An HIV-preventive intervention for youth living with HIV

Network Analysis of Organizations Providing HIV Services in Chicago: Toward an Integrated Response to the HIV Epidemic

CONTEXT

The public health response to the HIV epidemic has increasingly centered on the uptake of and adherence to biomedical interventions (eg, pre-exposure prophylaxis [PrEP], treatment as prevention [TasP]). Traditionally, various community and health care organizations have worked to address different stages of PrEP or TasP care.

OBJECTIVE

To understand the importance of how HIV prevention organizations providing these services interact to provide the comprehensive care needed for successful HIV and PrEP continuum outcomes.

DESIGN

Utilizing an Organizational Network Survey, network ties were examined between formal and informal partnerships among community agencies.

SETTING

This study examined community agencies in the current HIV prevention system in Chicago.

PARTICIPANTS

Seventy-two community agencies across the Chicago metropolitan area.

MAIN OUTCOME MEASURES

Using network analysis, this study examined ties between community agencies and assessed perceptions of collaboration and competitiveness in the current HIV prevention system in Chicago.

RESULTS

Overall, respondents reported that the current environment of HIV prevention in Chicago was extremely (18.8%), moderately (37.5%), or somewhat collaborative (37.5%) and extremely (68.8%) or moderately competitive (25.0%). The majority of partnerships reported were informal, with less than a quarter being formalized. That said, those who reported formal partnerships reported being satisfied with those relationships. There was a significantly negative association between density and perceived collaboration-grantees experiencing a more collaborative also reported less dense networks.

CONCLUSION

These findings indicate that, despite perceived competitiveness, agencies are willing to work together and create a cohesive HIV prevention and treatment system. However, more work should be done to foster an environment that can support the formation of partnerships, to improve a coordinated response to providing HIV care, and sustain mutually beneficial relationships.

Non-parental Adults and Sexual Health Behaviors Among Young Minority Men: A Qualitative Examination

Young Black and Latino sexual minority men (YBLSM) exhibit disproportionately high rates of negative sexual health outcomes, including HIV and other sexually transmitted infections, compared to other groups, partly due to relatively higher rates of exposure to a host of socio-structural risk factors (e.g., unstable housing and under-employment). However, an under-studied interpersonal resource exists for many YBLSM, non-parental adults (NPAs, i.e., adults who act as role models and provide social support), who may be able to influence contextual (e.g., unemployment) and individual (e.g., reduced health expectations) factors underlying sexual health disparities.

Aims: This study sought to examine the role of NPAs in factors that affect sexual health behaviors and in supporting those health behaviors directly, among YBLSM living in a mid-sized city in the southern United States. A total of n=20 participants, n=10 YBLSM (ages 16 to 22), and n=10 NPAs (ages 26 to 52) were interviewed using semi-structured guides to examine NPA involvement in the lives of YBLSM from both sides of the relationship. The research team used a framework analysis approach to iteratively identify and define meaningful codes and sub-codes. Both YBLSM and NPAs described NPAs helping YBLSM through role modeling and social support in a variety of areas found to affect sexual health behaviors, such as housing instability and psychological distress, as well as in specific behaviors, such as condom use and HIV medication adherence. Given the multiple socio-structural obstacles facing YBLSM and their multifaceted relationships with NPAs, NPAs may be a promising resource to help address these impediments to health. Partnering more intentionally with NPAs is a potentially promising strategy to help reduce HIV-related disparities affecting YBLSM that is worthy of additional empirical attention.

Impact of peer education on sexual health knowledge among adolescents and young persons in two North Western states of Nigeria

Background

Generally, social development among young people is largely influenced by their peers. Peer education is a proven and effective approach for promoting reproductive health among young people, especially HIV/AIDS education. This study was conducted to assess the effectiveness of a peer-led education intervention in addressing sexual and reproductive health related knowledge and concerns among young people in Kaduna and Kano States, northwest Nigeria.

Methods

A pre and post-test study was conducted among 8930 young people aged 15–24 years who participated in the MTV Shuga Peer Education intervention selected from communities in Kaduna and Kano States. A baseline pre-test was conducted before the education program, and it was followed up with a post-test at the end of the five-day long peer education sessions.

