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

Measuring Implementation Outcomes Change Over Time Using an Adapted Checklist for Assessing Readiness to Implement (CARI)

In 2017, the Health Resources and Services Administration's HIV/AIDS Bureau funded an Evaluation Center (EC) to assess the rapid implementation of 11 evidence-informed interventions at 25 HIV care and treatment providers across the U.S. The EC conducted an implementation science-based evaluation, including longitudinal assessment of implementation outcomes as defined by Implementation Outcome Framework (IOF) of the Conceptual Model for Implementation Research. The EC adapted a measure originally designed for implementation readiness to capture seven implementation outcomes and administered the measure to site leadership every six months, from intervention launch through the end of the initiative. The adapted measure demonstrated adequate internal consistency within and across time periods. Individual outcomes changed over the course of implementation, with the greatest period of growth during the first six months. Longitudinal relationships between outcomes posited to be most relevant at early, mid- or late-implementation were not evident in these analyses; rather, relationships between the outcomes were significant within time periods. Finally, there were differences in the trajectory of outcomes based on characteristics of the site's larger context. The use of this adapted measure across multiple implementation settings, assessing multiple interventions, is an important step forward in the comparability of implementation outcomes more broadly.

Sociocultural Contexts of Access to HIV Primary Care and Participant Experience with an Intervention Project: African American Transgender Women Living with HIV in Alameda County, California

The baseline data of the intervention project for African American transgender women living with HIV showed that more than one-third of the participants having ever enrolled in HIV care had not received ART and that among those in ART, more than half reported their adherence to ART was poor. Those who had engaged in sex work, sold drugs, or experienced higher levels of transphobia were less likely to have enrolled in care. The qualitative interviews with participants who had completed the intervention or dropped out revealed barriers to enroll in care, such as community stigma and transphobia.

Understanding and addressing hepatitis C reinfection in the oral direct-acting antiviral era

The availability of effective, simple, well-tolerated oral direct-acting antiviral (DAA) hepatitis C regimens has raised optimism for hepatitis C virus (HCV) elimination at the population level. HCV reinfection in key populations such as people who inject drugs (PWID) and HIV-infected men who have sex with men (MSM) however threatens the achievement of this goal from a patient, provider and population perspective. The goal of this review was to synthesize our current understanding of estimated rates and factors associated with HCV reinfection. This review also proposes interventions to aid understanding of and reduce hepatitis C reinfection among PWID and HIV-infected MSM in the oral direct-acting antiviral era.

HIV/STI Prevention Interventions: A Systematic Review and Meta-analysis

Behavioral interventions can prevent the transmission of HIV and sexually transmitted infections. This systematic review and meta-analysis assesses the effectiveness and quality of available evidence of HIV prevention interventions for people living with HIV in high-income settings. Searches were conducted in MEDLINE, EMBASE, PsycINFO, and CDC Compendium of Effective Interventions. Interventions published between January, 1998 and September, 2015 were included. Quality of evidence was assessed using the Grading of Recommendations Assessment, Development and Evaluation (GRADE). Forty-six articles and 63 datasets involving 14,096 individuals met inclusion criteria. Included articles were grouped by intervention type, comparison group and outcome. Few of these had high or moderate quality of evidence and statistically significant effects. One intervention type, group-level health education interventions, were effective in reducing HIV/STI incidence when compared to attention controls. A second intervention type, comprehensive risk counseling and services, was effective in reducing sexual risk behaviors when compared to both active and attention controls. All other intervention types showed no statistically significant effect or had low or very low quality of evidence. Given that the majority of interventions produced low or very low quality of evidence, researchers should commit to rigorous evaluation and high quality reporting of HIV intervention studies.

The Relationship of Repeated Technical Assistance Support Visits to the Delivery of Positive Health, Dignity, and Prevention (PHDP) Messages by Healthcare Providers in Mozambique: A Longitudinal Multilevel Analysis

BACKGROUND

Positive health, dignity, and prevention (PHDP) is Mozambique's strategy to engage clinicians in the delivery of prevention messages to their HIV-positive clients. This national implementation strategy uses provider trainings on offering key messages and focuses on intervening on 9 evidence-based risk reduction areas. We investigated the impact of longitudinal technical assistance (TA) as an addition to this basic training.

METHODS

We followed 153 healthcare providers in 5 Mozambican provinces over 6 months to evaluate the impact of on-site, observation-based TA on PHDP implementation. Longitudinal multilevel models were estimated to model change in PHDP message delivery over time among individual providers.

RESULTS

With each additional TA visit, providers delivered about 1 additional PHDP message ( P < .001); clinicians and nonclinicians started at about the same baseline level, but clinicians improved more quickly ( P = .004). Message delivery varied by practice sector; maternal and child health sectors outperformed other sectors.

CONCLUSION

Longitudinal TA helped reach the programmatic goals of the PHDP program in Mozambique.

A systematic review of peer-supported interventions for health promotion and disease prevention

Prior research has examined peer programs with respect to specific peer roles (e.g.; peer support) or specific health/wellness domains (e.g.; exercise/diet), or have aggregated effects across roles and domains. We sought to conduct a systematic review that categorizes and assesses the effects of peer interventions to promote health and wellness by peer role, intervention type, and outcomes. We use evidence mapping to visually catalog and synthesize the existing research. We searched PubMed and WorldCat databases (2005 to 2015) and New York Academy of Medicine Grey Literature Report (1999 to 2016) for English-language randomized control trials. We extracted study design, study participants, type of intervention(s), peer role(s), outcomes assessed and measures used, and effects from 116 randomized controlled trials. Maps were created to provide a visual display of the evidence by intervention type, peer role, outcome type, and significant vs null or negative effects. There are more null than positive effects across peer interventions, with notable exceptions: group-based interventions that use peers as educators or group facilitators commonly improve knowledge, attitudes, beliefs, and perceptions; peer educators also commonly improved social health/connectedness and engagement. Dyadic peer support influenced behavior change and peer counseling shows promising effects on physical health outcomes. Programs seeking to use peers in public health campaigns can use evidence maps to identify interventions that have previously demonstrated beneficial effects. Those seeking to produce health outcomes may benefit from identifying the mechanisms by which they expect their program to produce these effects and associated proximal outcomes for future evaluations.

PROSPERO REGISTRATION NUMBER

Although we attempted to register our protocol with PROSPERO, we did not meet eligibility criteria because we were past the data collection phase. The full PROSPERO-aligned protocol is available from the authors.

