A Protocol for the Analytical Aspects of a Systematic Review of HIV Prevention Research:

Association of Back Pain with Mortality: a Systematic Review and Meta-analysis of Cohort Studies

BACKGROUND

Back pain is the most common cause of disability worldwide. While disability generally is associated with greater mortality, the association between back pain and mortality is unclear. Our objective was to examine whether back pain is associated with increased mortality risk and whether this association varies by age, sex, and back pain severity.

METHODS

A systematic search of published literature was conducted using PubMed, Web of Science, and Embase databases from inception through March 2019. We included English-language prospective cohort studies evaluating the association of back pain with all-cause mortality with follow-up periods >5 years. Three reviewers independently screened studies, abstracted data, and appraised risk of bias using the Quality in Prognosis Studies (QUIPS) tool. A random-effects meta-analysis estimated combined odds ratios (OR) and 95% confidence intervals (CI), using the most adjusted model from each study. Potential effect modification by a priori hypothesized factors (age, sex, and back pain severity) was evaluated with meta-regression and stratified estimates.

RESULTS

We identified eleven studies with 81,337 participants. Follow-up periods ranged from 5 to 23 years. The presence of any back pain, compared to none, was not associated with an increase in mortality (OR, 1.06; 95% CI, 0.97 to 1.16). However, back pain was associated with mortality in studies of women (OR, 1.22; 95% CI, 1.02 to 1.46) and among adults with more severe back pain (OR, 1.26; 95% CI, 1.14 to 1.40).

CONCLUSION

Back pain was associated with a modest increase in all-cause mortality among women and those with more severe back pain.

Research Synthesis, HIV Prevention Response, and Public Health: CDC's HIV/AIDS Prevention Research Synthesis Project

OBJECTIVE

Research synthesis, through qualitative or quantitative systematic reviews, allows for integrating results of primary research to improve public health. We examined more than 2 decades of work in HIV prevention by the Centers for Disease Control and Prevention's (CDC's) HIV/AIDS Prevention Research Synthesis (PRS) Project. We describe the context and contributions of research synthesis, including systematic reviews and meta-analyses, through the experience of the PRS Project.

METHODS

We reviewed PRS Project publications and products and summarized PRS contributions from 1996 to July 2020 in 4 areas: synthesis of interventions and epidemiologic studies, synthesis methods, prevention programs, and prevention policy.

RESULTS

PRS Project publications summarized risk behaviors and effects of prevention interventions (eg, changing one's perception of risk, teaching condom negotiation skills) across populations at risk for HIV infection and intervention approaches (eg, one-on-one or group meetings) as the HIV/AIDS epidemic and science evolved. We used the PRS Project cumulative database and intervention efficacy reviews to contribute to prevention programs and policies through identification of evidence-based interventions and development of program guidance. Subject matter experts and scientific evidence informed PRS Project products and contributions, which were implemented through strategic programmatic partnerships.

CONCLUSIONS

The contributions of the PRS Project to HIV prevention and public health efforts in the United States can be credited to CDC's long-standing support of the project and its context within a federal prevention agency, where HIV programs and policies were developed and implemented. The effect of the PRS Project was likely facilitated by opportunities to directly influence program and policy because of connections with other research translation activities and program and policy decision making within CDC.

Marijuana use and physical dating violence among adolescents and emerging adults: A systematic review and meta-analysis

BACKGROUND

As restrictions on marijuana are loosened, there is concern of a coming increase in marijuana use among adolescents and emerging adults, which could be coupled with commensurate increases in behavioral problems associated with use, such as physical dating violence (PDV). To summarize what is known about the association between marijuana use and PDV victimization and perpetration among 11-21year olds, we conducted a systematic review and meta-analysis of the relevant literature published between 2003 and 2015.

METHODS

Candidate articles were identified with a systematic search, and we used inclusion and exclusion criteria to review titles, abstracts, and the full text of studies for consideration. There were 13 articles examining marijuana in association with PDV; five addressed victimization and 11 addressed perpetration.

RESULTS

Findings suggest that marijuana use is associated with a 54% increase in the odds PDV victimization, and a 45% increase in the odds of perpetration.

CONCLUSIONS

Findings suggest that dating violence is a correlate of marijuana use, and that association is strongest among adolescents (vs. emerging adults) and girls (vs. boys). Therefore, it should be routinely included as a core data item in marijuana surveillance systems, so as to allow for behavioral monitoring.