Results

Majority of the respondents, 7846 (87.9%) were adolescents aged 15–19 years while the rest 1084 (12.1%) were young adults aged 20–24 years. A total of 6099 (68.3%) of the respondents correctly stated that condoms prevent pregnancy during the pre-test compared to 6429 (72.0%) peers during the post test. Lower abdominal pain was correctly indicated as a symptom of STI by 6282 (70.3%) and 6984 (78.2%) of the respondents at pre-test and post-test respectively. More males (58.5%) had good knowledge about condom use compared to the females, 51.9% (χ² = 24.62, p < 0.001). while more females (79.6%) compared to 74.7% males opined that going for HIV test with their sexual partner is important to them during the pre-test (χ² = 19.44, p≤ 0.001).However, no significant difference was observed on knowledge of condom use and opinion on going for HIV testing with sexual partner among either gender at post-test.

Conclusion

Significant positive changes in knowledge, views and opinions regarding STIs and HIV, HIV anti-stigma and the use of condoms were observed following exposure to the peer sessions of the MTV Shuga peer education intervention. Sustained exposure and access to informative and enlightening peer education sessions over time have the potential to comprehensively improve SRH knowledge, influence positive opinion change and in turn adoption of positive behaviours among young people.

Peer education is an approach to health promotion, in which community members are supported to promote health-enhancing change among their peers. This approach is being adopted to improve access to comprehensive sexual and reproductive health information among young people. Society for Family Health implemented a peer education intervention (MTV Shuga Naija Peer Education Project) among young people aged 15–24 years in Kaduna and Kano States, Nigeria. This study presents findings on the effectiveness of peer-education in addressing myths, misconceptions and improving knowledge on sexual and reproductive health issues.

The knowledge and opinion of the project beneficiaries were assessed before and after exposure to the project’s interventions (the MTV Shuga drama series and peer education). Findings from both assessments were compared and the results were presented in this article. In total, 8930 persons between the age of 15–24 years were assessed. We observed that more proportion of the respondents after exposure to the project’s intervention correctly identified that condom use can prevent pregnancy and that lower abdominal pain is a sign of sexually transmitted illnesses, when compared to before the intervention. Significant improvement was observed for most of other questions that the respondents were asked about.

We generally observed that the peer education strategy used in this study resulted in the knowledge of HIV/AIDS, sexually transmitted illnesses, contraception, and other reproductive health issues among young people. The use of peer-to-peer education should be encouraged and consistently adopted to improve knowledge of pertinent health issues among young people.

Preventing mental health conditions in adolescents living with HIV: an urgent need for evidence

INTRODUCTION

As adolescents transition from childhood to adulthood, they experience major physical, social and psychological changes, and are at heightened risk for developing mental health conditions and engaging in health-related risk behaviours. For adolescents living with HIV (ALHIV), these risks may be even more pronounced. Research shows that this population may face additional mental health challenges related to the biological impact of the disease and its treatment, the psychosocial burdens of living with HIV and HIV-related social and environmental stressors.

DISCUSSION

Psychosocial interventions delivered to adolescents can promote positive mental health, prevent mental health problems and strengthen young people's capacity to navigate challenges and protect themselves from risk. It is likely that these interventions can also benefit at-risk populations, such as ALHIV, yet there is little research on this. There is an urgent need for more research evaluating the effects of interventions designed to improve the mental health of ALHIV. We highlight four priorities moving forward. These include: generating more evidence about preventive mental health interventions for ALHIV; including mental health outcomes in research on psychosocial interventions for ALHIV; conducting intervention research that is sensitive to differences among ALHIV populations and involving adolescents in intervention design and testing.

CONCLUSIONS

More robust research on promotive and preventive mental health interventions is needed for ALHIV. Programmes should be informed by adolescent priorities and preferences and responsive to the specific needs of these groups.