Pre/post evaluation of a pilot prevention with positives training program for healthcare providers in North West Province, Republic of South Africa

BACKGROUND

Prevention interventions for people living with HIV/AIDS are an important component of HIV programs. We report the results of a pilot evaluation of a four-hour, clinic-based training for healthcare providers in South Africa on HIV prevention assessments and messages. This pre/post pilot evaluation examined whether the training was associated with providers delivering more prevention messages.

METHODS

Seventy providers were trained at four public primary care clinics with a high volume of HIV patients. Pre- and post-training patient exit surveys were conducted using Audio-Computer Assisted Structured Interviews. Seven provider appropriate messaging outcomes and one summary provider outcome were compared pre- and post-training using Poisson regression.

RESULTS

Four hundred fifty-nine patients pre-training and 405 post-training with known HIV status were interviewed, including 175 and 176 HIV positive patients respectively. Among HIV positive patients, delivery of all appropriate messages by providers declined post-training. The summary outcome decreased from 56 to 50%; adjusted rate ratio 0.92 (95% CI = 0.87-0.97). Sensitivity analyses adjusting for training coverage and time since training detected fewer declines. Among HIV negative patients the summary score was stable at 32% pre- and post-training; adjusted rate ratio 1.05 (95% CI = 0.98-1.12).

CONCLUSIONS

Surprisingly, this training was associated with a decrease in prevention messages delivered to HIV positive patients by providers. Limited training coverage and delays between training and post-training survey may partially account for this apparent decrease. A more targeted approach to prevention messages may be more effective.

HIV transmission risk behaviors among people living with HIV/AIDS: the need to integrate HIV prevention interventions and public health strategies into HIV care

CONTEXT

People living with human immunodeficiency virus (HIV)/AIDS (PLWHA) who continue high-risk behaviors may represent an important source for transmitting HIV infections.

OBJECTIVE

To identify factors associated with high-risk behaviors among PLWHA and to plan better HIV prevention intervention strategies in HIV care.

DESIGN

A cross-sectional survey to assess HIV transmission risk behaviors including sexual practices, disclosure of HIV infection status to sexual partner(s), and injection drug use.

SETTING

Five HIV outpatient clinics serving diverse PLWHA in south central Pennsylvania.

PARTICIPANTS

A total of 519 HIV-infected patients.

MAIN OUTCOME MEASURES

Two high-risk behaviors that may increase HIV transmission risk: (1) any unsafe sexual behavior and (2) nondisclosure of HIV infection status to sexual partner(s). An unsafe sexual behavior was defined as inconsistent condom use, sex under the influence of alcohol or drugs, or exchange of sex for money. A subgroup analysis was performed to examine factors related to unprotected anal intercourse among sexually active men who have sex with men.

RESULTS

About two-thirds of 519 HIV patients (65.7%) were sexually active, and nearly 50% of sexually active patients reported at least 1 unsafe sexual behavior. Nondisclosure of HIV infection status was reported by about 15% of the patients. Partners' characteristics including HIV infection status and the perceived partner behavior (ie, partner may have sex with other people) were significantly associated with unsafe sexual behaviors and with nondisclosure of HIV infection status. Non-Hispanic black males were more likely to withhold their HIV infection status from their sexual partner(s) (adjusted odds ratio = 4.51) than their white counterparts. In addition, the perceived partner sexual behavior was significantly related to unprotected anal intercourse among men who have sex with men (adjusted odds ratio = 2.00).

CONCLUSIONS

High-risk sexual behaviors are commonly reported by PLWHA, and these behaviors may be influenced by their partners' characteristics. HIV prevention interventions and public health strategies need to be incorporated into HIV care.

Delivery of HIV Transmission Risk-Reduction Services by HIV Care Providers in the United States-2013

OBJECTIVES

Evidence-based guidelines have long recommended that HIV care providers deliver HIV transmission risk-reduction (RR) services, but recent data are needed to assess their adoption.

METHODS

The authors surveyed a probability sample of 1234 US HIV care providers on delivery of 9 sexual behavior- and 7 substance use-related HIV transmission RR services and created an indicator of "adequate" delivery of services in each area, defined as performing approximately 70% or more of applicable services.

RESULTS

Providers were most likely to encourage patients to disclose HIV status to all partners since HIV diagnosis (81%) and least likely to ask about disclosure to new sex and drug injection partners at follow-up visits (both 41%). Adequate delivery of sexual behavior- and substance use-related RR services was low (37% and 43%, respectively).

CONCLUSION

The majority of US HIV care providers may need additional support to improve delivery of comprehensive HIV transmission RR services.

Frequency and predictors of estimated HIV transmissions and bacterial STI acquisition among HIV-positive patients in HIV care across three continents

Introduction

Successful global treatment as prevention (TasP) requires identifying HIV-positive individuals at high risk for transmitting HIV, and having impact via potential infections averted. This study estimated the frequency and predictors of numbers of HIV transmissions and bacterial sexually transmitted infection (STI) acquisition among sexually active HIV-positive individuals in care from three representative global settings.

Methods

HIV-positive individuals (n=749), including heterosexual men, heterosexual women and men who have sex with men (MSM) in HIV care, were recruited from Chiang Mai (Thailand), Rio De Janeiro (Brazil) and Lusaka (Zambia). Participants were assessed on HIV and STI sexual transmission risk variables, psychosocial characteristics and bacterial STIs at enrolment and quarterly for 12 months (covering 15 months). Estimated numbers of HIV transmissions per person were calculated using reported numbers of partners and sex acts together with estimates of HIV transmissibility, accounting for ART treatment and condom use.

Results

An estimated 3.81 (standard error, (SE)=0.63) HIV transmissions occurred for every 100 participants over the 15 months, which decreased over time. The highest rate was 19.50 (SE=1.68) for every 100 MSM in Brazil. In a multivariable model, country×risk group interactions emerged: in Brazil, MSM had 2.85 (95% CI=1.45, 4.25, p<0.0001) more estimated transmissions than heterosexual men and 3.37 (95% CI=2.01, 4.74, p<0.0001) more than heterosexual women over the 15 months. For MSM and heterosexual women, the combined 12-month STI incidence rate for the sample was 22.4% (95% CI=18.1%, 27.3%; incidence deemed negligible in heterosexual men). In the multivariable model, MSM had 12.3 times greater odds (95% CI=4.44, 33.98) of acquiring an STI than women, but this was not significant in Brazil. Higher alcohol use on the Alcohol Use Disorders Identification Test (OR=1.04, 95% CI=1.01, 1.08) was also significantly associated with increased STI incidence. In bivariate models for both HIV transmissions and STI incidence, higher depressive symptoms were significant predictors.