HIV Risk-Reduction Strategies for Substance Abusers: Effecting Behavior Change

Substance abuse has a strong link to HIV/AIDS in the United States. Use and abuse of alcohol and other drugs often reduce inhibitions and encourage engagement in high-risk sexual behaviors that can ultimately result in HIV and AIDS. The HIV/AIDS epidemic in the United States has disproportionately affected minorities with African Americans being the group hardest hit. This article presents some of the behavioral, social, and psychological factors that influence the risk for drug use. It highlights and assesses the effectiveness of HIV risk-reduction strategies developed for drug-using populations and makes recommendations for a more holistic and integrated approach utilizing multiple interventions at multiple levels.

An international systematic review and meta-analysis of multisession psychosocial interventions compared with educational or minimal interventions on the HIV sex risk behaviors of people who use drugs

This systematic review and meta-analysis examines the effectiveness of multisession psychosocial interventions compared with educational interventions and minimal interventions in reducing sexual risk in people who use drugs (51 studies; 19,209 participants). We conducted comprehensive searches (MEDLINE, EMBASE, CINAHL, Cochrane Central Register of Controlled Trials and PsychINFO 1998-2012). Outcomes (unprotected sex, condom use, or a composite outcome) were extracted by two authors and synthesised using meta-analysis. Subgroup analyses and meta-regression were conducted to explore heterogeneity. Multisession psychosocial interventions had modest additional benefits compared to educational interventions (K = 46; OR 0.86; 95% CI 0.77, 0.96), and large positive effects compared to minimal interventions (K = 7; OR 0.60; 95% CI 0.46, 0.78). Comparison with previous meta-analyses suggested limited progress in recent years in developing more effective interventions. Multisession psychosocial and educational interventions provided similar modest sexual risk reduction justifying offering educational interventions in settings with limited exposure to sexual risk reduction interventions, messages, and resources.

Does the alcohol make them do it? Dating violence perpetration and drinking among youth

Strong evidence links alcohol use to partner violence perpetration among adults, but the relation between youth alcohol use and dating violence perpetration (DVP) is not as well studied. The authors used meta-analytic procedures to evaluate current knowledge on the association between alcohol use and DVP among youth. The authors reviewed 28 studies published in 1985-2010; most (82%) were cross-sectional. Alcohol use was measured in 3 main ways: 1) frequency or quantity of use, 2) frequency of heavy episodic drinking, or 3) problem use. Collectively, results support the conclusion that higher levels of alcohol use are positively associated with youth DVP. With fixed-effects models, the combined odds ratios for DVP for frequency/quantity, heavy episodic drinking, and problem use were 1.23 (95% confidence interval (CI): 1.16, 1.31), 1.47 (95% CI: 1.17, 1.85), and 2.33 (95% CI: 1.94, 2.80), respectively. This association persisted even after accounting for heterogeneity and publication bias. No studies were designed to assess the immediate temporal association between drinking and DVP. Future research should assess whether there are acute or pharmacologic effects of alcohol use on youth DVP. Furthermore, few studies have been hypothesis driven, controlled for potential confounding, or examined potential effect measure modification. Studies designed to investigate the youth alcohol-DVP link specifically, and whether results vary by individuals' gender, developmental stage, or culture, are needed.

Efficacy of structural-level condom distribution interventions: a meta-analysis of U.S. and international studies, 1998-2007

This systematic review examines the overall efficacy of U.S. and international-based structural-level condom distribution interventions (SLCDIs) on HIV risk behaviors and STIs and identifies factors associated with intervention efficacy. A comprehensive literature search of studies published from January 1988 through September 2007 yielded 21 relevant studies. Significant intervention effects were found for the following outcomes: condom use, condom acquisition/condom carrying, delayed sexual initiation among youth, and reduced incident STIs. The stratified analyses for condom use indicated that interventions were efficacious for various groups (e.g., youth, adults, males, commercial sex workers, clinic populations, and populations in areas with high STI incidence). Interventions increasing the availability of or accessibility to condoms or including additional individual, small-group or community-level components along with condom distribution were shown to be efficacious in increasing condom use behaviors. This review suggests that SLCDIs provide an efficacious means of HIV/STI prevention.

