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Community based hiv interventions


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By Yvonne O'Brien

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  • 1. Community-Based HIV Intervention 1 Review of the Literature While many advances have been made in HIV and AIDS treatment, communities stillneed to be proactive in prevention and education. It is imperative that communities worktogether to provide culturally-based interventions and work with researchers to implementevidence-based interventions into community-based organizations and settings. This isespecially true in African American, Latino, injecting drug users (IDUs) and low incomecommunities. Since there is still no cure for HIV and AIDS, behavior change is the mosteffective way to decrease infection of the virus. Community-based organizations need to findthe best prevention interventions that can help change high risk behaviors. To halt the continuation of HIV, it is important to raise awareness through communitymobilization, education prevention and behavior change in special groups. According to Cai, Li,and Li’s (2009) article, community-based interventions have been successful in changing riskybehavior and in prevention of HIV. In order to accurately assess the success of interventionsCAI, et al. (2009) believe special attention needs to be paid to socioeconomic and behavioralaspects at the local level. Community volunteers and leaders as well as religious leaders shouldall be included in education programs pertaining to HIV intervention and prevention. In their research article, CAI, et al. (2009) studied community participation, programactivities and outreach strategies which they believe are necessary for a successful communityeducation program. One model to prevent HIV transmission was discussed. The PRECEDE-PROCEED model for community planning and health promotion was adopted and led by publichealth professionals. Discussion groups and input from community members and communitybased organization assessed information. Twelve areas which accounted for 73% of reported
  • 2. Community-Based HIV Intervention 2AIDS cases among African Americans and Latinos aged 18-39 were selected for interventions.Horizontal outreach to residents, vertical outreach to stakeholders, strategic communications andinfrastructure development were chosen to promote behavioral change. 2,011 surveys were conducted with community residents in the first year, and 2,381follow-up interviews were done the next year. The results showed that program awareness wasup from 5.4% in 2001 to 6.7% in 2002. Recognition of HIV/AIDS problems increased to 35.3%.Participation in HIV prevention increased significantly. The America Responds to AIDS (ARTA) campaign was also studied. ARTA used serialtheme education programs and was based on established theory and practice. Originallydeveloped as a response to the early AIDS crisis, it has evolved into the development ofobjectives to combat HIV/AIDS. ARTA includes state and local health agencies andcommunity-based organizations. All objectives are based on public need and specificorganizations. Input from all participants was used to implement strategies. The results showedthat community-based interventions which promoted HIV/AIDS awareness and change of riskybehavior did prevent the spread of HIV/AIDS (CAI, et al., 2009). According to Williams, Wyatt and Wingood, (2010), even though African Americansonly make up 12% of the population, they account for 51% of new HIV/AIDS cases and 48% ofall people currently living with HIV/AIDS. Williams, et al. (2009), believe that since sexualbehaviors are the most common mode of transmission, changing behavior is the key toprevention. Therefore, they researched different prevention interventions which focused onbehavioral changes in African Americans.
  • 3. Community-Based HIV Intervention 3 In 1996 the Prevention Research Branch Division of HIV/AIDS Prevention (DHAP)began the HIV/AIDS Prevention Research Synthesis (PRS) project to review HIV behavioralprevention research literature to find the most effective preventions. The PRS created acompendium where community-based organizations (CBO) would implement programs bestsuited for their target populations. They found that identifying variables that influence HIVtransmissions and sexual behaviors is critical for interventions to be successful. One of the mostimportant variables is culture, which needs to be included in interventions. Interventions mustinclude core cultural and community elements (Williams, et al., 2009). Previous HIV prevention has generally focused on safe sex with condoms. All ethnicgroups were targeted the same way. According to Williams, et al. (2009), research has shownthat different ethnic groups need to be targeted in ways that are familiar to them. Interventionpresentation strategies use videos, and models of the same race/ethnicity. The person deliveringthe message should be a member of the target population and community. Curriculum contentincludes cultural concepts into interventions, such as racial pride. HIV intervention for African Americans needs to address institutional variables, whichoperate on either an individual, community and health level. Individual factors include beingpoor, lack of health insurance and discrimination. Community and health systems include lackof services and lack of culturally aware providers which act as barriers. Williams, et al. (2010)found that while evidenced-based interventions (EBI) may work with study participants, theyoften do not achieve the same outcomes in real world settings. Most EBIs are conducted inuniversity setting and making the transition into the community is challenging.