Agency-Based Empowerment Interventions: Efforts to Enhance Decision-Making and Action in Health and Development

This paper outlines the critical role of personal agency in influencing health and development outcomes and presents a framework for implementing non-therapeutic cognitive-behavioral interventions that foster agency, especially for women, in resource-poor settings. The United Nations' Sustainable Development Goals (SDGs) has placed "empowerment" at the center of global targets, particularly to improve individuals' health and development. Despite extensive research on individual and community empowerment, there is limited focus on the role of psychological and behavioral approaches directly fostering individual and collective agency in health programs. Fundamental to this process is the understanding that decision-making is an interaction between mental processes and one's current context. Approaches that allow individuals to understand how their beliefs, values, emotions, and thoughts impact their behaviors and can be modulated to increase their personal agency are needed. This model is illustrated through a pilot behavioral intervention with women engaged in sex work in Pune, India, demonstrating substantive benefits.

Empowerment Evaluation: A Case Study of Citywide Implementation within an HIV Prevention Context

HIV continues to significantly impact the health of communities, particularly affecting racially and ethnically diverse men who have sex with men and transgender women. In response, health departments often fund a number of community organizations to provide each of these subgroups with comprehensive and culturally responsive services. To this point, evaluators have focused on individual interventions, but have largely overlooked the complex environment in which these interventions are implemented, including other programs funded to do similar work. The Evaluation Center was funded by the City of Chicago in 2015 to conduct a city-wide evaluation of all HIV prevention programming. This article will describe our novel approach to adapt the principles and methods of the Empowerment Evaluation approach, to effectively engage with 20 city-funded prevention programs to collect and synthesize multi-site evaluation data, and ultimately build capacity at these organizations to foster a learning-focused community.

Transhealth Information Project: A Peer-Led HIV Prevention Intervention to Promote HIV Protection for Individuals of Transgender Experience

Individuals of transgender experience (ITE) in the United States face an elevated risk of HIV infection. Several conditions have been attributed to the high HIV incidence and prevalence within this group, including experiences of discrimination, unemployment, incarceration, stigma, and elevated rates of sexual risk and substance use. In response to these needs, the Gay and Lesbian Latino AIDS Education Initiative and Prevention Point Philadelphia, two local community-based organizations in Philadelphia, developed the Transhealth Information Project (TIP). TIP is a peer-led six-session hybrid individual- and group-based intervention emphasizing leadership, social and structural interventions, and HIV risk reduction that incorporates other evidence-based practices for HIV prevention and care. Since 2003, TIP has served over 1,500 ITE and linked them to HIV prevention and care services. TIP has an established record of reaching ITE and linking them to HIV prevention services and HIV primary care. TIP’s utilization speaks to the need for interventions to respond to the complex, interacting syndemic factors that cumulatively determine HIV vulnerability among ITE.

Adaptation of an Evidence-Based Intervention to Reduce HIV Risk in an Underserved Population: Young Minority Men in New York City Jails

To address HIV-risk among justice-involved minority men, New York City Health + Hospitals Correctional Health Services implemented a modified version of Choosing Life: Empowerment, Action Results (CLEAR), an evidence-based intervention to influence behavior. A total of 166 young (i.e., 20-29 years old) minority (e.g., non-Hispanic Black or Latinx) men at risk for HIV and incarcerated in New York City jails completed the adapted group-format intervention and corresponding evaluation assessments. Participants showed significantly improved HIV knowledge on the 18-item HIV-KQ-18 scale (mean increase = 3.11 correct, from 13.23 [SD = 3.80] pre-intervention to 16.34 [SD = 2.29] post-intervention). Similarly, participant summary scores for substance use risk, sexual risk, and health promotion improved significantly. At 90 days after jail release, participants reported improved "CLEAR thinking," reduced risk behaviors and improved health-promoting behaviors. Health and HIV-prevention education programs implemented in the jail setting may help reduce health inequities and improve health outcomes.

