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Spring 2000 Update

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HIV Community Planning Group
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Augusta, Maine 04330
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ME HIV CPG  - Community Plan

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Chapter 4: Identifying Effective Interventions: Background Information

Before choosing interventions, it is crucial to understand which are the most effective and the reasons why.  Behavioral science, since it seeks to explain how behavior is influenced and modified, gives important information about why some HIV prevention methods are more effective than others in changing or reducing risky behavior. 

For this reason, the CPG recommends that all HIV prevention programs rely both on current behavioral research on the effectiveness of interventions as well as on experiential knowledge.  In addition, it is recommended that program planners modify successful programs in culturally competent ways to suit the specific needs of the populations addressed by each program or intervention.

Because the vast category of “behavioral science” has the potential to overwhelm, this chapter outlines basic, science-based information about effective interventions, suggests ways to access information about behavioral science, and shows what we believe to be fundamental criteria for effective interventions.   In addition, we have included our “Taxonomy,” which is a categorization of interventions we recommend because of their proven effectiveness.  Finally, a list of definitions is provided at the end of the chapter to define words and terms often used when discussing or describing HIV prevention interventions.

4.1       Information about Effective, Science-Based HIV Prevention Interventions

In developing this HIV Prevention Comprehensive Plan, a number of different sources of information concerning theories of behavior change and effective HIV prevention interventions were used.  Foremost among these sources are the work and research findings of Jeffrey A. Kelley and Thomas Coates. Particular emphasis has been given to the work of  Jeffrey A. Kelley, Ph.D., Director of the Center for AIDS Intervention Research, and Professor of Psychiatry at the Medical College of Wisconsin as published in his book, Changing HIV Risk Behavior: Practical Strategies, a basic text for effective HIV prevention efforts. The information which follows is based on Kelly's HIV-specific field research and is applicable to all prioritized populations.

A basic understanding of behavior change theory is essential to the planning of effective HIV prevention interventions. While the list of factors which influence behavior is complex, the Maine CPG, following Kelley’s published research findings, has accepted several key elements as being most important in making behavior change possible. Interventions found by Kelly to be most successful in changing behaviors related to HIV transmission include the following key elements:  

Knowledge: Provide a practical understanding of the factors responsible for risk and the behavioral changes needed to reduce/avoid risk of HIV infection. Provide appropriate referrals and written materials, handouts, pamphlets, etc. Correct myths and misconceptions about HIV/AIDS.

Threat personalization: Promote the ability to accurately appraise one’s personal level of risk based upon an assessment of one’s own behavior.

Self-efficacy: Promote the belief that one can effectively make those behavioral changes and that change will work to reduce HIV risk.

Readiness to change: Promote and support a commitment to change risky behavior.

Skills: Promote the acquisition and skillful performance of behavioral skills needed to reduce behavioral risk (condom and lubrication use, safer sex practices, assertiveness skills to refuse risk coercion, negotiation and communication skills with sex and needle-sharing partners), and self-management skills to implement cognitive and environmental changes to reduce risk vulnerability.

Intervention activities that focus on skills should be culturally competent in staff and in program design and implementation to their target audience and provide accurate information including STD linkages, demonstrations and models, opportunities for practice, risk assessment, and appropriate referrals.

Planning: Promote and support the planning of strategies for implementing behavior changes and courses of action if obstacles are encountered or lapses occur. Provide condoms and lubricants.

Support network: Promote and support self-reinforcement, peer relationships, social supports, community building and referrals to sustain behavior changes over time.

Kelly's field research in male and female populations has shown that, overall, there are five primary characteristics of successful interventions.  Interventions must:

Be intensive - total of four hours minimum contact where possible. This minimum level of contact is shown through Kelly's field research to have a positive measurable impact on the success of the intervention.

Be tailored to client’s relationship / risk circumstance. Delivery of interventions works best when provided in a client-focussed way and when the intervention is as tailored as possible to the client's personal risk circumstances.

 Be culturally appropriate. Cultural competence (see Definitions) means that all interventions be appropriate to the target audience for the intervention. One way of achieving cultural competency is to actively involve members of the target population in the planning, implementation and evaluation of the interventions.