Conclusions

These data help to estimate the potential number of HIV infections transmitted and bacterial STIs acquired over time in patients established in care, a group typically considered at lower transmission risk, and found substantial numbers of estimated HIV transmissions. These findings provide an approach for evaluating the impact (in phase 2 studies) and potentially cost-effectiveness of global TasP efforts.

'Proyecto Orgullo', an HIV prevention, empowerment and community mobilisation intervention for gay men and transgender women in Callao/Lima, Peru

We used qualitative, quantitative, and observational methods to assess the feasibility, acceptability, and potential efficacy of Proyecto Orgullo (PO), a pilot community mobilisation intervention to decrease sexual risk, promote health-seeking behaviours, and facilitate personal and community empowerment among gay men (GM) and transgender women (TW) in Peru. PO was adapted from Mpowerment and Hermanos de Luna y Sol, two US interventions. PO included six interrelated core elements: (1) Self-reflection Small Group sessions; (2) Supporting peers in HIV prevention; (3) Mobilisation Activities addressing HIV, GM/TW issues, and community empowerment; (4) A Core Group (staff + GM/TW volunteers) designing/implementing those activities; (5) A Project Space; (6) Publicity. PO included specific components for TW, but promoted that GM/TW, who historically have not worked well together, collaborate for a common goal. We found that PO was embraced by GM/TW. PO positively influenced GM/TW's HIV prevention beliefs, self-efficacy, and behaviours; provided social support and created community; facilitated individual and community empowerment; achieved that GM/TW collaborate; and established a functional Community Centre for socialising/conducting mobilisation activities. Community mobilisation strategies, lacking from HIV prevention efforts in Peru but considered key to HIV prevention, can help improve health-seeking behaviours and consolidate social norms supporting preventive behaviours among GM/TW.

Randomized Controlled Trial of an Internet Application to Reduce HIV Transmission Behavior Among HIV Infected Men Who have Sex with Men

We conducted a prospective, randomized controlled trial of an internet-based safer-sex intervention to reduce HIV transmission risk behaviors. HIV-infected men who have sex with men (n = 179) were randomized to receive a monthly internet survey alone or a monthly survey plus tailored risk reduction messages over 12 months. The primary outcome was the cumulative sexually transmitted infection (STI) incidence over 12 months. Secondary outcomes included self-reported unprotected sex with an at risk partner and disclosure of HIV status to partners. In a modified intent to treat analysis, there was no difference in 12-month STI incidence between the intervention and control arms (30 vs. 25 %, respectively; p = 0.5). Unprotected sex decreased and disclosure increased over time in both study arms. These improvements suggest that addition of the risk-reduction messages provided little benefit beyond the self-monitoring of risky behavior via regular self-report risk behavior assessments (as was done in both study arms).

Brief Report: Sexual Risk Behaviors of HIV Seroconverters in the US Army, 2012-2014

The United States (US) Army implemented a comprehensive HIV characterization program in 2012 following repeal of the Don't Ask, Don't Tell policy banning openly homosexual individuals from serving in the US military. Program staff administered a standardized case report form to soldiers newly diagnosed with HIV from 2012 to 2014 in compliance with new program requirements. The case report form documented sociodemographic, sexual, and other risk behavior information elicited from US Army regulation-mandated epidemiologic interviews at initial HIV notification. A majority of HIV-infected soldiers were male and of black/African American racial origin. In the HIV risk period, male soldiers commonly reported male-male sexual contact, civilian partners, online partner-seeking, unprotected anal sex, and expressed surprise at having a positive HIV result. Don't Ask, Don't Tell repeal allows for risk screening and reduction interventions targeting a newly identifiable risk category in the US Army. At-risk populations need to be identified and assessed for possible unmet health needs.

The Impact of Visual Aids and Enhanced Training on the Delivery of Positive Health, Dignity, and Prevention Messages to Adult Patients Living with HIV in Rural North Central Mozambique

Introduction

Positive health, dignity, and prevention (PHDP) interventions target people living with HIV and AIDS (PLHIV) to promote well-being and prevent onward transmission. Concern that increased life expectancy and improved well-being would lead to increased risky sexual behaviour and subsequent HIV transmission motivated researchers to test novel strategies to support treatment adherence, encourage safer sex, STI treatment and partner testing, prevention of mother to child transmission, and support uptake of family planning.

Methods

We assessed the number and type of PHDP messages delivered to PLHIV before and after the implementation of an educational intervention for health providers combined with the distribution of visual job aids and monthly technical assistance.

Results

From April 21, 2013 to March 20, 2014, we documented 54,731 clinical encounters at three rural health centres in Zambézia province, Mozambique from 9,248 unique patients. The percentage of patients who received all seven PHDP messages during their last three visits was 1.9% pre-intervention vs. 13.6% post- intervention (p=<0.001). Younger patients (25 years vs. 35) and those with a recent HIV diagnosis (two weeks vs. two years) had higher odds of receiving any PHDP message (Odds Ratio [OR]: 1.22 and 2.79, respectively). Patients >59 days late collecting medications were not more likely to receive adherence messages than adherent patients (p=0.17).

Discussion

Targeting HIV prevention efforts to PLHIV is an effective HIV prevention approach to eliminate HIV transmission. Despite intensive training and support, PHDP message delivery remained unacceptably low in rural Mozambique. Patients at high risk for treatment abandonment were not more likely to be counselled about adherence and support measures, something that needs to be addressed.

Conclusions

We need to develop novel strategies to motivate health care providers to deliver these messages more consistently to all patients and develop a system that assists counsellors and clinicians to quickly and effectively determine which messages should be delivered.