First Evaluation of a Contingency Management Intervention Addressing Adolescent Substance Use and Sexual Risk Behaviors: Risk Reduction Therapy for Adolescents

There is a need for interventions that comprehensively address youth substance use disorders (SUD) and sexual risk behaviors. Risk Reduction Therapy for Adolescents (RRTA) adapts a validated family-focused intervention for youth SUD to include sexual risk reduction components in a single intervention. In this first evaluation of RRTA, drug court involved youth were randomly assigned to RRTA (N=45) or usual services (US; N=60) and followed through 12-months post-baseline. RRTA included weekly cognitive behavior therapy and behavior management training and contingency-contracting with a point earning system managed by caregivers targeting drug use and sexual risk antecedents. Longitudinal models estimated within-group change and between-group differences through 6- and 12-month follow-up on outcomes for substance use, sexual risk behaviors, and protective HIV behaviors. Robust effects of the intervention were not detected under conditions of the study that included potent background interventions by the juvenile drug court. Considerations about future development and testing of sexual risk reduction therapy for youth are discussed, including the potential role of contingency management in future interventions.

A qualitative analysis of the concepts of fidelity and adaptation in the implementation of an evidence-based HIV prevention intervention

Continued debate about the relative value of fidelity versus adaptation, and lack of clarity about the meaning of fidelity, raise concerns about how frontline service providers resolve similar issues in their daily practice. We use SISTA ('Sisters Informing Sisters on Topics about acquired immune deficiency syndrome'), an evidence-based human immunodeficiency virus (HIV) prevention intervention for African American women, to understand how facilitators and program directors interpret and enact implementation fidelity with the need for adaptation in real-world program delivery. We conducted 22 in-depth, semi-structured interviews with service providers from four agencies implementing SISTA. Facilitators valued their skills as group leaders and ability to emotionally engage participants as more critical to program effectiveness than delivering the intervention with strict fidelity. Consequently, they saw program manuals as guides rather than static texts that should never be changed and, moreover, viewed the prescriptive nature of manuals as undermining their efforts to fully engage with participants. Our findings suggest that greater consideration should be given to understanding the role of facilitators in program effectiveness over and above the question of whether they implement the program with fidelity. Moreover, training curricula should provide facilitators with transferable skills through general facilitator training rather than only program-specific or manual-specific training.

Translating primary into 'positive' prevention for adolescents in Eastern Africa

There is an urgent need to develop positive prevention interventions for adolescents living with HIV in high endemic regions. Adapting existing evidence-based interventions for resource-constrained settings is effective when the intervention's theoretical core elements are preserved while achieving cultural relevance. We describe the process of adapting a primary prevention to a secondary/positive prevention programme for adolescents living with HIV in Kenya and Uganda. The systematic adaptation was guided by the Centers for Diseases Control's map for the adaptation process, describing an iterative process. The procedure included: assessing the target positive prevention group's needs (safer sex; fertility-related issues), identifying the potential interventions through a literature review, conducting qualitative adaptation research to identify areas for adaptation by ensuring cultural relevance (revising the intervention logic by adding topics such as adherence; HIV-related stigma; HIV-disclosure; safer sex), pilot-testing the adapted programme and conducting a process evaluation of its first implementation. Areas added onto the original intervention's logic framework, based on social cognitive theory, the theories of reasoned action and planned behaviour were information and skills building on sexual relationships and protection behaviour, prevention of vertical HIV transmission, contraception, HIV-disclosure, HIV-related stigma, HIV-treatment and adherence. The process evaluation using mixed methods showed that we delivered a feasible and acceptable intervention for HIV-positive adolescents aged 13-17 years. The systematic approach adopted facilitated the development of a contextualized and developmentally appropriate (i.e. age-specific) intervention for adolescents living with HIV.

Psychosocial influences on engagement in care among HIV-positive young black gay/bisexual and other men who have sex with men

Young black gay/bisexual and other men who have sex with men (YB-GBMSM) living with HIV are at risk for poor engagement in HIV care. Relatively little is known about factors that impact engagement outcomes at various stages along the HIV care continuum in this specific population. The purpose of this analysis was to examine associations between various psychosocial factors and likelihood of engagement at each stage of the care continuum, among a geographically diverse sample of 132 YB-GBMSM living with HIV. Negative self-image, a component of HIV stigma, had an inverse association with early care seeking after HIV diagnosis (OR=1.05; 95% CI 1.01-1.10). Negative self-image was also inversely associated with adherence to medical appointments (OR=0.95; 95% CI 0.91-0.99), while employment (OR=0.30; 95% CI 0.12-0.75) and ethnic identity affirmation (OR=0.28; 95% CI 0.12-0.68) were both positively associated with appointment adherence. HIV-positive identity salience was associated with a higher likelihood of being on antiretroviral therapy (OR=1.06; 95% CI 1.02, 1.09). These findings highlight the importance of processes related to identity development, as both barriers and facilitators of engagement in care for HIV-positive YB-GBMSM.

