A community-level HIV prevention intervention for inner-city women: results of the women and infants demonstration projects

Structural Barriers to HIV Prevention and Services: Perspectives of African American Women in Low-Income Communities

BACKGROUND

African American women are at a disproportionate HIV risk compared with other U.S. women. Studies show that complex structural and social determinants, rather than individual behaviors, place African American women at greater risk of HIV infection; however, little is known about women's views of what puts them at risk.

AIMS

This study sought to comprehend the perceptions of African American women living in low-income housing regarding the factors that influence both their personal sexual health behaviors and use of HIV prevention services.

METHODS

We conducted seven focus groups with 48 African American women from 10 public housing communities in a small city in the southeastern United States. We analyzed the focus group transcripts using thematic data analysis to identify salient themes and points of interest related to the study aim.

RESULTS

Women identified factors related to the health care system (trustworthiness of the health care system), the external environment (racism, classism, patriarchal structures, and violence/crime), as well as predisposing (health beliefs, stigma, and gender norms), enabling (agency to negotiate gendered power), and need (perceived HIV risk and perceptions of partner characteristics) features of individuals in the population.

CONCLUSION

African American women living in public housing are especially vulnerable to HIV infection due to intersectional discrimination based on racism, classism, gender power dynamics, and community conditions. Our findings confirm the need to develop HIV intervention programming addressing intersectional identities of those making up the communities they plan to address, and being informed by those living in the communities they plan to act on.

Livelihood intervention and mental well-being among women living with HIV in Delhi

ABSTRACTPoverty-alleviation programmes aimed to improved mental well-being among persons living with HIV (PLWH) in low and middle income countries have underscored the importance of understanding how and why such programmes work. We present findings from a six-month ethnographic process evaluation of Kiran, an economic livelihood programme locally designed to improve mental well-being among women affected by HIV in Delhi, India. In addition to benefits of improved economic standing, we found that supportive relationships cultivated among participants (n = 9) and with providers (n = 3) provided respite from worry about their illness and reframed what was relationally and practically possible in the context of living with HIV. In acquiring marketable craft skills with peers, participants challenged internalized scripts of being socially devalued and regained agency about their abilities to contribute to their community and support their children's immediate and future needs. We found that the benefits of Kiran weighed less on the direct alleviation of mental distress and more on the instillation of hope for their children. Our findings exemplify the importance of re-visiting a priori theories that inform interventions for PLWH and highlight the methodological merits of ethnographic approaches that underscore how theory and intervention praxis are bidirectionally informed.

Factors associated with condom use among HIV-positive women living in Atlanta, Georgia

Objectives

Consistent condom use is essential to reducing heterosexual transmission of HIV. African Americans are disproportionately affected by HIV in the United States despite comprising a small percentage of the population. Our objectives were to evaluate factors associated with self-reported condom use in a cohort of predominantly African American women receiving HIV care in Atlanta, Georgia.

Methods

A cross-sectional study of reproductive knowledge, attitudes, and practices among adult, sexually-active, HIV-positive women attending the Grady Infectious Disease Clinic in Atlanta, Georgia was conducted from July, 2013 to November, 2014 to evaluate factors associated with self-reported condom use. Primary outcomes included: condom use at last vaginal intercourse and consistent condom use with vaginal intercourse over the last six months. Descriptive, bivariable, and multivariable logistic regression analyses were performed.

Results

Of 187 women enrolled, 170 reported having vaginal intercourse in the last six months. Seventy-four percent used condoms at last vaginal intercourse, whereas 53% reported consistent condom use over the last six months. In adjusted analyses, factors associated with condom use at last intercourse included decreased frequency of sex, no history of drug use, and confidence to discuss condom use with sexual partners (p<0.05). Factors associated with consistent condom use in the past six months were older age, being single/dating, and confidence to discuss condom use with sexual partners. History of drug use, having HIV-positive partners, and unprotected anal intercourse were associated with inconsistent use (p<0.05).

Conclusions

Improved strategies are needed to educate women on the importance of safe sexual practices and condom negotiation. Healthcare providers should strive to have an open dialogue with patients about condom use, whether they engage in anal sex, and its risks.

Selecting Evidence-Based HIV Prevention Behavioral Interventions for HIV-Negative Persons for National Dissemination

This paper describes the development of a formula to determine which evidence-based behavioral interventions (EBIs) targeting HIV-negative persons would be cost-saving in comparison to the lifetime cost of HIV treatment and the process by which this formula was used to prioritize those with greatest potential impact for continued dissemination. We developed a prevention benefit index (PBI) to rank risk-reduction EBIs for HIV-negative persons based on their estimated cost for achieving the behavior change per one would-be incident infection of HIV. Inputs for calculating the PBI included the mean estimated cost-per-client served, EBI effect size for the behavior change, and the HIV incidence per 100,000 persons in the target population. EBIs for which the PBI was ≤ $402,000, the estimated lifetime cost of HIV care, were considered cost-saving. We were able to calculate a PBI for 35 EBI and target population combinations. Ten EBIs were cost-saving having a PBI below $402,000. One EBI did not move forward for dissemination due to high start-up dissemination costs. DHAP now supports the dissemination of 9 unique EBIs targeting 13 populations of HIV-negative persons. The application of a process, such as the PBI, may assist other health-field policymakers when making decisions about how to select and fund implementation of EBIs.

Recalling, Sharing and Participating in a Social Media Intervention Promoting HIV Testing: A Longitudinal Analysis of HIV Testing Among MSM in China

Social media interventions may enhance HIV services among key populations, including men who have sex with men (MSM). This longitudinal analysis examined the effect of recalling, sharing, and participating in different components of a social media intervention on HIV testing among MSM. The social media intervention included six images/texts and information about an online local community contest to promote testing. Of the 1033 men, they recalled a mean of 2.7 out of six images and shared an average of one image online. 34.5% of men recalled information on the online local community contest and engaged in a mean of 1.3 contest. Recalling images/texts (aOR = 1.13, 95% CI 1.02-1.25) and recalling a local contest (aOR = 1.59, 95% CI 1.13-1.24) were associated with facility-based HIV testing. This study has implications for the development and evaluation of social media interventions to promote HIV testing.

