highly infectious and the opportunity to intervene to prevent forward transmission is extremely limited. HPTN 062 partnered with CHAVI 001 to evaluate the feasibility and acceptability of a motivational interviewing (MI)-based counseling intervention to reduce HIV-transmission risk behaviors among individuals with acute and early HIV infection in Lilongwe, Malawi. Participants were randomized to receive either (1) brief education sessions about HIV and AHI; or (2) the same brief education sessions plus an MI-based counseling intervention called Uphungu Wanga. Although Uphungu Wanga was determined to be feasible and acceptable, few major differences existed between the two arms with regard to acceptability, feasibility, and self-reported sexual behaviors. We therefore conclude that an additional MI-based counseling intervention may not be needed during the short period of AHI. Instead, we recommend that individuals with AHI receive frequent, but brief, counseling immediately after diagnosis and then transition to receiving counseling at less frequent intervals until they can initiate antiretroviral therapy. Other recommendations are provided.

Positive choices: outcomes of a brief risk reduction intervention for newly HIV-diagnosed men who have sex with men

Positive choices (PC), a brief sexual risk reduction intervention conducted with newly HIV-diagnosed men who have sex with men (MSM), was evaluated for preliminary efficacy. Participants were enrolled if they reported unprotected anal intercourse (UAI) in the three months prior to HIV diagnosis (n = 102). Three months after diagnosis, participants completed baseline assessments and were randomly assigned to receive the 3-session PC intervention or the comprehensive standard of care (C-SoC) at a community health center. Participants completed assessments at 3- (post intervention), 6-, and 9- months after baseline. Compared to C-SoC participants, PC participants significantly reduced the frequency of UAI with HIV serodiscordant (HIV negative or status unknown) partners over the 9-month follow-up period. No differences by condition were found in the frequency of UAI with all partners. The findings from this trial suggest that brief risk reduction approaches for newly-diagnosed MSM integrated into HIV care can benefit secondary HIV prevention efforts.

HIV prevention in clinical care settings: 2014 recommendations of the International Antiviral Society-USA Panel

IMPORTANCE

Emerging data warrant the integration of biomedical and behavioral recommendations for human immunodeficiency virus (HIV) prevention in clinical care settings.

OBJECTIVE

To provide current recommendations for the prevention of HIV infection in adults and adolescents for integration in clinical care settings.

DATA SOURCES, STUDY SELECTION, AND DATA SYNTHESIS

Data published or presented as abstracts at scientific conferences (past 17 years) were systematically searched and reviewed by the International Antiviral (formerly AIDS) Society-USA HIV Prevention Recommendations Panel. Panel members supplied additional relevant publications, reviewed available data, and formed recommendations by full-panel consensus.

RESULTS

Testing for HIV is recommended at least once for all adults and adolescents, with repeated testing for those at increased risk of acquiring HIV. Clinicians should be alert to the possibility of acute HIV infection and promptly pursue diagnostic testing if suspected. At diagnosis of HIV, all individuals should be linked to care for timely initiation of antiretroviral therapy (ART). Support for adherence and retention in care, individualized risk assessment and counseling, assistance with partner notification, and periodic screening for common sexually transmitted infections (STIs) is recommended for HIV-infected individuals as part of care. In HIV-uninfected patients, those persons at high risk of HIV infection should be prioritized for delivery of interventions such as preexposure prophylaxis and individualized counseling on risk reduction. Daily emtricitabine/tenofovir disoproxil fumarate is recommended as preexposure prophylaxis for persons at high risk for HIV based on background incidence or recent diagnosis of incident STIs, use of injection drugs or shared needles, or recent use of nonoccupational postexposure prophylaxis; ongoing use of preexposure prophylaxis should be guided by regular risk assessment. For persons who inject drugs, harm reduction services should be provided (needle and syringe exchange programs, supervised injection, and available medically assisted therapies, including opioid agonists and antagonists); low-threshold detoxification and drug cessation programs should be made available. Postexposure prophylaxis is recommended for all persons who have sustained a mucosal or parenteral exposure to HIV from a known infected source and should be initiated as soon as possible.

CONCLUSIONS AND RELEVANCE

Data support the integration of biomedical and behavioral approaches for prevention of HIV infection in clinical care settings. A concerted effort to implement combination strategies for HIV prevention is needed to realize the goal of an AIDS-free generation.