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.

Risk Reduction Therapy for Adolescents: Targeting Substance Use and HIV/STI-Risk Behaviors

This paper describes a family-based intervention for addressing both substance use and unprotected sexual behavior in adolescents presenting for outpatient substance use treatment. The intervention combines contingency management (CM) for adolescent substance use, which is a behavioral intervention modeled on the Community Reinforcement Approach, with a sexual risk reduction protocol that mirrors aspects of the CM model. As a family-based intervention, caregivers attend every session and actively collaborate with the therapist to address their youth's behavior problems. The treatment is criterion-based with treatment duration determined by the youth's achievement of reduced substance use and unprotected sexual behavior goals. A case study describes the implementation of this treatment with an adolescent presenting a history of polysubstance use and unprotected sexual intercourse. Following the adolescent and caregiver's participation in weekly sessions, the adolescent demonstrated improvements in substance use, unprotected sexual behavior, and other behavior problems. Clinical summary data from two outpatient clinics reveal similar positive outcomes for youth receiving the intervention. This paper illustrates the potential utility of an integrated treatment approach targeting substance use and unprotected sexual behavior in an adolescent population.

Self-management interventions for people living with human immunodeficiency virus: a scoping review

BACKGROUND

Self-management is an important emerging intervention for people with human immunodeficiency virus (PHAs). The principles of self-management are consistent with the principles of client-centred occupational therapy.

PURPOSE

This scoping review addressed three questions about self-management interventions for PHAs: (a) What knowledge, skills, and attitudes are taught? (b) What outcomes are intended? (c) What are the participation experiences of PHAs?

METHOD

Questions were searched in six databases. Two researchers independently reviewed abstracts and articles before inclusion. Extracted data were iteratively themed.

FINDINGS

Thirty-five articles were included. Interventions taught self-care, interpersonal skills, technical knowledge, cognitive skills, positive attitudes, planning for the future, and role management. Outcomes included well-being, health and illness management, and health services use. Participation experiences reflected social experiences, needs of PHAs, specific needs of women, participation, empowerment, intervention importance, and experiences with service delivery.

IMPLICATIONS

Self-management interventions are a promising approach for occupational therapists to enable PHAs' occupational performance goals.

Caregiver Involvement in Sexual Risk Reduction with Substance Using Juvenile Delinquents: Overview and Preliminary Outcomes of a Randomized Trial

BACKGROUND

Substance using juvenile offenders have some of the highest rates for engaging in risky sexual behaviors compared to other adolescent subgroups.

METHODS

An overview of the literature on sexual risk behaviors among these youth is provided, including the empirical support for including caregivers/parents as critical partners in sexual risk reduction efforts with this population. In particular, there is (a) evidence that family factors contribute to adolescent sexual risk, (b) emerging support for caregiver focused interventions that target adolescent sexual risk, and (c) established support for caregiver focused interventions that target other complex adolescent behavior problems. In addition, this paper presents preliminary results from a randomized controlled trial evaluating a family-based intervention for substance using juvenile delinquents that combines contingency management (CM) for adolescent substance use with a novel sexual risk reduction (SRR) protocol. Results through six months post-baseline (corresponding with the end of treatment) are presented for intervention fidelity and outcomes including number of intercourse acts (Sex Acts), use of condoms or abstinence (Safe Sex), and obtaining HIV testing (Testing).

CONCLUSIONS

In comparison to youth focused group substance abuse treatment, the CM-SRR intervention was associated with significantly greater therapist use of SRR techniques and greater caregiver involvement in treatment sessions (supporting treatment fidelity) and significantly lower increases in Sex Acts (supporting treatment efficacy). There were also higher odds for Safe Sex and for Testing, although these results failed to reach statistical significance. Findings add to the growing literature supporting the feasibility and efficacy of caregiver focused interventions targeting sexual risk behaviors among high-risk adolescent populations.