Structural Interventions in HIV Prevention: A Taxonomy and Descriptive Systematic Review

One of the four national HIV prevention goals is to incorporate combinations of effective, evidence-based approaches to prevent HIV infection. In fields of public health, techniques that alter environment and affect choice options are effective. Structural approaches may be effective in preventing HIV infection. Existing frameworks for structural interventions were lacking in breadth and/or depth. We conducted a systematic review and searched CDC's HIV/AIDS Prevention Research Synthesis Project's database for relevant interventions during 1988-2013. We used an iterative process to develop the taxonomy. We identified 213 structural interventions: Access (65%), Policy/Procedure (32%), Mass Media (29%), Physical Structure (27%), Capacity Building (24%), Community Mobilization (9%), and Social Determinants of Health (8%). Forty percent targeted high-risk populations (e.g., people who inject drugs [12%]). This paper describes a comprehensive, well-defined taxonomy of structural interventions with 7 categories and 20 subcategories. The taxonomy accommodated all interventions identified.

Effectiveness of community-based condom distribution interventions to prevent HIV in the United States: A systematic review and meta-analysis

BACKGROUND

Despite significant public health implications, the extent to which community-based condom distribution interventions (CDI) prevent HIV infection in the United States is not well understood.

METHODS

We systematically reviewed research evidence applying Cochrane Collaboration methods. We used a comprehensive search strategy to search multiple bibliographic databases for relevant randomized controlled trials (RCTs) and non-RCTs published from 1986-2017. We focused on CDI that made condoms widely available or accessible in community settings. Eligible outcomes were HIV infection (primary), sexually transmitted infections, condom use, and multiple sexual partnership. Two reviewers independently screened citations to assess their eligibility, extracted study data, and assessed risk of bias. We calculated risk ratios (RR) with 95% confidence intervals (CI) and pooled them using random-effects models. We assessed evidence quality using GRADE.

RESULTS

We reviewed 5,110 unique records. Nine studies (including one RCT) met eligibility criteria. Studies were conducted in 10 US states between 1989 and 2011. All studies were at high risk of bias. Interventions were categorized into three groups: "Ongoing" (unlimited access to condoms), "Ongoing-plus" (unlimited access to condoms, with co-interventions), and "Coupon-based" (coupons redeemed for condoms). No studies reported incident HIV. Ongoing CDI (four non-RCTs) modestly reduced condomless sex (RR 0.88, 95% CI 0.78 to 0.99). Ongoing-plus CDI (two non-RCTs) significantly reduced multiple sexual partnership (RR 0.37, 95% CI 0.16 to 0.87). Of two coupon-based studies, one (non-RCT) showed reduction in condomless sex in female participants (Odds Ratio 0.67, 95% CI 0.47 to 0.96), while the other one (RCT) showed no effect on STI incidence (RR 0.91, 95% CI 0.63 to 1.31). Evidence quality was "very low" for all outcomes.

CONCLUSIONS

CDI may reduce some risky sexual behaviors, but the evidence for any reduction is limited and of low-quality. Lack of biological outcomes precludes assessing the link between CDI and HIV incidence.

Advice for prevention from HIV-positive African-American women: 'My story is not just a story'

Large disparities in HIV incidence, prevalence and mortality exist for African-American women, especially in the southern region of the USA. Based on the culture-centric health promotion model, HIV-positive African American women can use their stories to support primary prevention. The purpose of this study was to document advice from HIV-positive African-American women (n = 25) to young African-American women, as described in their own cultural narratives collected through qualitative interviews. Content analysis of women's advice identified five common themes revolving broadly around: (1) advice for prevention, (2) support systems for prevention, (3) education, (4) empowerment/self-care and (5) potential barriers to prevention. Advice reflected recommendations based on personal experience and highlighted social determinants linked to HIV, such as stigma, access to education and healthcare, social support, and gender and power dynamics. Women also offered advice for coping with an HIV-positive diagnosis. Communication with parents, family and friends regarding education and social support emerged as an important interpersonal factor for participants, as were interactions with sexual/romantic partners. Stigma, at the community level, was consistently discussed as a hindrance to prevention. Narratives of HIV-positive women as community health agents of change can enhance the effectiveness of HIV prevention interventions for young US African-American women.

Evaluating Teach One Reach One-An STI/HIV Risk-Reduction Intervention to Enhance Adult-Youth Communication About Sex and Reduce the Burden of HIV/STI

PURPOSE

Parents and caregivers play an important role in sexual socialization of youth, often serving as the primary source of information about sex. For African American rural youth who experience disparate rates of HIV/sexually transmitted infection, improving caregiver-youth communication about sexual topics may help to reduce risky behaviors. This study assessed the impact of an intervention to improve sexual topic communication.

DESIGN

A Preintervention-postintervention, quasi-experimental, controlled, and community-based trial.

SETTING

Intervention was in 2 rural North Carolina counties with comparison group in 3 adjacent counties.

SUBJECTS

Participants (n = 249) were parents, caregivers, or parental figures for African American youth aged 10 to 14.

INTERVENTION

Twelve-session curriculum for participating dyads.

MEASURES

Audio computer-assisted self-interview to assess changes at 9 months from baseline in communication about general and sensitive sex topics and overall communication about sex.

ANALYSIS

Multivariable models were used to examine the differences between the changes in mean of scores for intervention and comparison groups.