Reliability and validity of a treatment fidelity assessment for motivational interviewing targeting sexual risk behaviors in people living with HIV/AIDS

This study psychometrically evaluates the Motivational Interviewing Treatment Integrity Code (MITI) to assess fidelity to motivational interviewing to reduce sexual risk behaviors in people living with HIV/AIDS. 74 sessions from a pilot randomized controlled trial of motivational interviewing to reduce sexual risk behaviors in people living with HIV were coded with the MITI. Participants reported sexual behavior at baseline, 3-month, and 6-months. Regarding reliability, excellent inter-rater reliability was achieved for measures of behavior frequency across the 12 sessions coded by both coders; global scales demonstrated poor intraclass correlations, but adequate percent agreement. Regarding validity, principle components analyses indicated that a two-factor model accounted for an adequate amount of variance in the data. These factors were associated with decreases in sexual risk behaviors after treatment. The MITI is a reliable and valid measurement of treatment fidelity for motivational interviewing targeting sexual risk behaviors in people living with HIV/AIDS.

Motivational interviewing by HIV care providers is associated with patient intentions to reduce unsafe sexual behavior

OBJECTIVE

Motivational interviewing (MI) can promote behavior change, but HIV care providers rarely have training in MI. Little is known about the use of MI-consistent behavior among untrained providers. This study examines the prevalence of such behaviors and their association with patient intentions to reduce high-risk sexual behavior.

METHODS

Audio-recorded visits between HIV-infected patients and their healthcare providers were searched for counseling dialog regarding sexual behavior. The association of providers' MI-consistence with patients' statements about behavior change was assessed.

RESULTS

Of 417 total encounters, 27 met inclusion criteria. The odds of patient commitment to change were higher when providers used more reflections (p=0.017), used more MI consistent utterances (p=0.044), demonstrated more empathy (p=0.049), and spent more time discussing sexual behavior (p=0.023). Patients gave more statements in favor of change (change talk) when providers used more reflections (p<0.001) and more empathy (p<0.001), even after adjusting for length of relevant dialog.

CONCLUSION

Untrained HIV providers do not consistently use MI techniques when counseling patients about sexual risk reduction. However, when they do, their patients are more likely to express intentions to reduce sexual risk behavior.

PRACTICE IMPLICATIONS

MI holds promise as one strategy to reduce transmission of HIV and other sexually transmitted infections.

Do safer sex self-efficacy, attitudes toward condoms, and HIV transmission risk beliefs differ among men who have sex with men, heterosexual men, and women living with HIV?

To understand sexual decision-making processes among people living with HIV, we compared safer sex self-efficacy, condom attitudes, sexual beliefs, and rates of unprotected anal or vaginal intercourse with at-risk partners (UAVI-AR) in the past 3 months among 476 people living with HIV: 185 men who have sex with men (MSM), 130 heterosexual men, and 161 heterosexual women. Participants were enrolled in SafeTalk, a randomized, controlled trial of a safer sex intervention. We found 15% of MSM, 9% of heterosexual men, and 12% of heterosexual women engaged in UAVI-AR. Groups did not differ in self-efficacy or sexual attitudes/beliefs. However, the associations between these variables and UAVI-AR varied within groups: greater self-efficacy predicted less UAVI-AR for MSM and women, whereas more positive condom attitudes--but not self-efficacy--predicted less UAVI-AR for heterosexual men. These results suggest HIV prevention programs should tailor materials to different subgroups.

Current interventions to reduce sexual risk behaviors and crack cocaine use among HIV-infected individuals

The dual global epidemics of crack cocaine use and HIV have resulted in a large number of people living with HIV who use crack cocaine, many of whom continue to engage in unprotected sex. Crack use also increases the rate of HIV progression. Consequently, there is an urgent need for effective interventions to decrease crack use and unprotected sex and to improve antiretroviral therapy (ART) adherence in this population. This article reviews the recent published literature on interventions for reducing crack use and unprotected sex among people living with HIV. Only a few intervention outcome studies targeting exclusively HIV positive crack cocaine users were identified, whereas other studies used a mixed sample. Some interventions focused on reducing crack use and several focused on reducing sex-risk behaviors. Consequently, there is a critical need for efficacious interventions that address crack use, risky sex and ART adherence among people living with HIV.