Sexually transmitted diseases treatment guidelines, 2015

These guidelines for the treatment of persons who have or are at risk for sexually transmitted diseases (STDs) were updated by CDC after consultation with a group of professionals knowledgeable in the field of STDs who met in Atlanta on April 30-May 2, 2013. The information in this report updates the Sexually Transmitted Diseases Treatment Guidelines, 2010 (MMWR Recomm Rep 2010;59 [No. RR-12]). These updated guidelines discuss 1) alternative treatment regimens for Neisseria gonorrhoeae; 2) the use of nucleic acid amplification tests for the diagnosis of trichomoniasis; 3) alternative treatment options for genital warts; 4) the role of Mycoplasma genitalium in urethritis/cervicitis and treatment-related implications; 5) updated HPV vaccine recommendations and counseling messages; 6) the management of persons who are transgender; 7) annual testing for hepatitis C in persons with HIV infection; 8) updated recommendations for diagnostic evaluation of urethritis; and 9) retesting to detect repeat infection. Physicians and other health-care providers can use these guidelines to assist in the prevention and treatment of STDs.

Behavioral Interventions to Reduce Sexual Risk Behavior in Adults with HIV/AIDS Receiving HIV Care: A Systematic Review

Regular interactions with people living with HIV/AIDS (PLWHA) who are receiving care provide caregivers opportunities to deliver interventions to reduce HIV-related risks. We conducted a systematic review of behavioral interventions for PLWHA (provided at individual level by caregivers at HIV care settings) to determine their efficacy in reducing sexual risk behavior. Conference websites and biomedical literature databases were searched for studies from 1981 to 2013. Randomized and quasi-randomized controlled trials (with standard-of-care control groups), considering at least one of a list of HIV-related behavioral or biological outcomes in PLWHA aged ≥18 receiving HIV care with at least 3-month follow-up were included. No language or publication status restrictions were set. Standardized search, data abstraction, and evaluation methods were used. Five randomized controlled trials were included in the review. We found limited evidence that sexual risk reduction interventions increase condom use consistency in HIV transmission risk acts, and reduce the number of (casual) sexual partners. We still believe that regular interactions between HIV care providers and PLWHA provide valuable opportunities for theory-based sexual risk reduction interventions to restrain the spread of HIV.

Integrating prevention interventions for people living with HIV into care and treatment programs: a systematic review of the evidence

INTRODUCTION

This review assesses the impact of prevention interventions for people living with HIV on HIV-related mortality, morbidity, retention in care, quality of life, and prevention of ongoing HIV transmission in resource-limited settings (RLSs).

METHODS

We conducted a systematic review of studies reporting the results of prevention interventions for people living with HIV in RLS published between January 2000 and August 2014. Standardized methods of searching and data abstraction were used.

RESULTS

Ninety-two studies met the eligibility criteria: 24 articles related to adherence counseling and support, 13 on risk reduction education and condom provision, 19 on partner HIV testing and counseling, 14 on provision of family planning services, and 22 on assessment and treatment of other sexually transmitted infections. Findings indicate good evidence that adherence counseling and sexually transmitted infection treatment can have a high impact on morbidity, whereas risk reduction education, partner HIV testing and counseling, and family planning counseling can prevent transmission of HIV. More limited evidence was found to support the impact of these interventions on retention in care and quality of life. Most studies did not report cost information, making it difficult to draw conclusions about the cost-effectiveness of these interventions.

CONCLUSIONS

This evidence suggests that these prevention interventions, if brought to sufficient scale and coverage, can help support and optimize the impact of core treatment and prevention interventions in RLS. Further operational research with more rigorous study designs, and ideally with biomarkers and costing information, is needed to determine the best model for providing these interventions in RLS.

Psychological symptoms are associated with both abstinence and risky sex among men with HIV

Sexual abstinence is often deemed the "safest behavior" in HIV prevention, but is sometimes associated with psychological symptoms (e.g., depression) just as sexually risky behavior is. This study explored whether sexual abstinence and risky sexual behavior among men with HIV were associated with similar constellations of psychological symptoms. Prior research has not addressed this issue because abstinent people often are not included in the sample or, when data are analyzed, researchers combine abstinent people with sexually active people who practice safer sex. Past research also neglects the co-morbidity of psychological symptoms. A latent class analysis of the psychological symptoms (assessed with the Symptom Check List 90-R; Derogatis, 1994) of 140 men with HIV, mostly from rural New England, revealed three latent classes: men who were asymptomatic on all symptom domains (28.8 %), men who were symptomatic on all domains (34.1 %), and men who were symptomatic on internalizing domains (37.1 %), but were asymptomatic on the externalizing symptoms of hostility and paranoid ideation. Logistic regression showed that sexual behavior during the past 90 days of men in the all symptom class and the internalizing symptoms class was similar, with abstinence and risky sex predominating, and safer sex being relatively uncommon for both classes. The sexual behavior of men in the asymptomatic class differed, with safer sex being relatively more likely to occur compared to the symptomatic classes. These findings suggest that the psychological symptom profile of sexually abstinent people places them at risk for inconsistent condom use should they engage in sexual behavior.

Sexual risk reduction for HIV-infected persons: a meta-analytic review of "positive prevention" randomized clinical trials

BACKGROUND

Prevention intervention trials have been conducted to reduce risk of sexual transmission among people living with HIV/AIDS (PLWHA), but the findings were inconsistent. We performed a systematic review and meta-analysis to evaluate overall efficacy of prevention interventions on unprotected vaginal or anal intercourse (UVAI) among PLWHA from randomized clinical trials (RCTs).

METHODS

RCTs of prevention interventions among PLWHA published as of February 2012 were identified by systematically searching thirteen electronic databases. The primary outcome was UVAI. The difference of standardized mean difference (SMD) of UVAI between study arms, defined as effect size (ES), was calculated for each study and then pooled across studies using standard meta-analysis with a random effects model.

RESULTS

Lower likelihood of UVAI was observed in the intervention arms compared with the control arms either with any sexual partners (mean ES: -0.22; 95% confidence interval [CI]: -0.32, -0.11) or with HIV-negative or unknown-status sexual partners (mean ES and 95% CI: -0.13 [-0.22, -0.04]). Short-term efficacy of interventions with ≤ 10 months of follow up was significant in reducing UVAI (1-5 months: -0.27 [-0.45, -0.10]; 6-10 months: -0.18 [-0.30, -0.07]), while long-term efficacy of interventions was weaker and might have been due to chance (11-15 months: -0.13 [-0.34, 0.08]; >15 months: -0.05 [-0.43, 0.32]).

CONCLUSIONS

Our meta-analyses confirmed the short-term impact of prevention interventions on reducing self-reported UVAI among PLWHA irrespective of the type of sexual partner, but did not support a definite conclusion on long-term effect. It is suggested that booster intervention sessions are needed to maintain a sustainable reduction of unprotected sex among PLWHA in future risk reduction programs.