RESULTS

Statistically significant differences in changes in mean scores for communication about general sex topics ( P < .0001), communication about sensitive sex topics ( P < .0001), and overall communication about sex ( P < .0001) existed. Differences in change in mean scores remained significant after adjusting baseline scores and other variables in the multivariate models.

CONCLUSIONS

In Teach One Reach One intervention, adult participants reported improved communication about sex, an important element to support risk reduction among youth in high-prevalence areas.

Condom Use Predictors for Low-Income African American Women

The purpose was to investigate whether an HIV-prevention curriculum and a health maintenance curriculum produced different rates of change in reported consistent condom use and to explore what mediating variables predicted reported consistent condom use over time. A longitudinal crossover research design with extended posttest observations was used with a sample of 279 African American women. After pretesting, women received the designated curriculum and were posttested at completion, 3, 6, and 9 months. After the 9-month posttest, the curriculum was switched, and the above procedure was repeated. Using SAS macro GLIMMIX, the data revealed that the HIV curriculum yielded higher consistent condom use than did the health maintenance curriculum and that the mediating variables that predicted consistent condomuse over time were self-efficacy for low-risk HIV behavior, HIV-related community behavior, and social norms. Enhancing consistent condom use over time may require the promotion and reinforcement of these mediating variables.

Theoretical Domains: A Heuristic for Teaching Behavioral Theory in HIV/STD Prevention Courses

The HIV/STD epidemics have broadened the need for better behavioral intervention programs and highlighted the importance of providing training in behavioral theory to frontline program practitioners. However, there is a lack of effective methods for teaching theoretical concepts to people who may not have a background in behavioral science. This article presents a solution to this challenge by introducing a new heuristic for teaching theory and for placing individual theories/models in a broader context. Using a broad framework, we identify five domains that influence behavior: risk appraisal, self-perceptions, emotions and arousal, relationships and social influence, and environmental and structural factors. Each domain is described, and a brief overview of supporting literature is provided. Following the presentation of domains, we discuss course structure and activities.

Application of the Transtheoretical Model for HIV Prevention in a Facility-Based and a Community-Level Behavioral Intervention Research Study

This article describes the application of the transtheoretical model of behavior change to prevention programs for women at risk for or infected with HIV. The focus of these multisite demonstration projects was to increase condom and contraceptive use. The model was operationalized for use in the following two different intervention approaches: facility-based interventions (individual counseling for women in clinics, shelters, and drug treatment centers) and community-level interventions (including production of small media materials, street outreach, and community mobilization). The authors found that interventions derived from a complex theory can be disseminated to frontline providers who have little prior HIV education experience or academic training. They suggest that the transtheoretical model has value for the design and implementation of HIV prevention programs.

Adapting an evidence-based intervention for HIV to avail access to testing and risk-reduction counseling for female victims of sexual violence in post-earthquake Haiti

Haiti has the highest prevalence of HIV/AIDS in the Caribbean. Before the 2010 earthquake, Haitian women bore a disproportionate burden of HIV/AIDS, had lower HIV knowledge, less capacity to negotiate for safer sex, and limited access to HIV testing and risk-reduction (RR) counseling. Since 2010, there has been an increase in sexual violence against women, characterized by deliberate vaginal injuries by non-intimate partners, increasing victims' risk of sexually transmitted infections including HIV/AIDS. Needed is an adaptation of evidence-based interventions for HIV that include HIV testing and counseling for this stigmatized population. We reviewed several features of Centers for Disease Control and Prevention's 103 evidence-based interventions for HIV (e.g., measures used, participant risk characteristics, theoretical framework, outcome variables, and evidence tier) in an attempt to seek a feasibly adaptable evidence-based intervention for HIV that could be used for victims of sexual violence (VOSV). RESPECT, one of the reviewed evidence-based HIV interventions, comprises of one-on-one, client-focused HIV prevention/RR counseling, and RAPID HIV testing. Adapting RESPECT can enhance access to testing for Haitian VOSV and can influence their perceptions of HIV risk, and establishment of RR goals for future consensual intimate relations. Adapting and implementing RESPECT can increase uptake of evidence-based HIV interventions among Haitians and positively affect a region with high HIV prevalence and increased rates of sexual violence.

A systematic review of sexual health interventions for adults: narrative evidence

Recent work has explored the intersection between sexual health (as construed by the World Health Organization and others) and public health domains of action in the United States of America. This article reports the narrative results of a systematic review of sexual health intervention effects on public health-relevant outcomes. To qualify, interventions had to be based on the principles (1) that sexual health is intrinsic to individuals and their overall health and (2) that relationships reflecting sexual health must be positive for all parties concerned. Outcomes were classed in domains: knowledge, attitudes, communication, health care use, sexual behavior, and adverse events. We summarized data from 58 studies (English language, adult populations, 1996-2011) by population (adults, parents, sexual minorities, vulnerable populations) across domains. Interventions were predominantly individual and small-group designs that addressed sexual behaviors (72%) and attitudes/norms (55%). They yielded positive effects in that 98% reported a positive finding in at least one domain; 50% also reported null effects. The most consistently positive effects on behaviors and adverse events were found for sexual minorities, vulnerable populations, and parental communication. Whether via direct action or through partnerships, incorporating principles from existing sexual health definitions in public health efforts may help improve sexual health.

Adapting an evidence-based intervention for homeless women: engaging the community in shared decision-making

As interest grows in the diffusion of evidence-based interventions (EBIs), there is increasing concern about how to mitigate implementation challenges; this paper concerns adapting an EBI for homeless women. Complementing earlier focus groups with homeless women, homeless service providers (n = 32) were engaged in focus groups to assess capacity, needs, and barriers with implementation of EBIs. Deductive analyses of data led to the selection of four EBIs. Six consensus groups were then undertaken; three each with homeless women (n = 24) and homeless service providers (n = 21). The selected EBI was adapted and pretested with homeless women (n = 9) and service providers (n = 6). The structured consensus group process provided great utility and affirmed the expertise of homeless women and service providers as experts in their domain. Engaging providers in the selection process reduced the structural barriers within agencies as obstacles to diffusion.