 Foster skills development

 Be “fun” and perceived as useful

Kelly's published field research also concludes that successful interventions include the following specific internal and external elements as important in the successful delivery of intervention programs:

  • a) Assess personal risk

  • b) Encourage skills building in communication, assertiveness and condom use

  • c) Implement HIV prevention case management where appropriate

  • d) Provide Secondary Prevention

  • e) Provide information, personalization, skills, practice, and reinforcement

  • f) Provide written materials, handouts, pamphlets, condoms and lubricants

  • g) Promote Counseling and Testing for early identification and referrals

  • h)  Promote use of hotlines and chat rooms

  • i) Inform contacts about the effect of STD prevention on their HIV prevention decisions

  • j)  Teach risk / harm reduction skills

  • k)  Provide resources / referrals

During the coming year the CPG will undertake a review of behavior change models specific to HIV infection in populations at risk.  This review may expand upon the Kelly and Coates model most familiar currently.

4.2      Ways to Access Behavioral Science Information and Models

Some suggestions follow to assist in locating pertinent information about behavioral science:

  • “HIV Prevention: Looking Back, Looking Ahead” are one page sheets summarizing issues pertinent to populations and behaviors. To inquire about information from this source, you may call the National AIDS Clearinghouse at 800/458-5231.  They also have a web site at http:\\  HIV prevention topics are diverse and numerous.

Call the National AIDS Clearinghouse at 800/458-5231 with other specific requests such as Guides to Services for:

  • Adolescents/Youth

  • People of Color including African Americans, Asians and Pacific Islanders, Latinos/Latinas, American Indians

  • Injecting Drug Users

  • Men who have sex with men

  • Prevention Case Management

  • Prevention Social Marketing Initiatives

  • Substance Abusers

  • Other populations.  One such guide is: “Guide to Selected HIV Services and Materials for Women”  May 1997.  CDC National AIDS Clearinghouse at 800/458-5231

In addition, you may find the following works, or others by these authors, to be helpful.

·        Network Briefs, “Adolescents and the HIV/AIDS Epidemic:  Stemming the Tide”, April 1993.  A publication of the Women’s NETWORK of the National Conference of State Legislatures with offices in Denver, Colorado and Washington, DC.

·        Bor, Robert; Miller, Riva; Goldman, Eleanor, Theory and Practice of HIV Counseling, A Systemic Approach.  Brunner/Mazel Publishers, New York, 1993

·        Dilley, James E.; Pies, Cheri; Helquist, Michael, Face to Face, A Guide of AIDS Counseling.  AIDS Health Project, University of California, San Francisco, 1989, distributed by Celestial Arts, Berkeley.

·        Glanz, Karen, et al., Eds. Health Behavior and Health Education: Theory, Research and Practice. Second Edition, Jossey-Bass, San Francisco, 1997.

·        Kelley, Jeffrey A., Changing HIV Risk Behavior: Practical Strategies, Guilford Press, New York, 1995.

·        Marlatt, Alan G. and Gordon, Judith R., Eds., Relapse Prevention, The Guilford Press, New York, 1985.

·        Odets, Walt, In the Shadow of the Epidemic: Being HIV-Negative in the Age of AIDS. Duke University, Durham, NC. 1995.

·        Rofes, Eric, Reviving the Tribe: Regenerating Gay Men’s Sexuality and Culture in the Ongoing Epidemic, Harrington Press, New York, 1996.

·        Rofes, Eric, Dry Bones Breathe, Gay Men Creating Post-AIDS Identities and Cultures, Harrington Press, New York, 1998.

·        Sorensen, James L.; Wermuth, Laurie A.; Gibson, David R.; Choi, Kyun-Hee; Guydish, Joseph R.; Batki, Steven L.; Preventing AIDS in Drug Users and Their Sexual Partners.  The Guilford Press, New York, 1991.

·        Sobo, E.J., Choosing Unsafe Sex: AIDS-Risk Denial Among Disadvantaged Women. University of Pennsylvania Press, Philadelphia, 1995.