Amphetamine-group substances and HIV

Amphetamine-group substances are used worldwide and are more prevalent than either cocaine or opioids. We reviewed published reports about amphetamine-group substances and did a meta-analysis of randomised controlled trials of behavioural interventions for their use. Most research was done in developed countries. Many, but not all, studies show an association between amphetamine-group substance use and risk of HIV infection. Much use of amphetamine-group substances is non-injection and is associated with increased HIV risk, particularly in men who have sex with men. The structural, social, interpersonal, and personal factors that link to amphetamine-group substance use and HIV risk are poorly understood. 13 studies, with a cumulative sample size of 1997 individuals, qualified for the meta-analysis. Overall, high-intensity behavioural interventions were moderately effective in reducing use of amphetamine-group substances (effect size 0.28, 95% CI 0.13-0.44). We did not find conclusive evidence that behavioural interventions as a group are more effective than are passive or minium treatment for reduction of amphetamine-group substance use or sexual risk behaviours. The search for effective, scalable, and sustainable interventions for amphetamine-group substance use, including pharmacotherapies, should be supported and encouraged.

Efficacy of a web-based intervention to reduce sexual risk in men who have sex with men

To the extent that men who have sex with men (MSM) use the Internet, it serves as a promising medium for behavioral intervention. The present study sought to investigate the efficacy of a web-based skills training and motivational intervention in a randomized trial (N = 112) conducted completely online. After a detailed assessment, MSM were randomly assigned to an online intervention or a control website. The experimental intervention consisted of risk assessment and feedback, motivational exercises, skills training, and education while the control intervention focused on relaxation skills. Follow-up data were collected 3 months later and analyzed with repeated-measures MANOVA. Although both groups evidenced across-the-board reductions in unprotected sex, perhaps due to the detailed assessment, the experimental group showed greater reductions with the riskiest partners, those of positive or unknown serostatus. Thus, this study gives preliminary evidence that a brief web-based intervention offering cognitive behavioral skills training and motivational enhancement can effectively reduce sexual risk in MSM.

The efficacy of HIV/STI behavioral interventions for African American females in the United States: a meta-analysis

OBJECTIVES

We evaluated the efficacy of HIV behavioral interventions for African American females in the United States, and we identified factors associated with intervention efficacy.

METHODS

We conducted a comprehensive literature review covering studies published from January 1988 to June 2007, which yielded 37 relevant studies. Data were analyzed using mixed-effects models and meta-regression.

RESULTS

Overall, behavioral interventions had a significant impact on reductions in HIV-risk sex behaviors (odds ratio [OR] = 0.63; 95% confidence interval [CI] = 0.54, 0.75; n = 11 239; Cochrane Q(32) = 84.73; P < .001) and sexually transmitted infections (STIs; OR = 0.81; 95% CI = 0.67, 0.98; n = 8760; Cochrane Q(16) = 22.77; P = .12). Greater intervention efficacy was observed in studies that specifically targeted African American females used gender- or culture-specific materials, used female deliverers, addressed empowerment issues, provided skills training in condom use and negotiation of safer sex, and used role-playing to teach negotiation skills.

CONCLUSIONS

Behavioral interventions are efficacious at preventing HIV and STIs among African American females. More research is needed to examine the potential contribution of prevention strategies that attend to community-level and structural-level factors affecting HIV infection and transmission in this population.

A comparative analysis of sexual risk characteristics of Black men who have sex with men or with men and women

Many behavioral studies of Black men fail to differentiate between those who have sex exclusively with men (MSM) and those who have sex with both men and women (MSMW). Respondent-driven sampling was used to recruit a total of 1,154 Black MSM and MSMW in New York City and Philadelphia. In descriptive analyses, MSMW and MSM were compared on several demographic, health, and behavioral risk correlates using chi-square tests. Differences in prevalence of unprotected anal intercourse (UAI) between these two groups were examined in two multivariate logistic regressions. Age, country of birth, self-identified sexual orientation, experience of being forced to have sex, self-reported HIV status, exchange sex for money/food/ drug, and drug use in the past 3 months were significantly associated with either insertive or receptive UAI in the past 3 months. The strongest correlate of either insertive or receptive UAI among both groups of men was engaging in exchange sex. Differences between MSMW and MSM were found in the areas of forced sexual experiences, disclosure of same sex behavior, and history of being arrested or incarcerated. Findings from our study highlight the need for specific HIV prevention interventions targeting Black MSMW as distinguished from Black MSM.