Addressing sexual health behaviour during emerging adulthood: a critical review of the literature

AIMS AND OBJECTIVES

In this critical literature review, we examine evidence-based interventions that target sexual behaviours of 18- to 25-year-old emerging adult women.

BACKGROUND

Nurses and clinicians implement theory-driven research programmes for young women with increased risk of HIV/AIDS and sexually transmitted infections. Strategies to decrease transmission of HIV and sexually transmitted infections are rigorously evaluated and promoted by public health agencies such as the United States Centers for Disease Control and Prevention. While many interventions demonstrate episodic reductions in sexual risk behaviours and infection transmission, there is little evidence they build sustainable skills and behaviours. Programmes may not attend to contextual and affective influences on sexual behaviour change.

DESIGN

Discursive paper.

METHODS

We conducted a conceptually based literature review and critical analysis of the Centers for Disease Control and Prevention's best-evidence and good-evidence HIV behavioural interventions. In this review, we examined three contextual and affective influences on the sexual health of emerging adult women: (1) developmental age, (2) reproduction and pregnancy desires and (3) sexual security or emotional responses accompanying relationship experiences.

RESULTS

Our analyses revealed intervention programmes paid little attention to ways age, desires for pregnancy or emotional factors influence sexual decisions. Some programmes included 18- to 25-year-olds, but they made up small percentages of the sample and did not attend to unique emerging adult experiences. Second, primary focus on infection prevention overshadowed participant desires for pregnancy. Third, few interventions considered emotional mechanisms derived from relationship experiences involved in sexual decision-making.

CONCLUSIONS

Growing evidence demonstrates sexual health interventions may be more effective if augmented to attend to contextual and affective influences on relationship risks and decision-making. Modifying currently accepted strategies may enhance sustainability of sexual health-promoting behaviours.

RELEVANCE TO CLINICAL PRACTICE

This study provides nurses and public health educators with recommendations for broadening the content of sexual health promotion intervention programming.

Is there life after DEBI? Examining health behavior maintenance in the diffusion of effective behavioral interventions initiative

The evidence-based interventions that are identified, packaged, and disseminated by the Division of HIV/AIDS Prevention at the Centers for Disease Control and Prevention as part of the Diffusion of Effective Behavioral Interventions (DEBI) initiative-commonly referred to the "DEBIs"-currently represent a primary source of HIV prevention interventions for community-based providers. To date, little attention has focused on whether the intended outcomes of the DEBIs, i.e., reductions in HIV-related risk behaviors, are maintained over time. This review summarized evidence for the sustainability of the effects of the DEBIs on HIV sexual risk behavior and intravenous drug use from studies of original and adapted DEBIs. Evidence of intervention decay or a lack of any intervention effect was identified in several original and adapted versions of the DEBIs included in this review. Recommendations include modifications to current criteria for inclusion in the DEBI portfolio, in addition to the development of remediation strategies to address intervention decay. Further, theoretical models that specify the processes that underlie the maintenance of health behaviors over time should be used in developing HIV prevention interventions.

Motivational barriers to retention of at-risk young adults in HIV-prevention interventions: perceived pressure and efficacy

Multi-session HIV-prevention interventions are efficacious but depend on the retention of clients over time. In a sample of at-risk young adults (N = 386), we investigated three potential motivational barriers that might affect the likelihood of retention. Perceived pressure, perceived efficacy and fear and anxiety during the initial session were measured, along with demographic characteristics, partner characteristics, and HIV-related health knowledge. Logistic regressions demonstrated that (1) in general, perceived ineffectiveness was negatively associated with retention; (2) perceived pressure or coercion was negatively associated with retention but only for younger clients; (3) experienced fear and anxiety had no significant association with retention. Implications for theory and counseling practices to reduce motivational barriers and effectively tailor interventions are discussed.

Participant and staff experiences in a peer-delivered HIV intervention with injection drug users

We explore ethical issues faced by investigators as they conduct research as part of a peer-delivered HIV/AIDS risk reduction program for injection drug users (IDUs). Staff and participant experiences in peer-delivered interventions among IDUs have come under scrutiny by ethics researchers because of their potential to inadvertently and negatively impact participant rehabilitation due to continued engagement with drug-using networks during the course of outreach. This study explores whether enhanced communication of participant concerns and experiences with clinic and research staff helps to reduce inadvertent malfeasance in peer-delivered drug treatment interventions. Results contribute to the development of patient support infrastructure in peer-delivered risk reduction programs involving IDUs.

Personalized Biobehavioral HIV Prevention for Women and Adolescent Girls

Background:

Women and adolescent girls bear a significant burden of the global HIV pandemic. Both behavioral and biomedical prevention approaches have been shown to be effective. In order to foster the most effective combination HIV-prevention approaches for women and girls, it is imperative to understand the unique biological, social, and structural considerations that increase vulnerability to acquiring HIV within this population.

Primary Study Objective:

The purpose of this article is to propose novel ideas for personalized biobehavioral HIV prevention for women and adolescent girls. The central argument is that we must transcend unilevel solutions for HIV prevention toward comprehensive, multilevel combination HIV prevention packages to actualize personalized biobehavioral HIV prevention. Our hope is to foster transnational dialogue among researchers, practitioners, educators, and policy makers toward the actualization of the proposed recommendations.

Methods:

We present a commentary organized to review biological, social, and structural factors that increase vulnerability to HIV acquisition among women and adolescent girls. The overview is followed by recommendations to curb HIV rates in the target population in a sustainable manner.