Adaptation of a U.S. evidence-based Positive Prevention intervention for youth living with HIV/AIDS in Kinshasa, Democratic Republic of the Congo

Effective HIV prevention programs for people living with HIV/AIDS (PLWH) are important to reduce new infections and to ensure PLWH remain healthy. This paper describes the systematic adaptation of a U.S.-developed Evidence Based Intervention (EBI) using the Centers for Disease Control and Prevention (CDC) Map of Adaption Process for use at a Pediatric Hospital in Kinshasa, Democratic Republic of the Congo (DRC). The adapted intervention, Supporting Youth and Motivating Positive Action or SYMPA, a six-session risk reduction intervention targeted for youth living with HIV/AIDS (YLWH) in Kinshasa was adapted from the Healthy Living Project and guided by the Social Action Theory. This paper describes the process of implementing the first four steps of the ADAPT framework (Assess, Select, Prepare, and Pilot). Our study has shown that an EBI developed and implemented in the U.S. can be adapted successfully for a different target population in a low-resource context through an iterative process following the CDC ADAPT framework. This process included reviewing existing literature, adapting and adding components, and focusing on increasing staff capacity. This paper provides a rare, detailed description of the adaptation process and may aid organizations seeking to adapt and implement HIV prevention EBIs in sub-Saharan Africa and beyond.

Where do youth in foster care receive information about preventing unplanned pregnancy and sexually transmitted infections?

Adolescents in foster care are at risk for unplanned pregnancy and sexually transmitted infections, including HIV infection. A study using a qualitative method was conducted to describe how and where foster youth receive reproductive health and risk reduction information to prevent pregnancy and sexually transmitted infections. Participants also were asked to describe their relationship with their primary health care provider while they were in foster care. Nineteen young adults, recently emancipated from foster care, participated in individual interviews. Using grounded theory as the method of analysis, three thematic categories were generated: discomfort visiting and disclosing, receiving and not receiving the bare essentials, and learning prevention from community others. Recommendations include primary health care providers providing a confidential space for foster youth to disclose sexual activity and more opportunities for foster youth to receive reproductive and risk prevention information in the school setting.

HealthMpowerment.org: feasibility and acceptability of delivering an internet intervention to young Black men who have sex with men

Young Black men who have sex with men (BMSM) are disproportionately affected by HIV/AIDS in the USA and continue to experience rapidly increasing HIV incidence. We designed a tailored, theory-based interactive HIV/STI prevention website for young BMSM, called HealthMpowerment.org (HMP) and conducted a small pilot trial comparing HMP to currently available HIV/STI websites. We present findings demonstrating feasibility and acceptability of delivering the intervention to the target population of young BMSM. Retention rates were 90% and 78% at one- and three-month follow-ups, respectively. Evaluation immediately after the intervention's completion revealed that participants who used the HMP website reported high levels of user satisfaction and interest and low levels of website difficulty and frustration. At the end of the intervention, there was a trend in increased behavioral intentions to use condoms and engage in preparatory condom use behaviors in the intervention group compared to the control group (p=0.10). We observed a reduction in mean scores on the CES-D scale among those in the intervention group that was not seen in the control group at the one-month follow-up, though this was not statistically significant. Feedback from exit interviews with study participants suggested that HMP is relevant to the prevention needs of young BMSM. Overall, the findings support the acceptability and feasibility of delivering this prevention program to a group that has few interventions despite bearing a significant burden of the epidemic. Future trials, combining Internet and mobile phone technologies, are planned to test HMP among larger and more diverse populations of young BMSM.