  • 4. Community-Based HIV Intervention 4 To solve this problem, community-based research (CBPR) was proposed. This was acollaborative approach designed to create structures for participation of communities,representatives of organizations and researchers to improve health and well-being. The CBPRcombines culturally and practiced-based evidence and indigenous research methods (Williams, etal., 2009). The flaw to this research is that CBOs have not been formally evaluated and do not havethe scientific basis to adapted supported interventions. Also, if CBOs do not have access and agood rapport to the target population, interventions may not be accepted or endorsed. Forinterventions to be successful, it is essential that community agencies and partners are includedin all stages of development and civic organizations need to be included. Interventions need tobe adapted specifically to fit the community they are to be implemented in. To have successfulprevention of HIV/AIDS in African American communities, all workers need to work together todevelop cultural HIV interventions and work on changing behaviors. Prevention strategiesshould also focus on HIV re-infection and transmission to non-infected partners (Williams, 2010). The introduction of Highly Active Anti Retroviral Treatment (HAART) has increased thelife expectancy of people living with HIV and AIDS. However according to a research article byRaymond (2005), HIV injecting drug users (IDUs) are not yet receiving the full benefit of thistreatment. There are several theories as to why this is. One theory of thought is thatcommunities do not provide ample interventions for IDUS. IDUs are discriminated againstbecause by doing drugs they are therefore criminals and not looked upon as favorably as otherssuffering from HIV and AIDS (Raymond, 2005).
  • 5. Community-Based HIV Intervention 5 Biologists believe it is because illicit drugs prey on the immune system. For example, ithas been long believed that cocaine makes HIV replicate at an increased rate. However, clinicaldata received from the Women and Infants Transmission Study (WITS) which included a groupof HIV African American and Latino women who were drug users, found a contradiction to thistheory. The results found no difference from non-drug using HIV women in CD4 cellpercentage, HIV viral load, or survival. They did find that drug users experienced more AIDSopportunistic infections such as tuberculosis and pneumonia (Raymond, 2005). The Journal of AIDS reported in 2004, that even though AIDS defining illnesses havedecreased with the use of HAART, these decreases were lower in HIV-IDUs. The death ofIDUS is higher than non drug users. It is hypothesized that this may not be necessarily due todrug use, but rather to less access to HIV treatment. According to Raymond, (2005), HIVpositive IDUs have less access to care, quality of care and adherence. This reflects lack ofsystem care such as housing and treatment for drug addiction. Because illicit drugs are illegalIDUs face a stigma and prejudice ranging from disapproval, police harassment, loss of jobs,custody of children and imprisonment. Communities need to provide HIV drug users with moresubstance abuse counseling, treatment, mental health care, housing and support. Delayed testing and treatment has been found to have extremely negative consequencesfor HIV-IDUS. Raymond, (2005) indicates a study in Baltimore which found that HIV-IDUswho began HAART when their CD4 cell count was over 350, had survival rates comparable toHIV negative IDUs. Other studies have shown that HIV-IDUs who received HAART respondedas well as HIV non drug users (Raymond, 2005). These results show that HIV-IDU’s need morecommunity-based programs, hospitals and clinics. Health care workers and staff need to be
  • 6. Community-Based HIV Intervention 6familiar with drug users’ needs and harm reduction models. Community-based programs alsoneed to be linked to hospitals, clinics, substance abuse programs and correctional facilities. Thelimits in these studies are that higher deaths among HIV-IDU’s may be from drug use rather thanHIV and AIDS complications. While HAART treatment for HIV is an effective treatment, getting HIV patients toadhere to the medication poses challenges (Mocalino, G. E., Hogan, J. W., Mitty, J. A.,Bazerman, L. B., Delong, A. K., Loewenthal, H., Caliendo, A. M., and Fanigan, T. P., (2007).In their article, Mocalino, et al. (2007), detail a study on a randomized trial of community-based,modify directly observed therapy (MDOT) for HIV positive drug users. This study focused onadherence and benefits of MDOT. According to Mocalino, et al. (2007), the study was conducted as an