Results:

The physiology of the lower female reproductive system biologically increases HIV risk among women and girls. Social (eg, intimate partner violence) and structural (eg, gender inequality) factors exacerbate this risk by increasing the likelihood of viral exposure. Our recommendations for personalized biobehavioral HIV prevention are to (1) create innovative mechanisms for personalized HIV risk—reduction assessments; (2) develop mathematical models of local epidemics; (3) prepare personalized, evidence-based combination HIV risk—reduction packages; (4) structure gender equity into society; and (5) eliminate violence (both physical and structural) against women and girls.

Conclusions:

Generalized programs and interventions may not have universal, transnational, and crosscultural implications. Personalized biobehavioral strategies are needed to comprehensively address vulnerabilities at biological, social, and structural levels.

The Girlfriends Project: Results of a pilot study assessing feasibility of an HIV testing and risk reduction intervention developed, implemented, and evaluated in community settings

African American women in the United States experience significant HIV health disparities. The majority of evidence-based risk reduction interventions do not incorporate HIV testing, and most are targeted only to narrow segments of the population such as women who are pregnant or seen in STI clinics. This pilot study assessed the feasibility and efficacy of The Girlfriends Project (TGP), a community developed and community evaluated HIV risk reduction and testing intervention. A group randomized wait-list design was used to recruit 149 women and to compare findings for intervention group versus control group participants. Women in the intervention group demonstrated statistically-significant increases in HIV knowledge scores and in condom use during vaginal sex. Eighty-seven percent of participants accessed HIV testing with a 100% return rate for results. Study findings suggest that TGP has the potential to be an effective intervention and to increase number of African American women who access HIV testing.

Community engagement to reduce inequalities in health: a systematic review, meta-analysis and economic analysis

Background

Community engagement has been advanced as a promising way of improving health and reducing health inequalities; however, the approach is not yet supported by a strong evidence base.

Objectives

To undertake a multimethod systematic review which builds on the evidence that underpins the current UK guidance on community engagement; to identify theoretical models underpinning community engagement; to explore mechanisms and contexts through which communities are engaged; to identify community engagement approaches that are effective in reducing health inequalities, under what circumstances and for whom; and to determine the processes and costs associated with their implementation.

Data sources

Databases including the Cochrane Database of Systematic Reviews (CDSR), The Campbell Library, the Database of Abstracts of Reviews of Effects (DARE), the Health Technology Assessment (HTA) database, the NHS Economic Evaluation Database (NHS EED) and EPPI-Centre’s Trials Register of Promoting Health Interventions (TRoPHI) and Database of Promoting Health Effectiveness Reviews (DoPHER) were searched from 1990 to August 2011 for systematic reviews and primary studies. Trials evaluating community engagement interventions reporting health outcomes were included.

Review methods

Study eligibility criteria: published after 1990; outcome, economic, or process evaluation; intervention relevant to community engagement; written in English; measured and reported health or community outcomes, or presents cost, resource, or implementation data characterises study populations or reports differential impacts in terms of social determinants of health; conducted in an Organisation for Economic Co-operation and Development (OECD) country. Study appraisal: risk of bias for outcome evaluations; assessment of validity and relevance for process evaluations; comparison against an economic evaluation checklist for economic evaluations. Synthesis methods: four synthesis approaches were adopted for the different evidence types: theoretical, quantitative, process, and economic evidence.

Results

The theoretical synthesis identified key models of community engagement that are underpinned by different theories of changes. Results from 131 studies included in a meta-analysis indicate that there is solid evidence that community engagement interventions have a positive impact on health behaviours, health consequences, self-efficacy and perceived social support outcomes, across various conditions. There is insufficient evidence – particularly for long-term outcomes and indirect beneficiaries – to determine whether one particular model of community engagement is likely to be more effective than any other. There are also insufficient data to test the effects on health inequalities, although there is some evidence to suggest that interventions that improve social inequalities (as measured by social support) also improve health behaviours. There is weak evidence from the effectiveness and process evaluations that certain implementation factors may affect intervention success. From the economic analysis, there is weak but inconsistent evidence that community engagement interventions are cost-effective. By combining findings across the syntheses, we produced a new conceptual framework.

Limitations

Differences in the populations, intervention approaches and health outcomes made it difficult to pinpoint specific strategies for intervention effectiveness. The syntheses of process and economic evidence were limited by the small (generally not rigorous) evidence base.

Conclusions

Community engagement interventions are effective across a wide range of contexts and using a variety of mechanisms. Public health initiatives should incorporate community engagement into intervention design. Evaluations should place greater emphasis on long-term outcomes, outcomes for indirect beneficiaries, process evaluation, and reporting costs and resources data. The theories of change identified and the newly developed conceptual framework are useful tools for researchers and practitioners. We identified trends in the evidence that could provide useful directions for future intervention design and evaluation.

Funding

The National Institute for Health Research Public Health Research programme.

Narrative means to preventative ends: a narrative engagement framework for designing prevention interventions

This article describes a Narrative Engagement Framework (NEF) for guiding communication-based prevention efforts. This framework suggests that personal narratives have distinctive capabilities in prevention. The article discusses the concept of narrative, links narrative to prevention, and discusses the central role of youth in developing narrative interventions. As illustration, the authors describe how the NEF is applied in the keepin' it REAL adolescent drug prevention curriculum, pose theoretical directions, and offer suggestions for future work in prevention communication.

The HIV risk reduction needs of homeless women in Los Angeles

BACKGROUND

Substance use, housing instability, and transactional sex all contribute to HIV risk engagement among homeless women. Because of the increased risk of HIV among homeless women, this study sought to understand the context of sexual behaviors and condom use among homeless women and elucidate modifiable factors that can be targeted by interventions.

METHODS

Homeless women (n = 45) participated in focus groups (n = 6) at shelters throughout Los Angeles County. Thematic analyses revealed that similar to other high-risk women, homeless women engage in sex with multiple types of partners (steady, casual, and transactional).