Motivational interviewing targeting risk reduction for people with HIV: a systematic review

Due to the co-occurrence of sexual risk behaviors and substance use among HIV-positive individuals, there is often a need for HIV prevention efforts to target multiple behaviors. Motivational Interviewing (MI), a widely disseminated behavior change intervention, has demonstrated effectiveness in promoting behavior change among persons with HIV and has been utilized to target these co-occurring risk behaviors. To identify the efficacy of MI in relation to sexual risk and substance use, we conducted a systematic review of research literature published before May 2012, which focused on treatment fidelity, study design, and findings. Results suggest that MI has the potential to reduce sexual risk behavior, but the effects on reducing substance use were less consistent. We identify opportunities for future research with HIV-positive individuals, including the development of interventions assessing the effects of MI on illicit drug use, utilizing higher fidelity standards in intervention implementation and studies of transportability and cost-effectiveness.

Serostatus disclosure to sexual partners among people living with HIV: examining the roles of partner characteristics and stigma

HIV serostatus disclosure among people living with HIV/AIDS (PLWHA) is an important component of preventing HIV transmission to sexual partners. Due to barriers like stigma, however, many PLWHA do not disclose their serostatus to all sexual partners. This study explored differences in HIV serostatus disclosure based on sexual behavior subgroup (men who have sex with men [MSM]; heterosexual men; and women), characteristics of the sexual relationship (relationship type and HIV serostatus of partner), and perceived stigma. We examined disclosure in a sample of 341 PLWHA: 138 MSM, 87 heterosexual men, and 116 heterosexual women who were enrolled in SafeTalk, a randomized, controlled trial of a safer sex intervention. We found that, overall, 79% of participants disclosed their HIV status to all sexual partners in the past 3 months. However, we found important differences in disclosure by subgroup and relationship characteristics. Heterosexual men and women were more likely to disclose their HIV status than MSM (86%, 85%, and 69%, respectively). Additionally, disclosure was more likely among participants with only primary partners than those with only casual or both casual and primary partners (92%, 54%, and 62%, respectively). Participants with only HIV-positive partners were also more likely to disclose than those with only HIV-negative partners, unknown serostatus partners, or partners of mixed serostatus (96%, 85%, 40%, and 60%, respectively). Finally, people who perceived more HIV-related stigma were less likely to disclose their HIV serostatus to partners, regardless of subgroup or relationship characteristics. These findings suggest that interventions to help PLWHA disclose, particularly to serodiscordant casual partners, are needed and will likely benefit from inclusion of stigma reduction components.

Motivational interviewing for improving outcomes in youth living with HIV

BACKGROUND

Almost half of all the new HIV infections occur in youth. Motivational interviewing (MI) is a counselling technique that is effective in bringing about positive behavior changes in the general population. It is unclear whether it can be used to improve outcomes in youth living with HIV.

OBJECTIVES

To determine whether MI is effective in improving outcomes in youth living with HIV.

SEARCH METHODS

We used a comprehensive and exhaustive strategy in an attempt to identify all relevant studies, regardless of language or publication status, in electronic databases (PubMed, the Cochrane Central Register of Controlled Trials, EMBASE, LILACS, CINAHL, PsycINFO), conference proceedings and specialised databases from January 1980 to March 2012.

SELECTION CRITERIA

Randomised controlled trials (RCTs) in which youth (aged 10 to 24) living with HIV received MI, singly or in combination with another intervention compared to any other intervention, and reporting on the outcomes of interest (adherence to medication, mortality, quality of life, viral load, CD4-positive-T-lymphocyte count, progression to AIDS, retention in care, substance abuse and condom use). All settings were considered.

DATA COLLECTION AND ANALYSIS

We identified 863 references.Two authors independently examined the titles and abstracts of all identified trials, of which 28 full-text articles were closely screened for eligibility based on criteria established a-priori. The included studies were appraised for quality in duplicate. Data were extracted using a pre-tested and standardised form. No meta-analyses were performed.

MAIN RESULTS

Two trials located in the United States, reported in four papers met our inclusion criteria. They enrolled a total of 237 participants and compared motivational interviewing singly to standard of care. None of these trials reported on adherence to HIV medication, mortality or quality of life. Both trials reported reductions in viral load (in the short term) and unprotected sexual acts. A reduction in alcohol use was identified only in one of two studies that reported on this outcome. One trial reported on retention. Retention rates were not affected by the intervention.

AUTHORS' CONCLUSIONS

There is moderate quality evidence, coming from two trials which suggests that MI is effective in reducing short term viral load and unprotected sexual acts. There is moderate quality evidence from one trial that MI is effective in reducing alcohol use. There is a need for more trials which report on outcomes such as adherence to medication, mortality and quality of life in youth.