Positive choices: outcomes of a brief risk reduction intervention for newly HIV-diagnosed men who have sex with men

Positive choices (PC), a brief sexual risk reduction intervention conducted with newly HIV-diagnosed men who have sex with men (MSM), was evaluated for preliminary efficacy. Participants were enrolled if they reported unprotected anal intercourse (UAI) in the three months prior to HIV diagnosis (n = 102). Three months after diagnosis, participants completed baseline assessments and were randomly assigned to receive the 3-session PC intervention or the comprehensive standard of care (C-SoC) at a community health center. Participants completed assessments at 3- (post intervention), 6-, and 9- months after baseline. Compared to C-SoC participants, PC participants significantly reduced the frequency of UAI with HIV serodiscordant (HIV negative or status unknown) partners over the 9-month follow-up period. No differences by condition were found in the frequency of UAI with all partners. The findings from this trial suggest that brief risk reduction approaches for newly-diagnosed MSM integrated into HIV care can benefit secondary HIV prevention efforts.

Qualitative evaluation of a Positive Prevention training for health care providers in Mozambique

The rapid scale-up of HIV care and treatment in Mozambique has provided an opportunity to reach people living with HIV (PLHIV) with prevention interventions in HIV care and treatment settings. A three-day Positive Prevention (PP) training intervention for health care providers that focused on pressing issues for PLHIV in Mozambique was adapted and delivered at sites in three provinces. In-depth interviews were conducted with 31 providers trained in the PP curriculum. Qualitative data were used to assess the appropriateness of the training materials and approach, which lessons providers learned and were able to implement and which PP messages were still difficult to deliver. Providers reported gaining numerous insights from the training, including how to conduct a risk assessment and client-centered counseling, negotiating disclosure, partner testing, condom use, PMTCT, treatment adherence and approaches for positive living. Training topics not commonly mentioned included discordance counseling, STIs, family planning, alcohol and drug use, and frank sexual risk discussions. While areas for improvement exist, the PP training was useful in transferring skills to providers and is a viable component of HIV care. This evaluation helps identify areas where future PP trainings and specific strategies and messages can be refined for the Mozambican context.

A systematic review of interventions for reducing HIV risk behaviors among people living with HIV in the United States, 1988-2012

OBJECTIVE

To conduct a systematic review to examine interventions for reducing HIV risk behaviors among people living with HIV (PLWH) in the United States.

METHODS

Systematic searches included electronic databases from 1988 to 2012, hand searches of journals, reference lists of articles, and HIV/AIDS Internet listservs. Each eligible study was evaluated against the established criteria on study design, implementation, analysis, and strength of findings to assess the risk of bias and intervention effects.

RESULTS

Forty-eight studies were evaluated. Fourteen studies (29%) with both low risk of bias and significant positive intervention effects in reducing HIV transmission risk behaviors were classified as evidence-based interventions (EBIs). Thirty-four studies were classified as non-EBIs due to high risk of bias or nonsignificant positive intervention effects. EBIs varied in delivery from brief prevention messages to intensive multisession interventions. The key components of EBIs included addressing HIV risk reduction behaviors, motivation for behavioral change, misconception about HIV, and issues related to mental health, medication adherence, and HIV transmission risk behavior.

CONCLUSION

Moving evidence-based prevention for PLWH into practice is an important step in making a greater impact on the HIV epidemic. Efficacious EBIs can serve as model programs for providers in healthcare and nonhealthcare settings looking to implement evidence-based HIV prevention. Clinics and public health agencies at the state, local, and federal levels can use the results of this review as a resource when making decisions that meet the needs of PLWH to achieve the greatest impact on the HIV epidemic.

A systematic review of interventions for reducing HIV risk behaviors among people living with HIV in the United States, 1988-2012

OBJECTIVE

To conduct a systematic review to examine interventions for reducing HIV risk behaviors among people living with HIV (PLWH) in the United States.

METHODS

Systematic searches included electronic databases from 1988 to 2012, hand searches of journals, reference lists of articles, and HIV/AIDS Internet listservs. Each eligible study was evaluated against the established criteria on study design, implementation, analysis, and strength of findings to assess the risk of bias and intervention effects.

RESULTS

Forty-eight studies were evaluated. Fourteen studies (29%) with both low risk of bias and significant positive intervention effects in reducing HIV transmission risk behaviors were classified as evidence-based interventions (EBIs). Thirty-four studies were classified as non-EBIs due to high risk of bias or nonsignificant positive intervention effects. EBIs varied in delivery from brief prevention messages to intensive multisession interventions. The key components of EBIs included addressing HIV risk reduction behaviors, motivation for behavioral change, misconception about HIV, and issues related to mental health, medication adherence, and HIV transmission risk behavior.

CONCLUSION

Moving evidence-based prevention for PLWH into practice is an important step in making a greater impact on the HIV epidemic. Efficacious EBIs can serve as model programs for providers in healthcare and nonhealthcare settings looking to implement evidence-based HIV prevention. Clinics and public health agencies at the state, local, and federal levels can use the results of this review as a resource when making decisions that meet the needs of PLWH to achieve the greatest impact on the HIV epidemic.

Rising Syphilis Infection among Rural HIV-Infected Men who Routinely Received Risk-Reduction Counseling: New Challenges to HIV Prevention in Clinical Care

OBJECTIVE

Syphilis incidence has been steadily increasing among HIV-infected men in the United States, representing an important public health challenge to HIV prevention. Clinic-based HIV prevention interventions are available but may need to be revisited in response to syphilis epidemic. We wanted to better understand the current epidemiology of syphilis in rural HIV-infected men who routinely received HIV risk-reduction counseling in order to plan more effective HIV prevention strategies in clinical care.

METHODS

We conducted a retrospective cohort study to examine factors associated with syphilis infections in rural HIV-infected men who received sexually transmitted disease screening and HIV risk-reduction counseling during HIV primary care from January 2008 to June 2013. We assessed patients' demographic, clinical, behavioral and psychosocial characteristics and performed a multivariable exact logistic regression to identify factors related to syphilis.