FINDINGS

Our findings indicate that, similar to use among other high-risk women, condom use by homeless women varied by type of partner. Substance use also contributed to condom non-use. In a departure from previous research, homeless women reported overarching feelings of hopelessness. Participants spoke of hopelessness contributing to risk engagement, specifically the number of ongoing stressors experienced because of homelessness contributing to despair. Without acknowledgement of this unique quality of homelessness, women felt their risk reduction needs would never truly be understood.

CONCLUSIONS

Interventions involving homeless women should include self-esteem building, acknowledgment and use of inherent resilience qualities gained during homelessness, respect for current knowledge and skills, and an exploration of when women choose to trust their partners and how they make safer sex choices.

[Evaluative designs in public health: methodological considerations]

Evaluation of public health interventions poses numerous methodological challenges. Randomization of individuals is not always feasible and interventions are usually composed of multiple factors. To face these challenges, certain elements, such as the selection of the most appropriate design and the use of a statistical analysis that includes potential confounders, are essential. The objective of this article was to describe the most frequently used designs in the evaluation of public health interventions (policies, programs or campaigns). The characteristics, strengths and weaknesses of each of these evaluative designs are described. Additionally, a brief explanation of the most commonly used statistical analysis in each of these designs is provided.

Results of a randomized controlled trial of a peer mentor HIV/STI prevention intervention for women over an 18 month follow-up

Despite numerous behavioral interventions designed for women, rates of HIV and STIs are increasing. Interventions are needed that reach a large number of at-risk individuals. This study was a randomized clinical trial of a HIV/STI behavioral intervention conducted in Baltimore, MD, USA. Heterosexual women (n = 169) completed a baseline and three semiannual follow-up visits. Participants were randomized into a standard of care comparison condition or a Peer Mentor condition. At the 6-month follow-up, Peer Mentors were less likely to have multiple sex partners [AOR: 0.28 (95% CI: 0.13, 0.63)]. At the 18 month follow-up assessment, Peer Mentors increased their condom use during vaginal [AOR: 0.47 (95% CI: 0.25, 0.87)] and anal sex [AOR: 0.24 (95% CI: 0.09, 0.68)] as well as with main [AOR: 0.41 (95% CI: 0.21, 0.77)] and non-main partners [AOR: 0.33 (95% CI: 0.14, 0.79)]. Peer education is a sustainable approach to change risky sexual behaviors.

Evaluation of a peer network-based sexual risk reduction intervention for men in beer halls in Zimbabwe: results from a randomized controlled trial

While much emphasis has been placed on involving men in AIDS prevention in sub-Saharan Africa, there remain few rigorously evaluated interventions in this area. A particularly appealing point of intervention is the sexual risk behavior associated with men's alcohol consumption. This article reports the outcomes of The Sahwira HIV Prevention Program, a male-focused, peer-based intervention promoting the idea that men can assist their friends in avoiding high-risk sexual encounters associated with alcohol drinking. The intervention was evaluated in a randomized, controlled trial (RCT) implemented in 24 beer halls in Harare, Zimbabwe. A cadre of 413 male beer hall patrons (~20% of the patronage) was trained to assist their male peers within their friendship networks. Activities included one-on-one interactions, small group discussions, and educational events centering on the theme of men helping their male friends avoid risk. Venues were randomized into 12 control versus 12 intervention beer halls with little cross-contamination between study arms. The penetration and impact of the intervention were assessed by pre- and post-intervention cross-sectional surveys of the beer hall patronage. The intervention was implemented with a high degree of fidelity to the protocol, with exposure to the intervention activities significantly higher among intervention patrons compared to control. While we found generally declining levels of risk behavior in both study arms from baseline to post-intervention, we found no evidence of an impact of the intervention on our primary outcome measure: episodes of unprotected sex with non-wife partners in the preceding 6 months (median 5.4 episodes for men at intervention beer halls vs. 5.1 among controls, P = 0.98). There was also no evidence that the intervention reduced other risks for HIV. It remains an imperative to find ways to productively engage men in AIDS prevention, especially in those venues where male bonding, alcohol consumption, and sexual risk behavior are intertwined.

Evaluation of stepping stones as a tool for changing knowledge, attitudes and behaviours associated with gender, relationships and HIV risk in Karnataka, India

Background

Stepping Stones training aims to help individuals explore sexual relationships and recognize gender inequalities, the structural drivers of the HIV epidemic, in order to understand risk behaviours and to seek solutions to factors that increase HIV vulnerability. Despite earlier studies suggesting the success of Stepping Stones, little data exist to show diffusion to trainees' social networks or the wider community.

Methods

A mixed-methods evaluation of this approach was undertaken using in-depth interviews of trainees and friends, and polling booth surveys in 20 villages where Stepping Stones training took place and in another 20 villages with no Stepping Stones intervention.

Results

The interview respondents and their friends reported significant changes in their relationships after training, and benefit from discussion of gender, sexuality, condom use and HIV vulnerability issues. However, though diffusion of this knowledge at the level of personal contacts was strong, the evaluation revealed that diffusion to the community level was limited.

Conclusions

The qualitative part of this study reflects other studies in different settings, in that SS participants gained immensely from the training. Wider behaviour change is a challenging goal that many programmes fail to attain, with most interventions too limited in scope and intensity to produce larger community effects. This may have contributed to the fact that we observed few differences between interventions and non-intervention villages in this study. However, it is also possible that we had excessive expectations of individual change at the community level, and that it might have been more appropriate to have had broader community level rather than individual behavioural change indicators. We suggest that SS could be enhanced by efforts to better engage existing community opinion leaders, to empower and train participants as community change agents, and to support the development of village-level action plans that combat sexual stereotyping and risky behaviours that lead to unhealthy sexual relationships.