Behavioral interventions to reduce risk for sexual transmission of HIV among men who have sex with men

BACKGROUND

Men who have sex with men (MSM) remain at great risk for HIV infection. Program planners and policy makers need descriptions of interventions and quantitative estimates of intervention effects to make informed decisions concerning prevention funding and research. The number of intervention strategies for MSM that have been examined with strong research designs has increased substantially in the past few years.

OBJECTIVES

1. To locate and describe outcome studies evaluating the effects of behavioral HIV prevention interventions for MSM.2. To summarize the effectiveness of these interventions in reducing unprotected anal sex.3. To identify study characteristics associated with effectiveness.4. To identify gaps and indicate future research, policy, and practice needs.

SEARCH STRATEGY

We searched electronic databases, current journals, manuscripts submitted by researchers, bibliographies of relevant articles, conference proceedings, and other reviews for published and unpublished reports from 1988 through December 2007. We also asked researchers working in HIV prevention about new and ongoing studies.

SELECTION CRITERIA

Studies were considered in scope if they examined the effects of behavioral interventions aimed at reducing risk for HIV or STD transmission among MSM. We reviewed studies in scope for criteria of outcome relevance (measurement of at least one of a list of behavioral or biologic outcomes, e.g., unprotected sex or incidence of HIV infections) and methodologic rigor (randomized controlled trials or certain strong quasi-experimental designs with comparison groups).

DATA COLLECTION AND ANALYSIS

We used fixed and random effects models to summarize rate ratios (RR) comparing intervention and control groups with respect to count outcomes (number of occasions of or partners for unprotected anal sex), and corresponding prevalence ratios (PR) for dichotomous outcomes (any unprotected anal sex vs. none). We used published formulas to convert effect sizes and their variances for count and dichotomous outcomes where necessary. We accounted for intraclass correlation (ICC) in community-level studies and adjusted for baseline conditions in all studies. We present separate results by intervention format (small group, individual, or community-level) and by type of intervention delivered to the comparison group (minimal or no HIV prevention in the comparison condition versus standard or other HIV prevention in the comparison condition). We examine rate ratios stratified according to characteristics of participants, design, implementation, and intervention content. For small group and individual-level interventions we used a stepwise selection process to identify a multivariable model of predictors of reduction in occasions of or partners for unprotected anal sex. We used funnel plots to examine publication bias, and Q (a chi-squared statistic with degrees of freedom = number of interventions minus 1) to test for heterogeneity.

MAIN RESULTS

We found 44 studies evaluating 58 interventions with 18,585 participants. Formats included 26 small group interventions, 21 individual-level interventions, and 11 community-level interventions. Sixteen of the 58 interventions focused on HIV-positives. The 40 interventions that were measured against minimal to no HIV prevention intervention reduced occasions of or partners for unprotected anal sex by 27% (95% confidence interval [CI] = 15% to 37%). The other 18 interventions reduced unprotected anal sex by 17% beyond changes observed in standard or other interventions (CI = 5% to 27%). Intervention effects were statistically homogeneous, and no independent variable was statistically significantly associated with intervention effects at alpha=.05. However, a multivariable model selected by backward stepwise elimination identified four study characteristics associated with reduction in occasions of or partners for unprotected anal sex among small group and individual-level interventions at alpha=.10. The most favorable reductions in episodes of or partners for unprotected anal sex (33% to 35% decreases) were observed among studies with count outcomes, those with shorter intervention spans (<=1 month), those with better retention in the intervention condition than in the comparison condition, and those with minimal to no HIV prevention intervention delivered to the comparison condition. Because there were only 11 community-level studies we did not search for a multivariable model for community-level interventions. In stratified analyses including only one variable at a time, the greatest reductions (40% to 54% decreases) in number of episodes of or partners for unprotected anal sex among community-level interventions were observed among studies where groups were assigned randomly rather than by convenience, studies with shorter recall periods and longer follow-up, studies with more than 25% non-gay identifying MSM, studies in which at least 90% of participants were white, and studies in which the intervention addressed development of personal skills.