Sexual agreement classifications for gay and bisexual men and implications for harm reduction HIV prevention

HIV prevention educators frequently encourage gay and bisexual men (GBM) to negotiate condom use prior to sexual engagement. Identifying groups of GBM based on their presexual agreements can aid efforts to tailor interventions. Using cross-sectional data from 1,188 GBM who reported having sex with a nonprimary sex partner in the 90 days prior to the survey, the authors identified presexual agreement patterns. For both HIV-positive and HIV-negative GBM, two groups existed: men agreeing to no anal sex and men agreeing to anal sex with condoms. Among HIV-negative participants, there was a group agreeing to anal sex without specifying condom use. Among HIV-positive participants, there was a group agreeing to anal sex without condoms; this was the largest group of HIV-positive participants. Despite a presexual agreement to use condoms, substance use during sex increased the risk of unprotected anal sex. Suggestions for applying harm reduction to HIV prevention based on agreement classifications are discussed.

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

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

The influence of substance use, social sexual environment, psychosocial factors, and partner characteristics on high-risk sexual behavior among young Black and Latino men who have sex with men living with HIV: A qualitative study

Understanding the sexual risk behaviors of youths living with HIV/AIDS is critical to secondary prevention of HIV. As part of a larger qualitative study of youths living with HIV, in-depth interviews were conducted with 27 African American and Latino, HIV-infected young men who have sex with men, aged 16-24 years, living in New York City. The study explored the role of substance use, the social-sexual-environmental, and psychological contexts in which sexual risk behaviors occurred. Since learning of their HIV infection, the majority of participants had reduced their risky sexual behaviors; however, a subset (26%) of participants continued to have unprotected sex, in most cases with multiple partners. Substance use, the social environmental context of the sexual encounter, the psychological impact of HIV on sexual behavior, and partner characteristics were associated with high-risk sexual behaviors in this group. Among high-risk participants, factors associated with risky sexual behaviors clustered, with 57% reporting two or more factors. More intensive interventions are needed for this subset of youths living with HIV, including assessment and treatment for substance use and mental health issues, strategies for stress reduction, and partner interventions.

Provision of psychosocial support for young people living with HIV: voices from the field

This review provides a synthesis of the experiences of organisations providing psychosocial support for young people living with HIV (YPLHIV) from throughout the world. Little research exists on psychosocial support for YPLHIV, with many providers uncertain about how to address their complex needs. Eighty-six organisations were sent a survey containing 15 semi-structured, open-ended questions. Sixty-eight organisations from the United States, Europe, Africa, Asia, Latin America and the Middle East responded. The survey asked what challenges the organisation's patient group face; what the organisational aims are; how, where and by whom psychosocial support is delivered; what types of psychosocial support have been effective and which have not; and what recommendations the organisation has for service provision and policy. Data were stratified by age of population, region of the world and whether youth were infected at birth or in adolescence. The problems and needs across groups were more consistent than disparate. Adherence to medication, disclosure of HIV status, issues relating to sex and lack of support networks are problems faced by all YPLHIV. Most organisations use a multi-disciplinary team of individuals to meet these needs, with particular emphasis on individual and group therapy, educational support, and skills-building programmes. The review stresses the importance of youth-centered and youth-led approaches that engage young people in the planning, implementation and evaluation of programmes. Organisations underlined the need for increased funding, capacity building and trained staff. They suggest that policy makers put more effort into understanding the distinctiveness of adolescence, particularly in the context of HIV, and challenge them to make longer-term commitments to funding and programme support. In order for organisations to provide better services, they need further evidence of effective solutions, programme guidance and support tools, and increased collaboration and communication with one another, and with policy-makers and donors.

Interventions delivered in clinical settings are effective in reducing risk of HIV transmission among people living with HIV: results from the Health Resources and Services Administration (HRSA)'s Special Projects of National Significance initiative

To support expanded prevention services for people living with HIV, the US Health Resources and Services Administration (HRSA) sponsored a 5-year initiative to test whether interventions delivered in clinical settings were effective in reducing HIV transmission risk among HIV-infected patients. Across 13 demonstration sites, patients were randomized to one of four conditions. All interventions were associated with reduced unprotected vaginal and/or anal intercourse with persons of HIV-uninfected or unknown status among the 3,556 participating patients. Compared to the standard of care, patients assigned to receive interventions from medical care providers reported a significant decrease in risk after 12 months of participation. Patients receiving prevention services from health educators, social workers or paraprofessional HIV-infected peers reported significant reduction in risk at 6 months, but not at 12 months. While clinics have a choice of effective models for implementing prevention programs for their HIV-infected patients, medical provider-delivered methods are comparatively robust.