Interventions for encouraging sexual behaviours intended to prevent cervical cancer

BACKGROUND

Human papillomavirus (HPV) is the key risk factor for cervical cancer. Continuing high rates of HPV and other sexually transmitted infections (STIs) in young people demonstrate the need for effective behavioural interventions.

OBJECTIVES

To assess the effectiveness of behavioural interventions for young women to encourage safer sexual behaviours to prevent transmission of STIs (including HPV) and cervical cancer.

SEARCH STRATEGY

Systematic literature searches were performed on the following databases: Cochrane Central Register of Controlled Trials (CENTRAL Issue 4, 2009) Cochrane Gynaecological Cancer Review Group (CGCRG) Specialised Register, MEDLINE, EMBASE, CINAHL, PsychINFO, Social Science Citation Index and Trials Register of Promoting Health Interventions (TRoPHI) up to the end of 2009. All references were screened for inclusion against selection criteria.

SELECTION CRITERIA

Randomised controlled trials (RCTs) of behavioural interventions for young women up to the age of 25 years that included, amongst other things, information provision about the transmission and prevention of STIs. Trials had to measure behavioural outcomes (e.g. condom use) and/or biological outcomes (e.g. incidence of STIs, cervical cancer).

DATA COLLECTION AND ANALYSIS

A narrative synthesis was conducted. Meta-analysis was not considered appropriate due to heterogeneity between the interventions and trial populations.

MAIN RESULTS

A total of 5271 references were screened and of these 23 RCTs met the inclusion criteria. Most were conducted in the USA and in health-care clinics (e.g. family planning).The majority of interventions provided information about STIs and taught safer sex skills (e.g. communication), occasionally supplemented with provision of resources (e.g. free sexual health services). They were heterogeneous in duration, contact time, provider, behavioural aims and outcomes. A variety of STIs were addressed including HIV and chlamydia. None of the trials explicitly mentioned HPV or cervical cancer prevention.Statistically significant effects for behavioural outcomes (e.g. increasing condom use) were common, though not universal and varied according to the type of outcome. There were no statistically significant effects of abstaining from or reducing sexual activity. There were few statistically significant effects on biological (STI) outcomes. Considerable uncertainty exists in the risk of bias due to incomplete or ambiguous reporting.

AUTHORS' CONCLUSIONS

Behavioural interventions for young women which aim to promote sexual behaviours protective of STI transmission can be effective, primarily at encouraging condom use. Future evaluations should include a greater focus on HPV and its link to cervical cancer, with long-term follow-up to assess impact on behaviour change, rates of HPV infection and progression to cervical cancer. Studies should use an RCT design where possible with integral process evaluation and cost-effectiveness analysis where appropriate. Given the predominance of USA studies in this systematic review evaluations conducted in other countries would be particularly useful.

Population-based biomedical sexually transmitted infection control interventions for reducing HIV infection

BACKGROUND

The transmission of sexually transmitted infections (STIs) is closely related to the sexual transmission of human immunodeficiency virus (HIV). Similar risk behaviours, such as frequent unprotected intercourse with different partners, place people at high risk of HIV and STIs, and there is clear evidence that many STIs increase the likelihood of HIV transmission. STI control, especially at the population or community level, may have the potential to contribute substantially to HIV prevention.This is an update of an existing Cochrane review. The review's search methods were updated and its inclusion and exclusion criteria modified so that the focus would be on one well-defined outcome. This review now focuses explicitly on population-based biomedical interventions for STI control, with change in HIV incidence being an outcome necessary for a study's inclusion.

OBJECTIVES

To determine the impact of population-based biomedical STI interventions on the incidence of HIV infection.

SEARCH STRATEGY

We searched PubMed, EMBASE, the Cochrane Central Register of Controlled Trials (CENTRAL), Web of Science/Social Science, PsycINFO, and Literatura Latino Americana e do Caribe em Ciências da Saúde (LILACS), for the period of 1 January1980 - 16 August 2010. We initially identified 6003 articles and abstracts. After removing 776 duplicates, one author (TH) removed an additional 3268 citations that were clearly irrelevant. Rigorously applying the inclusion criteria, three authors then independently screened the remaining 1959 citations and abstracts. Forty-six articles were chosen for full-text scrutiny by two authors. Ultimately, four studies were included in the review.We also searched the Aegis database of conference abstracts, which includes the Conference on Retroviruses and Opportunistic Infections (CROI), the International AIDS Conference (IAC), and International AIDS Society Conference on HIV Pathogenesis, Treatment and Prevention (IAS) meetings from their inception dates (1993, 1985 and 2001, respectively) through 2007. We manually searched the web sites of those conferences for more recent abstracts (up to 2010, 2010 and 2009, respectively)  In addition to searching the clinical trials registry at the US National Institutes of Health, we also used the metaRegister of Controlled Trials.We checked the reference lists of all studies identified by the above methods.

SELECTION CRITERIA

Randomised controlled trials involving one or more biomedical interventions in general populations (as opposed to occupationally or behaviourally defined groups, such as sex workers) in which the unit of randomisation was either a community or a treatment facility and in which the primary outcome was incident HIV infection. The term "community" was interpreted to include a group of villages, an arbitrary geographical division, or the catchment population of a group of health facilities.

DATA COLLECTION AND ANALYSIS

Three authors (BN, LB, TH) independently applied the inclusion criteria to potential studies, with any disagreements resolved by discussion. Trials were examined for completeness of reporting. Data were abstracted independently using a standardised abstraction form.