open-label,randomized, single center trial. Participants were selected from HIV primary care clinics, whichwere active users of cocaine, heroin and alcohol misuse and were also non-resistant to a oncedaily regimen. Participants were randomly chosen to receive either MDOT or standard of care(SOC) stratified by HAART therapy for a minimum of two weeks. SOC participants could alsoreceive any adherence interventions and could cross over to the MDOT arm if their therapywasn’t working. MDOT participants were given their own prescriptions. An outreach socialworker observed and transported participants every day for the first three months and then lesserdays over the next nine months. Assessments were conducted at screening, baseline, one month and then every twomonths afterward. Assessments consisted of a questionnaire and venipuncture. Participants
  • 7. Community-Based HIV Intervention 7were given incentives during assessments. The types of incentives given were not specified inthe article. Of the 87 participants, 43 received SOC and 44 received MDOT (Mocalino, 2007). The results showed that after one month, SOC participants missed at least one dosecompared to MDOT participants. The three month evaluation showed similar results. HIVseropositive drug users on MDOT were more likely to achieve HIV PVL suppression than thosereceiving SOC. HAART participants on MDOT also were hospitalized less than SOCparticipants. Therefore, there was an overall monetary savings on the MDOT arm (Mocalino,2007). One limitation to the study was that participants consisted of both drugs users and alcoholabusers, so the effects between the two groups could not be evaluated. Another limitation is thestudy’s endpoint was at three months, which means long-term effectiveness could not becalculated. The overall results showed that MDOT should be included into adherenceinterventions whose participants are failing therapy. However, more studies are needed tospecify which populations would benefit the most and also what the long-term benefits would be. For community-based interventions to be effectively implemented there needs to bebetter ways for scientists, researchers, policy makers, analysts and decision makers to discussand exchange HIV prevention and interventions. In his article, Holtgrave (2004) discusses hisframework for scientists, analysts and decision makers to better communicate preventioninterventions for HIV through technology transfer which also includes cost effective analysis.Community-based organizations have faced several barriers in adopting science-based HIVprevention interventions in the form of workshop-style training, supportive documentation andon-site technical assistance. According to Holtgrave (2004), these barriers include: lack of
  • 8. Community-Based HIV Intervention 8financial, human and resources to deliver intensive HIV prevention interventions; lack ofresources to fund enrollment incentives to participants; high staff turnover; lack of training; lackof science-based interventions that are specifically adapted to particular communities. Little research has been conducted on the most effective methods of delivering HIVprevention intervention technical assistance to community organizations. It is important forpolicy makers to know how effective interventions will be and their cost. Scientists working onHIV prevention and interventions generally do not provide their findings in a format that can beinputted into programmatic and policy decision making. Holtgrave’s (2004), frameworkprovides tools of analytic techniques which can be used, such as research synthesis, Metaanalysis and economic evaluation methods. According to Holtgrave (2004), dialogue betweenscientists and policy analysts is important. There also needs to be dialogue between policyanalysts and decision makers to discuss problems in interventions. Holtgrave’s (2004),framework shows the importance of using scientific results in a technological format to helppolicy analysts and decision makers to find the best prevention interventions. Another article by Bauer, Kilbourne, Neuman, Pincus and Stall (2007), discusses the beststrategies to implement evidenced-based interventions for HIV from academic settings tocommunity-based settings. Although many effective interventions have been developed for HIVin academic settings, very few have been successfully disseminated into community-basedorganizations. Bauer et al. (2007) describe different strategies that can help with this transfer.The first strategy is to determine when an organization is ready to implement an intervention.The second strategy is to work with senior leaders and providers to overcome barriers toadaptation.