RESULTS

Despite routine risk screening and HIV risk-reduction counseling, a total of 51 syphilis infections were diagnosed among 702 HIV-infected men (5 patients were diagnosed ≥ 2 episodes). The majority of the study participants was sexually active and reported at least one unsafe sexual behavior, mainly inconsistent condom use. Younger age (<35 years, adjusted odds ratio (aOR)=3.09), higher educational attainment (some college or above, aOR=3.72), and perception that the partner may have sex with other people (aOR=3.10) were significantly associated with syphilis infection. Non-injection drug use was related to syphilis in HIV-infected men who have sex with men (aOR=2.86).

DISCUSSION

Some HIV-infected men, especially young, educated men, or those who perceived that their partners may have sex with other people, continue to have high-risk behaviors that increase their own risks of acquiring syphilis and may also facilitate HIV transmission. New strategies need to be developed for HIV primary care providers to help HIV-infected patients maintain safer sex practices.

Lessons learned from field-testing a brief behavioral intervention package for African American women at risk for HIV/STDs

This article describes how Sister to Sister, an evidence-based HIV/STD intervention for African American women in clinical settings, was prepared for national dissemination using the Centers for Disease Control and Prevention's Replicating Effective Programs research translation process. To test the feasibility of the intervention in the "real world," Sister to Sister's original research team collaborated with community partners to field-test the intervention in three clinical settings. Experiences from field-testing and input from a community advisory board were used to translate research protocols into a package of user-friendly materials that could be easily adopted by frontline clinic staff throughout the nation. Process monitoring and evaluation data demonstrated that Sister to Sister could be implemented successfully by a variety of practitioners including nurses, health educators, and HIV test counselors. "Buy-in" from clinic administrators and providers was a prerequisite to the success of the intervention. Replicating Effective Programs provided a useful process that can be applied by others to successfully prepare evidence-based interventions such as Sister to Sister for national dissemination.

Disclosure, knowledge of partner status, and condom use among HIV-positive patients attending clinical care in Tanzania, Kenya, and Namibia

We describe the frequency of and factors associated with disclosure, knowledge of partner's HIV status, and consistent condom use among 3538 HIV-positive patients attending eighteen HIV care and treatment clinics in Kenya, Namibia, and Tanzania. Overall, 42% of patients were male, and 64% were on antiretroviral treatment. The majority (80%) had disclosed their HIV status to their partners, 64% knew their partner's HIV status, and 77% reported consistent condom use. Of those who knew their partner's status, 18% reported their partner was HIV negative. Compared to men, women were significantly less likely to report disclosing their HIV status to their sex partner(s), to knowing their partner's HIV status, and to using condoms consistently with HIV-negative partners. Other factors negatively associated with consistent condom use include nondisclosure, alcohol use, reporting a casual sex partner, and desiring a pregnancy. Health care providers should target additional risk reduction counseling and support services to patients who report these characteristics.

Counseling to reduce high-risk sexual behavior in HIV care: a multi-center, direct observation study

A key opportunity to reduce HIV transmission lies with healthcare providers counseling HIV-infected patients about safer sex. We audio-recorded and transcribed clinical encounters between 45 healthcare providers and 417 of their HIV-infected patients at four outpatient sites in the United States. We used logistic regressions to evaluate associations between patient and provider characteristics, and the occurrence of discussion (any talk about sex) and counseling (advice about safer sex). Of the 417 encounters, discussion of sex occurred in 187 (45% of encounters, 95% CI: 40-50%). Counseling occurred for 49% (95% CI: 35-63%) of patients reporting unsafe sex. Discussion of sex was more likely with younger or less-educated patients and with less cultural difference between patient and provider, while counseling was associated with greater provider mindfulness and lower provider empathy. These findings suggest targets to improve communication regarding sexual risk reduction in HIV care.

Moderate levels of depression predict sexual transmission risk in HIV-infected MSM: a longitudinal analysis of data from six sites involved in a "prevention for positives" study

Depression is highly comorbid with HIV and may contribute to increased sexual transmission risk behavior (TRB) amongst HIV-infected MSM, the largest risk group for HIV in the U.S. However, examinations of this effect are inconsistent. The present longitudinal analyses of 746 HIV-infected MSM is from a multi-site "prevention for positives" study. A non-linear association between depression and TRB emerged. Moderate levels of depression (compared to either low or high levels) were associated with a more modest decline in the odds of sexual risk behavior over 12-month follow-up. Assessing depression in HIV primary care settings may help to identify those at risk and integrating the treatment of depression into secondary prevention and treatment initiatives may decrease the likelihood of sexual risk and help to contain the epidemic among MSM.

Impact of a computer-assisted, provider-delivered intervention on sexual risk behaviors in HIV-positive men who have sex with men (MSM) in a primary care setting

Innovative strategies are needed to assist providers with delivering secondary HIV prevention in the primary care setting. This longitudinal HIV clinic-based study conducted from 2004-2007 in a Birmingham, Alabama HIV primary care clinic tested a computer-assisted, provider-delivered intervention designed to increase condom use with oral, anal and vaginal sex, decrease numbers of sexual partners and increase HIV disclosure among HIV-positive men-who-have-sex-with-men (MSM). Significant declines were found for the number of unprotected insertive anal intercourse acts with HIV+ male partners during the intervention period (p = 0.0003) and with HIV-/UK male partners (p = 0.0007), as well as a 47% reduction in the number of male sexual partners within the preceding 6 months compared with baseline (p = 0.0008). These findings confirm and extend prior reports by demonstrating the effectiveness of computer-assisted, provider-delivered messaging to accomplish risk reduction in patients in the HIV primary care setting.

Project enhance: a randomized controlled trial of an individualized HIV prevention intervention for HIV-infected men who have sex with men conducted in a primary care setting

OBJECTIVE

Men who have sex with men (MSM) are the largest group of individuals in the U.S. living with HIV and have the greatest number of new infections. This study was designed to test a brief, culturally relevant prevention intervention for HIV-infected MSM, which could be integrated into HIV care.

METHOD

HIV-infected MSM who received HIV care in a community health center (N = 201), and who reported HIV sexual transmission-risk behavior (TRB) in the prior 6 months, were randomized to receive the intervention or treatment as usual. The intervention, provided by a medical social worker, included proactive case management for psychosocial problems, counseling about living with HIV, and HIV TRB risk reduction. Participants were followed every 3 months for one year.

RESULTS

Participants, regardless of study condition, reported reductions in HIV TRB, with no significant differential effect by condition in primary intent-to-treat analyses. When examining moderators, the intervention was differentially effective in reducing HIV TRB for those who screened in for baseline depression, but this was not the case for those who did not screen in for depression.