Secondary prevention of HIV infection: the current state of prevention for positives

PURPOSE OF REVIEW

To provide a state-of-the-science review of the literature on secondary prevention of HIV infection or 'prevention for positives' (PfP) interventions.

RECENT FINDINGS

Early work on PfP focused on understanding the dynamics of risky behavior among People Living with HIV/AIDS (PLWH) and on designing, implementing, and evaluating a limited number of interventions to promote safer sexual and drug use behavior in this population (i.e., PfP interventions). Previous meta-analyses demonstrated that PfP interventions can effectively promote safer behavior. However, the understanding of risk dynamics among PLWH and the extant number and breadth of effective PfP interventions were scant. Recent work has addressed some of these problems, yielding greater understanding of risk dynamics and providing additional, effective interventions. Still, only a modest number of recent, rigorously evaluated, effective interventions have been identified. New ideas for creating stronger, more integrated, and effective PfP interventions have emerged that will guide future intervention research and practice.

SUMMARY

There remains much to be done to understand why, when, and under what conditions PLWH practice risk. Substantial work also needs to be performed to design, implement, rigorously evaluate, and when effective, to disseminate widely, additional, evidence-based PfP interventions targeting diverse populations. Directing such interventions to populations of PLWH at greatest risk for transmission of HIV has the potential to yield significant impact on the pandemic.

Sexual risk reduction needs of adolescents living with HIV in a clinical care setting

As anti-retroviral therapy becomes increasingly available, young people living with HIV need tailored support to adopt healthy sexual behaviors. There has been a gap in the availability of culturally appropriate techniques for secondary prevention and sexual risk reduction in this target group. This formative study assessed sexual and reproductive health needs and problems, as well as determinants of sexual risk-taking among young people living with HIV aged 11-21 years attending the Paediatric Infectious Disease Clinic in Kampala, Uganda. Theoretical guidance was provided by the Information-Motivation-Behavioral Skills Model. Socio-demographic and selected psychosexual data were assessed using a brief anonymous questionnaire. A total of 75 young people living with HIV participated in eight focus group discussions. In addition, one focus group was conducted with adult key informants (service providers). About a quarter of the young participants reported prior or current sexual experience. The study revealed knowledge gaps relating to reproductive health, HIV transmission, and contraceptive methods. Motivations for protection included hope for the future, good counseling, and fear of the consequences of sexual activity such as unwanted pregnancies. Barriers to adopting preventive behaviors included peer pressure, poverty, HIV-related stigma, ignorance of their partners, alcohol use, and a desire to have children for the older ones. Young sero-positive people in this setting lacked specific behavioral skills, such as disclosure of HIV status to their sexual partners, this being closely linked to fear of rejection and stigma. HIV-positive youths need support in developing the appropriate behavioral skills to adopt healthy sexual behaviors. Interventions in this field need to be developmentally appropriate and tailored to young people's specific needs. Structural interventions should at the same time address and reduce HIV-related stigma and socio-economic needs of young people living with HIV.

A brief HIV stigma reduction intervention for service providers in China

This study assessed the effect of a brief intervention aimed at reducing HIV-related stigma among service providers in China. From December 2005 to June 2006, 138 service providers from four county hospitals in the Yunnan province of China were randomly assigned into either an intervention or a control condition. HIV stigma reduction concepts were conveyed through participatory small group activities, including role-plays, games, group discussions, and testimony by an HIV advocate. Participants were assessed at baseline before the intervention, and at 3- and 6-month follow-ups. Data were analyzed using a logistic regression mixed-effects model. Service providers in the brief intervention condition were significantly more likely to report better protection of patients' confidentiality and right to HIV testing, lower levels of negative feelings toward people living with HIV/AIDS, and more accurate understanding and practice of universal precautions. This brief intervention pilot showed potential in reducing HIV stigma and discrimination among service providers in China. Further intervention trials are needed to test the efficacy and long-term outcomes of this intervention.