Additional HIV prevention research of effective interventions can be found in the following publications:

·        AIDS Education and Prevention: An Interdisciplinary Journal. Guilford Publications, New York. (Maine AIDS Alliance and the Maine HIV Prevention Community Planning Group subscribe to this journal)

·        Sexual Addictions & Compulsivity: The Journal of Treatment and Prevention. Brunner/Mazel, Inc. 215-785-5800  Fax 215-785-5515.

·        The Bureau of Health, HIV/STD program also has selected reference material.  Speak  with your grant manager about resources and availability.

4.3       Fundamental Criteria for Interventions

HIV prevention interventions for all populations must contain certain basic criteria to be considered useful.  Based upon scientific information such as described above and the experiential knowledge of CPG members, a list of Fundamental Criteria for Interventions has been developed and modified over time. Funding decisions should be based, at least in part, on these criteria:

1.  Program design elements include:

  • a)  A clearly defined population at risk

  • b)  A demonstrated need

  • c)  Behavioral science foundation for interventions

  • i)  Incorporation of behavioral change models which include consideration of such issues as the environment, levels of information, skills, attitudes and beliefs, into planning for effective prevention interventions.

  • ii) Adaptation of effective interventions used elsewhere for the priority populations.

  • iii) Include documented effective program elements in all prevention interventions

  • d) The intervention should fit within the prioritized intervention areas as identified within the Taxonomy, Revised 5/97

  • e) Description of cost effectiveness

  • f)  Evidence that the project/interventions is non-duplicative in a catchment area

  • g)  Documentation of potential or real impact on other related services

  • h) Involvement of members of the priority population, including HIV+ members where possible, in:

  • i)  Project development

  • ii)  Implementation of proposed prevention project

  • iii) Evaluation of programs

  • i) Demonstration that the intervention will reach a significant number of people from the priority population

  • i) Description of impact of the intervention on population at risk

  • j) Barriers must be adequately described and addressed

  • i)  Include strategies to overcome barriers described

  • ii) Include child care, stipends and travel expenses for population at risk

  • iii) Include/describe resources, assets, characteristics inherent in the program to overcome identified barriers

  • iv) Is this intervention consistent with community wide norms and values

  • v) Develop and implement appropriate referrals to community based programs paying particular attention to:

  • a) Issues of alcohol and other drug use and abuse

  • b) Physical, sexual, emotional abuse whether past, present or potential

  • c) Other sexually transmitted diseases

  • d) HIV Counseling, Testing and Partner Notification components of HIV Prevention

  • k) Cultural competence (see definitions) for interactions with the target population

  • i) Specific to gender, sexual orientation, race, ethnicity, age, socioeconomic conditions, and other marginalizing factors

  • ii) With particular attention to the variables attendant to conditions in cities, towns, and more rural areas

  • iii) Paying attention to regional variations from southern, to central, northern, coastal or the mountain regions

  • l)  Demonstrated actual or potential stability of the project:

  • i) Effective program elements (see above, 1. a)

  • ii) Adequate funding

  • iii) Adequate staff

  • iv)  Agency buy-in for this project

2. Program evaluation:

  • a) Include clear objectives and strategies and related measurable outcomes in the grant application.

  • b) Identify the process of evaluation and assessment to be used for this project

  • c) Include both members from the priority population and HIV+ individuals in the process of evaluation      

4.4       Taxonomy of HIV/AIDS Prevention Interventions and Related Components

A “taxonomy” is a classification of related subjects into an ordered system that indicates their natural relationships to one another.  In addition to the “Fundamental Criteria” described in the previous section, the CPG has created a taxonomy of HIV prevention interventions to demonstrate how different types of interventions are related, and to show the various activities associated with these interventions.

The CPG taxonomy contains one primary category:  HIV Risk Reduction and Education.  Four essential HIV prevention interventions are listed below this category, with activities or characteristics related to each.  Three other associated categories are also listed within this framework: Health Communications/Public Information Programs; Systemic Change; and Program Elements.  A list of definitions follows the taxonomy which describes certain key concepts and activities.