  • 9. Community-Based HIV Intervention 9 At the time of this article, no implementation frameworks had been specified on how toimplement and adapt interventions to fit community-based organizations. Because of this mostcommunity-based organizations do not implement evidence-based interventions. Bauer et al.,(2007) study and focus on Replicating Effective Programs (REP) which specifically outlines howto implement evidence-based interventions into community-based settings through a frameworkof strategies which include packaging, training, and technical assistance. The REP framework, developed by the U.S. Centers for Disease Control and Prevention(CDC) in 1996 is based on literature review and community input. The REP framework has fourphases. These phases consist of identifying the need for interventions for a particular population,researching whether the intervention has been successful in similar settings, and identifyingbarriers to implementation. After these phases have been completed, an intervention package isdrafted along with training and technical assistance plans. According to Bauer et al. (2007), theREP package is better than other intervention toolkits because it provides specific details andoptions for adaptation for different community-based organizations and settings. As of 2007, theCDC had funded over 500 prevention organizations (Bauer. et al., 2007). Once implemented, the REP interventions are thoroughly evaluated by collecting datathrough interviews of providers and consumers, checking to see that core elements of theintervention were implemented, patient-level outcomes are assessed and whether the interventionwas effective. After evaluations are completed the REP framework maintains and makeschanges as needed. REP has shown to be effective in implementing HIV interventions into community-basedsettings. The downside to REP is that it had not yet been evaluated for its effectiveness in
  • 10. Community-Based HIV Intervention 10reducing HIV/AIDS, patient outcome or costs as of 2007. No studies of the long-term effects ofREP beyond implementations had been done either. More studies that evaluate long-termoutcomes and sustainability of REP needs to be conducted. As mentioned in other articles, behavioral interventions are the most effective way toreduce risk and transmission of HIV. However, successfully implementing interventions fromresearch settings into community-based organizations are often faced with complications. Thisis due mostly to the fact that clinical settings often do not have the funding and resources todeliver, monitor and evaluate community-based interventions. According to an article byCopenhaven and Lee (2007), AIDS complacency has posed problems to interventions. Theintroduction of HIV medications, have made people complacent and the threat of HIV/AIDS isnot necessarily seen as the threat it was once was. Another problem is that targeted individualstend to recount prevention information if they view it as redundant. Analysis of randomized and controlled trials (RCTs) found that IDUs responded better incommunity-based interventions when the focus was on sex and drug related risks equally.Copenhaver and Lee (2007) developed the Community-Friendly Health Recovery Program(CHRP), which showed successful outcomes with enhanced HIV-knowledge, motivation,behavioral skills, and reduction in at risk sex and drug behaviors. A study was conducted tocheck whether the intervention effects decayed over time and whether the intervention should berepeated at a follow-point. The CHRP intervention was conducted at a methadone facility as a manual guidedbehavioral intervention which consisted of four 50 minute group sessions. These sessions’targeted sex and drug related HIV risks and were led by two trained facilitators, using cognitive
  • 11. Community-Based HIV Intervention 11remediation strategies. 226 participants participated in the initial intervention, and 62 subjectsparticipated in a repeated follow-up intervention. Participants did not receive compensation orany incentives. The follow-up rate was lower than similar interventions where participantsreceived incentives. No differences were found in regards to pre and post intervention measuressuch as HIV knowledge, behavior, attitudes and drug use (Copenhaver and Lee, 2007). To assess participants’ sex and drug HIV risk behaviors, the Risk Assessment Battery(RAB) was used. The RAB also assessed participants’ HIV knowledge, motivation andbehavior. The results of the study showed that a positive effect was found for the intervention,HIV risk group, and sex and drug risk reduction. HIV participants showed greater high HIV riskimprovement at immediate post-intervention. Decay over time was analyzed to see if outcomesdiminished. Results showed no evidence of decay in risk reduction at follow-up. However therewas a gradual decline in some areas in high HIV risk groups. Participants who had children athome, has less decay (Copenhaven and Lee, 2007). Therefore it is suggested that futureinterventions should enhance social support. Also future studies should also analyze the impactof family and social support on risk reduction outcomes. More decay was noticed in sex-relatedrisk groups, but follow-up interventions did lessen the decay. The limitations to the study werethat participants did not receive incentives or compensation. Also, this study was limited to onegroup, without control groups to compare outcomes. Further studies should have a separatecontrol group to better track results. As mentioned in previous articles, the issue of adapting evidence-based interventions intocommunity-based organizations is not always successful. In their article, Kao, Rosales, andVeniegas (2009) study how different community organizations adapt HIV prevention