CONCLUSIONS

The similar level of reduction in HIV TRB in the intervention and control groups, consistent with other recent secondary prevention interventions, speaks to the need for new, creative designs, or more potent interventions in secondary HIV prevention trials, as the control group seemed to benefit from risk assessment, study contact, and referrals provided by study staff. The differential finding for those with depression may suggest that those without depression could reap benefits from limited interventions, but those with a comorbid psychiatric diagnosis may require additional interventions to modify their sexual risk behaviors.

Helping clinicians deliver consistent HIV prevention counseling to their HIV-infected patients

The delivery of HIV risk assessment and behavioral counseling by clinicians in HIV clinical settings is one component in a comprehensive "positive prevention" strategy to help patients reduce their transmission risk behavior. Clinicians engage in behavioral prevention inconsistently, however, depending on whether patients are new to a practice or are established in regular care and on their attitudes and characteristics of their practices. We analyzed clinician reports of behavioral prevention delivered before and after participation in a large federal demonstration project of positive prevention interventions. The interventions that were part of this project were successful in increasing behavioral prevention among both new and returning patients. Prior to study interventions, clinicians reported counseling 69% of new patients and 52% of returning patients. In follow-up interviews 12 months after receiving training, clinicians reported delivering prevention messages to 5% more new patients and 9% of returning patients (both p<0.01). After 12 months, clinicians were more likely to engage in behavioral prevention if other providers in their sites were also involved. Clinicians agreeing that behavioral prevention was part of the clinic's mission were more likely to conduct it. The interventions were successful in mitigating the influence of provider attitudes precluding prevention delivery. Intervention strategies can help clinicians more consistently deliver behavioral prevention messages to their HIV-infected patients.

People living with HIV are receptive to HIV prevention interventions in clinical settings: a qualitative evaluation

In the United States, HIV prevention services are increasingly being offered in the context of healthcare settings. This includes prioritizing prevention services for people living with HIV (PLWH), otherwise known as "prevention with positives." We conducted sixty in-depth interviews to explore patients' perceptions of clinic-based HIV prevention interventions targeting people living with HIV. The majority of patients were receptive to the prevention interventions. Patients described experiencing feeling fulfilled by communicating about issues related to HIV prevention when the conversations were specific to their situation and with an interventionist who was objective, yet empathic and non-judgmental. Provider-delivered interventions opened up new areas of prevention discussions with patients. Specialist-delivered interventions, specifically group-level interventions, provided opportunities to integrate participants into social networks that in turn provided social support and a reduction in social isolation. HIV prevention counseling benefited patients regardless of risk status.

Routine brief risk-reduction counseling with biannual STD testing reduces STD incidence among HIV-infected men who have sex with men in care

BACKGROUND

We evaluated whether routine biannual sexually transmitted disease (STD) testing coupled with brief risk-reduction counseling reduces STD incidence and high-risk behaviors.

METHODS

The SUN study is a prospective observational HIV cohort study conducted in 4 US cities. At enrollment and every 6 months thereafter, participants completed a behavioral survey and were screened for STDs, and if diagnosed, were treated. Medical providers conducted brief risk-reduction counseling with all patients. Among men who have sex with men (MSM), we examined trends in STD incidence and rates of self-reported risk behaviors before and after exposure to the risk-reduction intervention. The "preintervention" visit was the study visit that was at least 6 months after enrollment STD screening and treatment and at which the participant was first exposed to the intervention. The "postintervention" visit was 12 months later.

RESULTS

Among 216 MSM with complete STD and behavioral data, median age was 44.5 years; 77% were non-Hispanic white; 83% were on highly active antiretroviral treatment; 84% had an HIV RNA level <400 copies/mL and the median CD4 (cluster of differentiation 4) count was 511 cells/mm. Twelve months after first exposure to the risk-reduction intervention, STD incidence declined from 8.8% to 4.2% (P = 0.041). Rates of unprotected receptive or insertive anal intercourse with HIV-positive partners increased (19% to 25%, P = 0.024), but did not change with HIV-negative partners or partners of unknown HIV status (24% to 22%, P = 0.590).

CONCLUSIONS

STD incidence declined significantly among HIV-infected MSM after implementing frequent, routine STD testing coupled with risk-reduction counseling. These findings support adoption of routine STD screening and risk-reduction counseling for HIV-infected MSM.

Helping patients talk about HIV: inclusion of messages on disclosure in prevention with positives interventions in clinical settings

Disclosure of HIV serostatus by HIV-infected individuals is considered a prevention strategy, under the assumption that disclosure will prompt risk reduction practices among sex partners. We examined patients' self-reports regarding disclosure messages they found relevant as part of prevention with positives (PwP) interventions in clinical settings. We conducted 52 in-depth interviews with patients participating in 13 PwP interventions. We found that the opportunity to reflect about living with HIV, explore fears of stigma and rejection, develop communication skills and strategies to disclose, and explore a sense of responsibility influenced patients' intention to disclose and their disclosure practices. PwP interventions need to include a combination of messages about disclosure strategies, stigma, and communication, as well as helping patients frame disclosure as a process that includes situations and interactions to consider post-disclosure. PwP disclosure counseling can help influence a shift in patients' risk towards safer sex practices.

Messages HIV clinicians use in prevention with positives interventions

Prevention with Positives (PwP) is a component of the US HIV prevention strategy that targets HIV-infected persons who are aware of their seropositive status. This paper examines the use of prevention messages by clinical providers during the PwP intervention period of the US Health Resources and Services Administration's Special Projects of National Significance program. Quantitative approaches were used to learn which prevention topics were most discussed and qualitative interviews were also utilized to better understand the clinician perspective in providing prevention counseling. At 12-month follow-up, there was a significant increase in the percent of patients receiving all PwP counseling messages (p<0.01). Providers reported discussing safer sex with 91% of patients when sexually transmitted infection (STI) screening was conducted during a visit, an increase from baseline (83.5%). The percent of providers reporting they regularly explained the risk of superinfection to their clients also increased from 75% at baseline to 90% at 12-month follow up (p<0.001). Qualitative data suggest that providers prioritize individual care over public health approaches to PwP in counseling. Discussing superinfection offered providers a way to discuss HIV prevention from a non-judgmental clinical perspective while focusing on a patient-centered philosophy of care. However, the threat of superinfection may not be the best counseling option. Examples such as STI screening, giving messages to reduce the number of sexual partners and adherence to medication, are more evidence-based approaches to changing HIV transmission risk behavior and may be more important in PwP. Findings suggest that in order for HIV care providers to incorporate HIV prevention discussions into their practice, acceptable approaches to speaking about risk behavior and prevention of HIV transmission must be developed.