AUTHORS' CONCLUSIONS

Behavioral interventions reduce self-reported unprotected anal sex among MSM. These results indicate that HIV prevention for this population can work and should be supported. Results of previous studies provide a benchmark for expectations in new studies. Meta-analysis can inform future design and implementation in terms of sample size, target populations, settings, goals for process measures, and intervention content. When effects differ by design variables, which are deliberately selected and planned, awareness of these characteristics may be beneficial to future designs. Researchers designing future small group and individual-level studies should keep in mind that to date, effects of the greatest magnitude have been observed in studies that used count outcomes and a shorter intervention span (up to 1 month). Among small group and individual-level studies, effects were also greatest when the comparison condition included minimal to no HIV prevention content. Nevertheless, statistically significant favorable effects were also seen when the comparison condition included standard or other HIV prevention content. Researchers choosing the latter option for new studies should plan for larger sample sizes based on the smaller expected net intervention effect noted above. When effects differ by implementation variables, which become evident as the study is conducted but are not usually selected or planned, caution may be advised so that future studies can reduce bias. Because intervention effects were somewhat stronger (though not statistically significantly so) in studies with a greater attrition in the comparison condition, differential retention may be a threat to validity. Extra effort should be given to retaining participants in comparison conditions. Among community-level interventions, intervention effects were strongest among studies with random assignment of groups or communities. Therefore the inclusion of studies where assignment of groups or communities was by convenience did not exaggerate the summary effect. The greater effectiveness of interventions including more than 25% non-gay identifying MSM suggests that when they can be reached, these men may be more responsive than gay-identified men to risk reduction efforts. Non-gay identified MSM may have had less exposure to previous prevention messages, so their initial exposure may have a greater impact. The greater effectiveness of interventions that include efforts to promote personal skills such as keeping condoms available and behavioral self-management indicates that such content merits strong consideration in development and delivery of new interventions for MSM. And the finding that interventions were most effective for majority white populations underscores the critical need for effective interventions for MSM of African and Latino descent. Further research measuring the incidence of HIV and other STDs is needed. Because most studies were conducted among mostly white men in the US and Europe, more evaluations of interventions are needed for African American and Hispanic MSM as well as MSM in the developing world. More research is also needed to further clarify which behavioral strategies (e.g., reducing unprotected anal sex, having oral sex instead of anal sex, reducing number of partners, avoiding serodiscordant partners, strategic positioning, or reducing anal sex even with condom use) are most effective in reducing transmission among MSM, the messages most effective in promoting these behaviors, and the methods and settings in which these messages can be most effectively delivered.

Abstinence-plus programs for HIV infection prevention in high-income countries

BACKGROUND

Abstinence-plus interventions promote sexual abstinence as the best means of preventing acquisition of HIV, but also encourage safer-sex strategies (eg condom use) for sexually active participants.

OBJECTIVES

To assess the effects of abstinence-plus programs for HIV prevention in high-income countries.

SEARCH STRATEGY

We searched 30 electronic databases (eg CENTRAL, PubMed, EMBASE, AIDSLINE, PsycINFO) ending February 2007. Cross-referencing, hand-searching, and contacting experts yielded additional citations.

SELECTION CRITERIA

We included randomized and quasi-randomized controlled trials evaluating abstinence-plus interventions in high-income countries (as defined by the World Bank). Interventions were any efforts that encouraged sexual abstinence as the best means of HIV prevention, but also promoted safer sex. Results were self-reported biological outcomes, behavioral outcomes, and HIV knowledge.

DATA COLLECTION AND ANALYSIS

Three reviewers independently appraised 20070 citations and 325 full-text papers for inclusion and methodological quality; 39 evaluations were included. Due to heterogeneity and data unavailability, we presented the results of individual studies instead of a meta-analysis.

MAIN RESULTS

Studies enrolled 37724 North American youth; participants were ethnically diverse. Programs took place in schools (10), community facilities (24), both schools and community facilities (2), healthcare facilities (2), and family homes (1). Median final follow-up occurred 12 months after baseline. Results showed no evidence that abstinence-plus programs can affect self-reported sexually transmitted infection (STI) incidence, and limited evidence that programs can reduce self-reported pregnancy incidence. Results for behavioral outcomes were promising; 23 of 39 evaluations found a significantly protective intervention effect for at least one behavioral outcome. Consistently favorable program effects were found for HIV knowledge.No adverse effects were observed. Several evaluations found that one version of an abstinence-plus program was more effective than another, suggesting that more research into intervention mechanisms is warranted. Methodological strengths included large samples and statistical controls for baseline values. Weaknesses included under-utilization of relevant outcomes, self-report bias, and analyses neglecting attrition and clustered randomization.