  • 12. Community-Based HIV Intervention 12interventions and how these changes affect the core elements of the interventions. The CDCstresses the importance of keeping core elements of interventions intact when transferring themfrom research settings to community-based settings. To ensure this, the CDC released threeversions of HIV prevention intervention guidance to help community agencies in planning andimplementing interventions. These guides outline core elements of evidence-based interventionsand also describe adaptation, resource requirements, recruitment, policies, standards, monitoringand evaluations for interventions. To help community-based organizations adapt interventions, the CDC state that agenciesadapting interventions need to conduct formative evaluations to define the target population,culture behaviors and HIV risk factors. The CDC also encourages agencies to developintervention implementation plans, provide leadership, solicit feedback from staff, providetraining, ensure fidelity to core elements and monitor client responsiveness. Kao, et al. (2009), conducted a study which consisted of interviews with staff who wereimplementing evidence-based HIV prevention interventions. Participants were eligible for thestudy if they were employed by an organization that provided HIV prevention interventions.Thirty-four participants who worked in twenty-two different organizations participated in thestudy. Twenty-one were female, ten were male and three were transgendered. Participants wereof mixed backgrounds and worked at the agencies from anywhere to six months to over 10 years(Kao, et al., (2009). Kao, et al. (2009), stated that semi-structured interviews were conducted with studyparticipants. The interviews were based upon research on the adoption of evidence-based HIVprevention programs. Afterwards, the interviews were transcribed, entered electronically and
  • 13. Community-Based HIV Intervention 13then coded. The results showed that agency staff adapted activities and delivery methods ofinterventions as recommended by the CDC. Most of the study participants said that they usedpilots and made changes after assessing and getting feedback from intervention participants.Some made changes on cultural issues. For example, if they showed a video about heterosexualsto homosexuals, participants said that they couldn’t relate to the video. Thus they would changeto a video that showed homosexuals. Other participants often made changes to includeincentives. According to Kao, et al. (2009), none of the staff who made changes consulted with atechnical assistance provider or other expert. Seven participants stated that reinvention duringthe implementation stage was required by their funders. Some staff reported making changesduring maintenance for quality assurance. These were mostly efforts made to improve activitiesand delivery methods. Few of these participants piloted their adaptations before commencingwith full implementation as recommended by the CDC. Also reinventions did sometimes changethe core elements of the interventions which the CDC cautions against. The results are that continuous measurements of fidelity are needed. Any adaptations tointerventions need to be recorded and these records should be included in periodic reports byagencies to funders, so that changes can be accessed. This will help the effectiveness of futureprevention interventions (Kao, et al. (2009). Piloting and technical assistance is also importantduring the pre-implementation phase. Re-invented interventions should be evaluated todemonstrate their ability to reduce HIV risk. The limitations to the study include interview questions that did not address as to specificprogram adaptations, or why changes were made. Since there was no program monitoring, or
  • 14. Community-Based HIV Intervention 14fidelity assessment, the reliability of the study participants cannot be verified. Also, the studyshould have included participants at varying levels in the organizations, to see if the results andinterviews varied by different positions. The article was also confusing, in that in one part Kao,et al. (2009) stated that all adaptations were within CDC guidelines with most using pilots first.However, it was later stated that some adaptations were not CDC approved and participants didnot use pilots. In the final analysis, combining all the information of the reviewed articles shows thateven though treatments such as HAART have been proven effective in prolonging the lives ofpeople who have HIV and AIDS, community-based interventions still need to be implemented.It is also important that more research is done to help implement successful evidence-basedprevention interventions into community-based organizations and settings. In order for theseinterventions to be successful, they need to focus on behavioral change and be custom tailored totheir specific target populations. This includes incorporating cultural aspects so that participantsare more willing to participate and adhere. Most of the research has shown that community-based interventions have been successful with lowering high risk behaviors when implementedsuccessfully.
  • 15. Community-Based HIV Intervention 15 ReferencesBauer, M. S., Kilbourne, A. M., Neuman, M. S., Pincus, H. A., and Stall, R. (2007). Implementing evidence-based interventions in health care: application of the replicating effective programs framework. Implementation Science. 2:42, p42.CAI, H., Li, Q., Li, Y. (2009). Community-based intervention for AIDS prevention. International Journal of Health and Science. 2:4, p226.Copenhaven, M., Lee, I. (2007). Examining the decay of HIV risk reduction outcomes following a community-friendly intervention targeting injection drug users in treatment. Journal of Psychoactive Drugs. 39.3, p223.Holtgrave, D., R. (2004). The role of quantitative policy analysis in HIV prevention technology Transfer. Public Health Reports. 119.1. P19Kao, U. H., Rosales, R., and Veniegas, R. C. (2009). Adapting HIV prevention evidence-based interventions in practice settings and interview study. Implementation Science. 4. P76Mocalino, G. E., Hogan, J. W., Mitty, J. A., Bazerman, L. B., DeLong, A. K., Loewenthal, H., Caliendo, A. M., Fanigan, T. P. (2007). A Randomized clinical trial of community-based directly observed therapy as an adherence intervention for HAART among substance users. AIDS. 21.11, p1473-1477.Raymond, D. (2005). HIV Care and Treatment as Harm Reduction. The Body. Retrieved from
  • 16. Community-Based HIV Intervention 16, J. K., Wyatt, G. E., Wingood, G. (2010). The Four Cs of HIV Prevention with African Americans: Crisis, Condoms, Culture, and Community. CUR HIV/AIDS Rep, 7:185-193