THE DEVELOPMENT AND FEASIBILITY OF A BRIEF RISK REDUCTION INTERVENTION FOR NEWLY HIV-DIAGNOSED MEN WHO HAVE SEX WITH MEN

Men who have sex with men (MSM) represent more than half of all new HIV infections in the United States. Utilizing a collaborative, community based approach, a brief risk reduction intervention was developed and pilot tested among newly HIV-diagnosed MSM receiving HIV care in a primary care setting. Sixty-five men, within 3 months of diagnosis, were randomly assigned to the experimental condition or control condition and assessed at baseline, 3-month, and 6-month follow-up. Effect sizes were calculated to explore differences between conditions and over time. Results demonstrated the potential effectiveness of the intervention in reducing risk behavior, improving mental health, and increasing use of ancillary services. Process evaluation data demonstrated the acceptability of the intervention to patients, clinic staff, and administration. The results provide evidence that a brief intervention can be successfully integrated into HIV care services for newly diagnosed MSM and should be evaluated for efficacy.

Change in sexual activity 12 months after ART initiation among HIV-positive Mozambicans

We assessed sexual behaviors before and 12-months after ART initiation among 277 Mozambicans attending an HIV clinic. Measured behaviors included the number of sexual partners, condom use, concurrent relationships, disclosure of HIV status, alcohol use, and partners' serostatus. Compared to before ART initiation, increases were seen 12 months after ART in the proportion of participants who were sexually active (48% vs. 64% respondents, P < 0.001) and the proportion of participants with HIV-negative or unknown serostatus partners (45% vs. 80%, P < 0.001). Almost all (96%) concurrent partnerships reported at 12 months formed after ART initiation. Although reported correct and consist condom use increased, the number of unprotected sexual relationships remained the same (n = 45). Non-disclosure of HIV-serostatus to sexual partners was the only significant predictor of practicing unprotected sex with partners of HIV-negative or unknown serostatus. Sexual activity among HIV-positive persons on ART increased 12 months after ART initiation. Ongoing secondary transmission prevention programs addressing sexual activity with multiple partners, disclosure to partners and consistent condom use with serodisconcordant partners must be incorporated throughout HIV care programs.

Discussion of sexual risk behavior in HIV care is infrequent and appears ineffectual: a mixed methods study

Consensus guidelines in HIV care call for clinicians to provide a brief sexual risk behavioral intervention in each visit. Studies based on participant reports find this occurs infrequently, but studies based on direct observation of clinical encounters are lacking. We conducted a mixed method study that used audio recordings of 116 routine outpatient visits by 58 different patients with HIV, in five different practice sites. Transcripts of the visits were coded and analyzed using a quantitative system. In addition, we conducted a qualitative analysis of the dialogue segments in which sexual risk behaviors arose as a topic. Discussion of sexual risk behavior occurred in 10 visits, and was generally quite brief. Two visits featured substantial counseling about sexual risk reduction; two others included substantial discussion which was not evidently directed at the patient's changing behavior. Cues suggesting a need or opportunity for such discussion that physicians did not follow up on occurred in seven additional visits. Interactions about sexual risk had less patient engagement than interactions about other health behaviors. Physicians seldom provide sexual risk reduction counseling in HIV care, even where specific indications are present.

The Treatment Advocacy Program: a randomized controlled trial of a peer-led safer sex intervention for HIV-infected men who have sex with men

OBJECTIVE

Primary care may be an effective venue for delivering behavioral interventions for sexual safety among HIV-positive men who have sex with men (MSM); however, few studies show efficacy for such an approach. We tested the efficacy of the Treatment Advocacy Program (TAP), a 4-session, primary-care-based, individual counseling intervention led by HIV-positive MSM "peer advocates" in reducing unprotected sex with HIV-negative or unknown partners (HIV transmission risk).

METHOD

We randomized 313 HIV-positive MSM to TAP or standard care. HIV transmission risk was assessed at baseline, 6 months, and 12 months (251 participants completed all study waves). We conducted intent-to-treat analyses using general estimating equations to test the interaction of group (TAP vs. standard care) by follow-up period.

RESULTS

At study completion, TAP participants reported greater transmission risk reduction than did those receiving standard care, χ2(2, N = 249) = 6.6, p = .04. Transmission risk among TAP participants decreased from 34% at baseline to about 20% at both 6 and 12 months: Transmission risk ranged from 23% to 25% among comparison participants.

CONCLUSIONS

TAP reduced transmission risk among HIV-positive MSM, although results are modest. Many participants and peer advocates commented favorably on the computer structure of the program. We feel that the key elements of TAP-computer-based and individually tailored session content, delivered by peers, in the primary care setting-warrant further exploration.

HIV intervention for providers study: a randomized controlled trial of a clinician-delivered HIV risk-reduction intervention for HIV-positive people

Clinician-delivered prevention interventions offer an opportunity to integrate risk-reduction counseling as a routine part of medical care. The HIV Intervention for Providers study, a randomized controlled trial, developed and tested a medical provider HIV prevention training intervention in 4 northern California HIV care clinics. Providers were assigned to either the intervention or control condition (usual care). The intervention arm received a 4-hour training on assessing sexual risk behavior with HIV-positive patients and delivering risk-reduction-oriented prevention messages to patients who reported risk behaviors with HIV-uninfected or unknown-status partners. To compare the efficacy of the intervention versus control on transmission risk behavior, 386 patients of the randomized providers were enrolled. Over six-months of follow-up, patients whose providers were assigned the intervention reported a relative increase in provider-patient discussions of safer sex (OR = 1.49; 95% CI = 1.06 to 2.09), assessment of sexual activity (OR = 1.60; 95% CI = 1.05 to 2.45), and a significant decrease in the number of sexual partners (OR = 0.49, 95% CI = 0.26 to 0.92). These findings show that a brief intervention to train HIV providers to identify risk and provide a prevention message results in increased prevention conversations and significantly reduced the mean number of sexual partners reported by HIV-positive patients.

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.