AUTHORS' CONCLUSIONS

Many abstinence-plus programs appear to reduce short-term and long-term HIV risk behavior among youth in high-income countries. Evidence for program effects on biological measures is limited. Evaluations consistently show no adverse program effects for any outcomes, including the incidence and frequency of sexual activity. Trials comparing abstinence-only, abstinence-plus, and safer-sex interventions are needed.

Abstinence-only programs for HIV infection prevention in high-income countries

BACKGROUND

Abstinence-only interventions promote sexual abstinence as the only means of preventing sexual acquisition of HIV; they do not promote safer-sex strategies (e.g., condom use). Although abstinence-only programs are widespread, there has been no internationally focused review of their effectiveness for HIV prevention in high-income countries.

OBJECTIVES

To assess the effects of abstinence-only programs for HIV prevention in high-income countries.

SEARCH STRATEGY

We searched 30 electronic databases (e.g., CENTRAL, PubMed, EMBASE, AIDSLINE, PsycINFO) ending February 2007. Cross-referencing, handsearching, and contacting experts yielded additional citations through April 2007.

SELECTION CRITERIA

We included randomized and quasi-randomized controlled trials evaluating abstinence-only interventions in high-income countries (defined by the World Bank). Interventions were any efforts to encourage sexual abstinence for HIV prevention; programs that also promoted safer-sex strategies were excluded. Results were biological and behavioral outcomes.

DATA COLLECTION AND ANALYSIS

Three reviewers independently appraised 20,070 records and 326 full-text papers for inclusion and methodological quality; 13 evaluations were included. Due to heterogeneity and data unavailability, we presented the results of individual studies instead of conducting a meta-analysis.

MAIN RESULTS

Studies involved 15,940 United States youth; participants were ethnically diverse. Seven programs were school-based, two were community-based, and one was delivered in family homes. Median final follow-up occurred 17 months after baseline. Results showed no indications that abstinence-only programs can reduce HIV risk as indicated by self-reported biological and behavioral outcomes. Compared to various controls, the evaluated programs consistently did not affect incidence of unprotected vaginal sex, frequency of vaginal sex, number of partners, sexual initiation, or condom use. One study found a significantly protective effect for incidence of recent vaginal sex (n=839), but this was limited to short-term follow-up, countered by measurement error, and offset by six studies with non-significant results (n=2615). One study found significantly harmful effects for STI incidence (n=2711), pregnancy incidence (n=1548), and frequency of vaginal sex (n=338); these effects were also offset by studies with non-significant findings. Methodological strengths included large samples, efforts to improve self-report, and analyses controlling for baseline values. Weaknesses included underutilization of relevant outcomes, underreporting of key data, self-report bias, and analyses neglecting attrition and clustered randomization.

AUTHORS' CONCLUSIONS

Evidence does not indicate that abstinence-only interventions effectively decrease or exacerbate HIV risk among participants in high-income countries; trials suggest that the programs are ineffective, but generalizability may be limited to US youth. Should funding continue, additional resources could support rigorous evaluations with behavioral or biological outcomes. More trials comparing abstinence-only and abstinence-plus interventions are needed.

The effectiveness of individual-, group-, and community-level HIV behavioral risk-reduction interventions for adult men who have sex with men: a systematic review

This article presents the results of a systematic review of the effectiveness and economic efficiency of individual-, group-, and community-level behavioral interventions intended to reduce the risk of acquiring sexually transmitted HIV in adult men who have sex with men (MSM). These results form the basis for recommendations by the Task Force on Community Preventive Services on the use of these interventions. Sexual risk behavior and condom use were the outcomes used to assess effectiveness. Intervention effectiveness on biological outcomes could not be assessed because too few studies of adequate quality have been published. The evidence found in our review shows that individual-level, group-level, and community-level HIV behavioral interventions are effective in reducing the odds of unprotected anal intercourse (range 27% to 43% decrease) and increasing the odds of condom use for the group-level approach (by 81%). The Task Force concluded that the findings are applicable to MSM aged 20 years or older, across a range of settings and populations, assuming that interventions are appropriately adapted to the needs and characteristics of the MSM population of interest. Based on findings from economic evaluation studies, the Task Force also concluded that group- and community-level HIV behavioral interventions for adult MSM are not only cost effective but also result in actual cost savings. Additional information about other effects, barriers to implementation, and research gaps is provided in this paper. The recommendations based on these systematic reviews are expected to serve the needs of researchers, planners, and other public health decision makers.

