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Development of a Compendium
    of Effective Structural
    Interventions for HIV
          Prevention
National HIV Prevention Conference
Atlanta, GA
August 15, 2011


        Shayna D. Cunningham, Ph.D.
          Sociometrics Corporation
Taxonomy of Interventions
1.   Individual-level
        Aim to directly change individual level HIV determinants
         such as knowledge, attitudes, skills, and behaviors
         through direct delivery of information to individuals or
         groups


2.   Community-level
        Requires the participation of peers, groups, community
         members, or media campaigns in order to modify
         interactions between individuals at the community level


3.   Structural-level
        Modify an aspect of the risk environment to create a
         barrier that prevents disease transmission or acquisition
         from occurring or to remove a barrier to enable
         prevention to occur
John Snow’s Pump
Development of a Compendium of Effective Structural Interventions for HIV Prevention
What is the Compendium of Effective
Structural Interventions?
    Provides HIV prevention service providers,
    planners, policymakers and others with information
    and materials to learn about, replicate, adapt, and
    evaluate structural interventions that have
    demonstrated efficaciousness in preventing HIV
    transmission

   Complements Sociometrics’ HIV/AIDS Prevention
    Program Archive
Contents
   Introduction to structural interventions

   Synthesis of available literature for major classes of
    structural interventions

   Detailed descriptions of selected interventions and links to
    intervention materials
       Rationale and history
       Implementation
       Evaluation methods and results
       Lessons learned
       Replications/Adaptations


   Analysis of trends related to the implementation of and
    methods used to evaluate effectiveness
Unique Features
   Includes only rigorously evaluated interventions

   Provides historical context for different classes of
    structural interventions

   Includes detailed descriptions of all intervention
    stages

   Content derived from multiple sources, including
    interviews with developers and/or evaluators

   Facilitates comparability among structural
    interventions

   Will be published as a book and an on-line resource
Development Procedures
1.   Establish panel of scientist experts
     •   Drs. Don Des Jarlais, Seth Kalichman, Ralph
         DiClemente, Gina Wingood, & Don Morisky
Development Procedures
1.   Establish panel of scientist experts

2.   Develop criteria for inclusion
Criteria for Inclusion
   Quality of program implementation
       Content quality; faithfulness of implementation
   Scientific rigor of evaluation
       Appropriate design, sample size, sampling procedures;
        control or comparison group where feasible, otherwise,
        another appropriate design such as time series analysis;
        adequate instrumentation and data collection procedures;
        adequate retention across follow-up data collection;
        appropriate analytic procedures
   Adequacy of follow-up time
       Minimum of 6 months after intervention initiation
   Positive impact on HIV risk behavior or STI/HIV
    infection rates, for one or more subgroups
       Sexual risk behaviors; drug injection risk behaviors;
        prenatal and perinatal transmission risk behaviors; ART
        adherence; STI/HIV infection rates; viral load (among HIV+)
Development Procedures
1.   Establish panel of scientist experts

2.   Develop criteria for program inclusion

3.   Develop list of candidate interventions
Development Procedures
1.   Establish panel of scientist experts

2.   Develop criteria for inclusion

3.   Develop list of candidate interventions

4.   Develop briefing materials
Development Procedures
1.   Establish panel of scientist experts

2.   Develop criteria for inclusion

3.   Develop list of candidate interventions

4.   Develop briefing materials

5.   Select interventions (Expert Panel)
Development Procedures
1.   Establish panel of scientist experts

2.   Develop criteria for inclusion

3.   Develop list of candidate interventions

4.   Develop briefing materials

5.   Select interventions (Expert Panel)

6.   Contact developer(s)
Development Procedures
1.   Establish panel of scientist experts

2.   Develop criteria for inclusion

3.   Develop list of candidate interventions

4.   Develop briefing materials

5.   Select interventions (Expert Panel)

6.   Contact developer(s)

7.   Prepare entries and materials
Development Procedures
1.   Establish panel of scientist experts

2.   Develop criteria for inclusion

3.   Develop list of candidate interventions

4.   Develop briefing materials

5.   Select interventions (Expert Panel)

6.   Contact developer(s)

7.   Prepare entries and materials

8.   Review and approve entries and materials (original
     developer)
Selected Interventions (N=18)
     Policies/Laws (17%)
         e.g., legislation to allow sale of needles and syringes in
          pharmacies, operation of needle-exchange programs and
          safer injecting facilities, mandating 100% condom use in
          commercial sex establishments, offering pre-natal HIV
          screening, and universal access to ART