A.  Health Education / Risk Reduction

1. Individual Level Interventions both professionally led and peer led including:

  • a) Behavior Change, Risk Reduction/Harm Reduction Counseling

  • b) Skills Training

  • c) HIV Prevention Counseling and Testing, Referral and Partner Notification

  • d) Prevention Case Management

  • e) Secondary Prevention Efforts

2.Group Level Interventions both professionally led and peer led including:

  • a) Behavior Change, Risk Reduction/Harm Reduction Counseling

  • b) Skills Training

  • c) Secondary Prevention Efforts

3. Outreach Interventions Including Those Appropriate for Individuals and Groups at the Following Locations:

  • a) Street

  • b) Community

  • c) Public Sex Environments

  • d) Institutions

4. Community Level Interventions Designed to Change Norms, Attitudes and Practices of the Community

  • a) Community Building Efforts for Social Networks

B.  Health Communications/Public Information Programs

  1. Mass Media Efforts

  2. Small Media Efforts

  3. Social Marketing Efforts

  4. Hotlines and Clearinghouses

C.  Systemic Change

  • 1. Systems Interventions

  • a) Policy Changes

  • b) Legal Changes

D. Program Elements

  • 1. Needs Assessment Efforts

  • 2. Capacity Building

  • a) Training of staff

  • b) Technical Assistance

  • 3. Program Design and Development

  • a) Goals and Measurable Objectives for Behavior Change

  • b) Program Evaluation

  • c)  Maintenance

4.5       Definitions

Community - is defined in terms of a neighborhood, region, or some other geographic area, and as a mechanism to capture the social networks that may be located within those boundaries. (For references to ‘communities’ of shared experience or shared identity, see Social networks, below.)

Community Level Interventions - aimed to reduce risky behaviors by changing attitudes, norms, and behaviors through health communication, social (prevention) marketing, community mobilization and organization, community wide events.

Cultural Competency - Programs and projects that are culturally competent and relevant include the following criteria.  They:  1) seek input from members of the identified population in developing materials and effective prevention methods; 2) strongly consider utilizing persons from the identified populations to conduct prevention activities; 3) have a working familiarity with attitudes and beliefs of members of the identified population; 4) utilize materials that are linguistically and culturally appropriate to the identified population.

Group Level Intervention - provides education and support in group settings to promote and reinforce safer behaviors and to provide interpersonal skills training in negotiating and sustaining appropriate behavior change to persons at increased risk of becoming infected or, if already infected, of transmitting the virus to others

Harm Reduction -  The philosophy and practice of respectfully recognizing and assisting all risk reduction actions.  The goal of harm reduction is to move the individual with the most or more harmful behaviors towards a less harmful behavior, to reduce the harmful consequences of the behaviors/habits.  Harm reduction interventions also are intended to decrease potential harm on the social network and community as well.

Individual Level Intervention - a range of one-to-one client services that offer counseling, assist clients in assessing their own behavior and planning individual behavior change, support and sustain behavior change, and facilitate linkages to services in clinic and community settings.

Outreach  - is a prevention activity conducted outside a more traditional health care setting for the purpose of providing other education and risk reduction/harm reduction services or referrals.

Prevention Case Management - an individual level intervention directed at persons who need highly individualized support, including substantial psychosocial, interpersonal skills training, and other support, to remain seronegative or to reduce the risk of HIV transmission to others.

Risk Reduction - interventions focused on the elimination or modification of behaviors to reduce the risk of HIV infection to the individual.

Secondary Prevention -  Prevention of additional infection by HIV and/or other Sexually Transmitted Diseases (STDs) in a person already infected by HIV; as well as prevention of transmission of HIV to others.

Sites - Physical location, setting, place where HIV prevention interventions are provided to populations at risk for infection.

Social Networks - people who are connected through either shared experiences or a shared identity  

Taxonomy - classification in an ordered system that indicates natural relationships.  In this instance, interventions and other HIV prevention components are organized in an ordered system indicating relationships to each other.

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