A systematic review and meta-analysis of behavioral interventions to reduce HIV risk behaviors of Hispanics in the United States and Puerto Rico

This systematic review examines the overall efficacy of HIV behavioral interventions designed to reduce HIV risk behaviors or incident sexually transmitted diseases (STDs) among Hispanics residing in the United States or Puerto Rico. Data from 20 randomized and nonrandomized trials (N = 6,173 participants) available through January 2006 were included in this review. Interventions successfully reduced the odds of unprotected sex and number of sex partners, increased the odds of condom use, and decreased the odds of acquiring new STD infections. Interventions successful in reducing the odds of any sex risk behavior used non-peer deliverers; included >or=4 intervention sessions; taught condom use or problem solving skills; or addressed barriers to condom use, sexual abstinence, or peer norms. Interventions that included the Hispanic cultural belief of machismo or those developed based on ethnographic interviews were successful in reducing the odds of sex risk behaviors among non-drug users. Interventions targeting injection drug users (IDUs; N = 3,569) significantly reduced the odds of injection drug use and the odds of sharing cotton or cookers, but did not significantly reduce the odds of engaging in risky sex behavior or needle sharing. Further development of culturally appropriate HIV prevention interventions for Hispanic populations, particularly men and persons living with HIV, are warranted.

THE PROMISE AND PITFALLS OF SYSTEMATIC REVIEWS

The systematic review "movement" that has transformed medical journal reports of clinical trials and reviews of clinical trials has taken hold in public health, with the most recent milestone, the publication of the first edition of The Guide to Community Health Services in 2005. In this paper we define and distinguish current terms, point out important resources for systematic reviews, describe the impact of systematic review on the quality of primary studies and summaries of the evidence, and provide perspectives on the promise of systematic reviews for shaping the agenda for public health research. Several pitfalls are discussed, including a false sense of rigor implied by the terms "systematic review" and "meta-analysis" and substantial variation in the validity of claims that a particular intervention is "evidence based," and the difficulty of translating conclusions from systematic reviews into public health advocacy and practice.

Behavior change and health-related interventions for heterosexual risk reduction among drug users

Prevention of heterosexual transmission of HIV between and from drug users is important for controlling the local and global HIV heterosexual epidemic. Sex risk reduction interventions and health-related interventions are important for reducing the sex risk behaviors of drug users. Sex risk reduction interventions address individual-level, peer-level, and structural-level determinants of risk reduction. Health-related interventions include HIV counseling and testing, prevention and treatment of sexually transmitted diseases, and delivery of highly active antiretroviral therapy. It is important to adapt effective interventions implemented in resource-rich countries to the realities of the resource-constrained settings and to address relevant contextual factors.

HIV intervention research for men who have sex with men: a 7-year update

We conducted a systematic review and meta-analysis to locate, characterize, and summarize effects of behavioral HIV prevention interventions for men who have sex with men (MSM). We found 54 interventions with 16,224 participants that were evaluated in 40 randomized trials and controlled observational studies with independent comparison groups. Formats included 26 small group interventions, 18 individual-level interventions, and 10 community-level interventions. Fifteen interventions focused on HIV-positive individuals including MSM. The 38 interventions that were compared with minimal or no HIV prevention interventions, reduced unprotected sex by 27% (95% confidence interval [CI] = 15-37%). The other 16 interventions reduced unprotected sex by 17% beyond changes observed in standard or other HIV prevention interventions (CI = 5-27%). Behavioral interventions reduce self-reported unprotected sex among MSM.