     Provision of resources (17%)
         e.g., distribution of clean needles and condoms, provision
          of HIV/STI testing and ART


     Social marketing (22%)

     Combination approach (44%)
Development of a Compendium of Effective Structural Interventions for HIV Prevention
Development of a Compendium of Effective Structural Interventions for HIV Prevention
Development of a Compendium of Effective Structural Interventions for HIV Prevention
Development of a Compendium of Effective Structural Interventions for HIV Prevention
Implementation Themes
   Emerged from a keen awareness of the needs of the
    community and were highly acceptable, engaging, and
    responsive to community needs

   Often initiated by a high status person or body, external
    to the local community. Over time, the external person
    either became an active member of the community or
    surrendered control to the community

   Evolved over time - the robust components were
    identified over time through experimentation and
    inspection from both external observers and
    participants

   Program leaders continually developed strategies to
    address structural issues and barriers for effective
    implementation
Evaluation Themes
   Quantifying the effectiveness of structural
    interventions is difficult
       There is no direct, one-to-one relationship between structural
        interventions and HIV incidence
       Structural interventions are not generally amenable to
        randomization
       Comparison groups are not always readily available
       Often other potentially confounding factors (e.g., other
        programs)
       Causal pathways from intervention to outcome are usually
        indirect and complex
Evaluation Methodologies
   78% used a prospective serial cross-sectional
    design

   50% included a control/comparison group
       33% random assignment of groups


   33% included some element of randomization as
    part of the participant selection process


   89% collected data via surveys

   28% incorporated tests for HIV/STIs
Looking Ahead
   Completion of all entries, introductory material,
    literature syntheses/reviews

   Translation of materials

   Development of associated website

   Further exploration of implementation and
    evaluation trends/themes
Acknowledgements
   National Institute of Allergy and Infectious
    Diseases (Grant R43-AI063937-01A2)


   National Center on Minority Health and Health
    Disparities (Grant R44 MD005177-02)
Contact Information

        Shayna Cunningham, Ph.D.
         Sociometrics Corporation
        170 State Street, Suite 260
        Los Altos, California 94022
               650-383-6259
           scunning@socio.com

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Development of a Compendium of Effective Structural Interventions for HIV Prevention

  • 1. Development of a Compendium of Effective Structural Interventions for HIV Prevention National HIV Prevention Conference Atlanta, GA August 15, 2011 Shayna D. Cunningham, Ph.D. Sociometrics Corporation
  • 2. Taxonomy of Interventions 1. Individual-level  Aim to directly change individual level HIV determinants such as knowledge, attitudes, skills, and behaviors through direct delivery of information to individuals or groups 2. Community-level  Requires the participation of peers, groups, community members, or media campaigns in order to modify interactions between individuals at the community level 3. Structural-level  Modify an aspect of the risk environment to create a barrier that prevents disease transmission or acquisition from occurring or to remove a barrier to enable prevention to occur
  • 5. What is the Compendium of Effective Structural Interventions?  Provides HIV prevention service providers, planners, policymakers and others with information and materials to learn about, replicate, adapt, and evaluate structural interventions that have demonstrated efficaciousness in preventing HIV transmission  Complements Sociometrics’ HIV/AIDS Prevention Program Archive
  • 6. Contents  Introduction to structural interventions  Synthesis of available literature for major classes of structural interventions  Detailed descriptions of selected interventions and links to intervention materials  Rationale and history  Implementation  Evaluation methods and results  Lessons learned  Replications/Adaptations  Analysis of trends related to the implementation of and methods used to evaluate effectiveness
  • 7. Unique Features  Includes only rigorously evaluated interventions  Provides historical context for different classes of structural interventions  Includes detailed descriptions of all intervention stages  Content derived from multiple sources, including interviews with developers and/or evaluators  Facilitates comparability among structural interventions  Will be published as a book and an on-line resource
  • 8. Development Procedures 1. Establish panel of scientist experts • Drs. Don Des Jarlais, Seth Kalichman, Ralph DiClemente, Gina Wingood, & Don Morisky
  • 9. Development Procedures 1. Establish panel of scientist experts 2. Develop criteria for inclusion
  • 10. Criteria for Inclusion  Quality of program implementation  Content quality; faithfulness of implementation  Scientific rigor of evaluation  Appropriate design, sample size, sampling procedures; control or comparison group where feasible, otherwise, another appropriate design such as time series analysis; adequate instrumentation and data collection procedures; adequate retention across follow-up data collection; appropriate analytic procedures  Adequacy of follow-up time  Minimum of 6 months after intervention initiation  Positive impact on HIV risk behavior or STI/HIV infection rates, for one or more subgroups  Sexual risk behaviors; drug injection risk behaviors; prenatal and perinatal transmission risk behaviors; ART adherence; STI/HIV infection rates; viral load (among HIV+)
  • 11. Development Procedures 1. Establish panel of scientist experts 2. Develop criteria for program inclusion 3. Develop list of candidate interventions
  • 12. Development Procedures 1. Establish panel of scientist experts 2. Develop criteria for inclusion 3. Develop list of candidate interventions 4. Develop briefing materials
  • 13. Development Procedures 1. Establish panel of scientist experts 2. Develop criteria for inclusion 3. Develop list of candidate interventions 4. Develop briefing materials 5. Select interventions (Expert Panel)
  • 14. Development Procedures 1. Establish panel of scientist experts 2. Develop criteria for inclusion 3. Develop list of candidate interventions 4. Develop briefing materials 5. Select interventions (Expert Panel) 6. Contact developer(s)
  • 15. Development Procedures 1. Establish panel of scientist experts 2. Develop criteria for inclusion 3. Develop list of candidate interventions 4. Develop briefing materials 5. Select interventions (Expert Panel) 6. Contact developer(s) 7. Prepare entries and materials
  • 16. Development Procedures 1. Establish panel of scientist experts 2. Develop criteria for inclusion 3. Develop list of candidate interventions 4. Develop briefing materials 5. Select interventions (Expert Panel) 6. Contact developer(s) 7. Prepare entries and materials 8. Review and approve entries and materials (original developer)
  • 17. Selected Interventions (N=18)  Policies/Laws (17%)  e.g., legislation to allow sale of needles and syringes in pharmacies, operation of needle-exchange programs and safer injecting facilities, mandating 100% condom use in commercial sex establishments, offering pre-natal HIV screening, and universal access to ART  Provision of resources (17%)  e.g., distribution of clean needles and condoms, provision of HIV/STI testing and ART  Social marketing (22%)  Combination approach (44%)
  • 22. Implementation Themes  Emerged from a keen awareness of the needs of the community and were highly acceptable, engaging, and responsive to community needs  Often initiated by a high status person or body, external to the local community. Over time, the external person either became an active member of the community or surrendered control to the community  Evolved over time - the robust components were identified over time through experimentation and inspection from both external observers and participants  Program leaders continually developed strategies to address structural issues and barriers for effective implementation
  • 23. Evaluation Themes  Quantifying the effectiveness of structural interventions is difficult  There is no direct, one-to-one relationship between structural interventions and HIV incidence  Structural interventions are not generally amenable to randomization  Comparison groups are not always readily available  Often other potentially confounding factors (e.g., other programs)  Causal pathways from intervention to outcome are usually indirect and complex
  • 24. Evaluation Methodologies  78% used a prospective serial cross-sectional design  50% included a control/comparison group  33% random assignment of groups  33% included some element of randomization as part of the participant selection process  89% collected data via surveys  28% incorporated tests for HIV/STIs
  • 25. Looking Ahead  Completion of all entries, introductory material, literature syntheses/reviews  Translation of materials  Development of associated website  Further exploration of implementation and evaluation trends/themes
  • 26. Acknowledgements  National Institute of Allergy and Infectious Diseases (Grant R43-AI063937-01A2)  National Center on Minority Health and Health Disparities (Grant R44 MD005177-02)
  • 27. Contact Information Shayna Cunningham, Ph.D. Sociometrics Corporation 170 State Street, Suite 260 Los Altos, California 94022 650-383-6259 scunning@socio.com