Behavioral Interventions—Rationale, Measurement, and Effectiveness

Effective STD and HIV prevention requires synergism of individual-based prevention behaviors and societal/structural supports that will promote and maintain these behaviors. We should also expect the unexpected. STD rates in gay men have risen after effective prevention of HIV/STD in gay men and effective antiretroviral therapy. New drugs of abuse, such as methamphetamine ("crystal meth"), have induced risky sexual behaviors in gay and heterosexual communities. Economic dislocation in Eastern Europe has resulted in trafficking of commercial sex workers to Europe, the Mideast, and Asia, all with the potential for STD and HIV spread. James Curran, formerly director of the HIV epidemiology and prevention effort at the CDC, has written: It is ironic that the two clearest examples of large-scale success in HIV prevention-reduction in HIV transmission in gay men in the United States and national declines in HIV incidence in Thailand-arise in societies/communities known in their own way for sexual openness....the openness in both communities provided the environment to make the powerful revolutionary changes needed. In Africa, the powerful voice of President Museveni of Uganda has also encouraged candor about sexual risk-taking and facilitated that nation's encouraging early success in reducing HIV prevalence...Unfortunately, most of the world remains unable or unwilling to deal frankly and consistently with sexuality despite the considerable risks of HIV infection in many communities. There is a worldwide sexual hangup hampering HIV prevention efforts.

Interventions to modify sexual risk behaviors for preventing HIV infection in men who have sex with men

BACKGROUND

MSM remain at great risk for HIV infection. Program planners and policy makers need descriptions of interventions and quantitative estimates of intervention effects to make informed decisions concerning prevention efforts.

OBJECTIVES

1. To locate and describe outcome studies evaluating the effects of behavioral and social interventions targeting MSM. 2. To summarize the effectiveness of these interventions among MSM. 3. To stratify results by characteristics of interventions and participants. 4. To identify gaps and indicate future research, policy, and practice needs.

SEARCH STRATEGY

We searched electronic databases (MedLine, PsycInfo, etc.); several current journals (e.g., AIDS, AIDS and Behavior, AIDS Education and Prevention, American Journal of Public Health, Journal of Acquired Immune Deficiency Syndromes, etc.); manuscripts submitted by researchers; bibliographies of relevant articles; and other published reviews, for published and unpublished reports from 1988 through 1997.

SELECTION CRITERIA

Studies were considered in scope if they examined the effects of behavioral interventions to reduce risk for HIV or STD transmission. We reviewed studies in scope for criteria of outcome relevance (measurement of at least one of a list of behavioral or biologic outcomes, e.g., unprotected sex or incidence of HIV infections) and methodologic rigor (randomized controlled trials or certain strong quasi-experimental designs with comparison groups).

DATA COLLECTION AND ANALYSIS

As of June 1998 we had identified 13 eligible studies. Twelve studies (7 trials of small group interventions, 3 community-level interventions, and 2 individual level interventions) reported intervention effects on unprotected sex. Because few studies reported effects on condom use (3 studies), number of sex partners without regard to condom use (4 studies), or HIV or STD incidence (1 study in which no infections occurred) we do not address these outcomes at this time. We present those analyses which can be performed in the current Cochrane RevMan software, followed by more complete analyses that permit inclusion of community-level studies, adjustment for baseline conditions, calculation of effect sizes from a wider variety of statistics (e.g., an F-statistic from a one-way ANOVA), and simultaneous meta-analysis of continuous and dichotomous outcomes (Johnson 2002b). We translate the summary effect to reduction in risk behavior based on the background prevalence of unprotected sex. Finally we provide analyses stratified by intervention content (interpersonal skills addressed or not), intervention format (community vs small group or individual) and mean age of participants (23 to 31 vs. 32 to 36).

MAIN RESULTS

A summary measure of intervention effects on reducing unprotected sex was favorable (odds ratio = 0.73) and statistically significant (CI, 0.60 to 0.88), corresponding to a 23% reduction in the proportion of men engaging in unprotected sex. Effects were homogeneous among studies, but were slightly more favorable among community-level interventions, those that served populations in their 20s rather than their 30s, and those that promoted interpersonal skills.

REVIEWER'S CONCLUSIONS

These studies demonstrate that interventions can promote risk reduction among MSM. Yet given the epidemiology of HIV in Pattern I countries, the small number of rigorous controlled intervention trials for this population is striking. Many more rigorous evaluations of HIV prevention efforts with MSM are needed to ascertain with confidence the effects of specific intervention components, population characteristics, and methodologic features.