MAIN RESULTS

We included four trials. One trial evaluated mass treatment of all individuals in a particular community. The other three trials evaluated various combinations of improved syndromic STI management in clinics, STI counselling, and STI treatment.In the mass treatment trial in rural southwestern Uganda, after three rounds of treatment of all community members for STIs, the adjusted rate ratio (aRR) of incident HIV infection was 0.97 (95% CI 0.81 - 1.2), indicating no effect of the intervention. The three STI management intervention studies were all conducted in rural parts of Africa. One study, in northern Tanzania, showed that the incidence of HIV infection in the intervention groups (strengthened syndromic management of STIs in primary care clinics) was 1.2% compared with 1.9% in the control groups (aRR = 0.58, 95% CI 0.42 - 0.79), corresponding to a 42% reduction (95% CI 21.0% - 58.0%) in HIV incidence in the intervention group. Another study, conducted in rural southwestern Uganda, showed that the aRR of behavioural intervention and STI management compared to control on HIV incidence was 1.00 (95% CI 0.63 - 1.58). In the third STI management trial, in eastern Zimbabwe, there was no effect of the intervention on HIV incidence (aRR = 1.3, 95% CI 0.92 - 1.8). These are consistent with data from the mass treatment trial showing no intervention effect. Overall, pooling the data of the four studies showed no significant effect of any intervention (rate ratio [RR] = 0.97, 95% CI 0.78 - 1.2).Combining the mass treatment trial and one of the STI management trials, we find that there is a significant 12.0% reduction in the prevalence of syphilis for those receiving a biomedical STI intervention (RR 0.88, 95% CI 0.80 - 0.96). For gonorrhoea, we find a statistically significant 51.0% reduction in its prevalence in those receiving any of these interventions (RR 0.49, 95% CI 0.31 - 0.77). Finally, for chlamydia, we found no significant difference between any biomedical intervention and control (RR 1.03, 95% CI 0.77 - 1.4).

AUTHORS' CONCLUSIONS

We failed to confirm the hypothesis that STI control is an effective HIV prevention strategy. Improved STI treatment services were shown in one study to reduce HIV incidence in an environment characterised by an emerging HIV epidemic (low and slowly rising prevalence), where STI treatment services were poor and where STIs were highly prevalent; Incidence was not reduced in two other settings. There is no evidence for substantial benefit from a presumptive treatment intervention for all community members. There are, however, other compelling reasons why STI treatment services should be strengthened, and the available evidence suggests that when an intervention is accepted it can substantially improve quality of services provided.

Behavioral surveillance of heterosexual exchange-sex partnerships in San Francisco: context, predictors and implications

Using San Francisco local data from the 2006 National HIV Behavioral Surveillance (NHBS), we initiated a study of male and female heterosexuals' involvement in exchange sex (money or goods for sex). We examined risk factors for engaging in exchange sex and the prevalence of risk behaviors amongst exchange and non-exchange partnerships. Overall, 13.2% of women and 7.6% of men engaged in exchange sex in the past 6 months; 130 of 1,230 (10.6%) opposite-sex partnerships involved exchange. Women of low socioeconomic status and those who inject drugs were more likely to engage in exchange sex. Men involved in exchange sex were no different from those who did not by age, socio-economic status, marital status, drug use, or history of incarceration or sexually transmitted diseases. Within exchange partnerships, high or drunk sex was more common than unprotected sex. Exchange partnerships had fewer instances of risky sex. In comparison to exchange partnerships, non-exchange partnerships had four times as many episodes of unprotected vaginal sex and twice as many episodes of high or drunk vaginal sex. Prevention efforts addressing exchange sex need to address substance use. Future research and surveillance are needed to better understand the sources of HIV risk and measure and track trends in risk within sexual dyads and networks.

Predictors of Unsafe Sex among At-Risk Heterosexual Women

Despite widespread intervention efforts to curtail the spread of HIV, heterosexual transmission of HIV continues to drive the HIV/AIDS epidemic in the United States, especially among women. Research has shown that knowledge about HIV and AIDS is relatively great, even among persons who engage in high rates of risky sexual behaviors. This begs the question: What characteristics underlie and are predictive of involvement in unprotected sex? The objective of this paper is to examine the factors that are associated with engaging in unprotected sex in a population of urban, at-risk, heterosexually-active women. Conceptually, the research is guided by the notion of understanding risk and, theoretically, by the Theory of Gender and Power. Face-to-face structured interviews were conducted with 178 sexually active adult at-risk heterosexual women in Atlanta, Georgia. Street outreach efforts were used to identify potential study participants, and ethnographic mapping and targeted sampling procedures guided the recruitment process. Using a multivariate path analysis approach, three factors-marital status, having two drug-abusing parents, and negative attitudes toward condom use-were identified as predictors of unsafe sex. Further exploration of the latter measure yielded two factors that were statistically-significant multivariate predictors of attitudes toward using condoms: age and self-esteem level. Structural equation modeling was used to assess the fit of a risk-prediction model containing all of these measures, and it was shown to be supported quite strongly by the data.

Are we going to close social gaps in HIV? Likely effects of behavioral HIV-prevention interventions on health disparities

Although experimental behavioral interventions to prevent HIV are generally designed to correct undesirable epidemiological trends, it is presently unknown whether the resulting body of behavioral interventions is adequate to correct the social disparities in HIV-prevalence and incidence present in the United States. Two large, diverse-population meta-analytic databases were reanalyzed to estimate potential perpetuation and change in demographic and behavioral gaps as a result of introducing the available behavioral interventions advocating condom use. This review suggested that, if uniformly applied across populations, the analyzed set of experimental (i.e. under testing) interventions is well poised to correct the higher prevalence and incidence among males (vs. females) and African-Americans and Latinos (vs. other groups), but ill poised to correct the higher prevalence and incidence among younger (vs. older) people, as well as men who have sex with men, injection-drug users, and multiple partner heterosexuals (vs. other behavioral groups). Importantly, when the characteristics of the interventions most efficacious for each population were included in the analyses of behavior change, results replicated with three exceptions. Specifically, after accounting for interactions of intervention and facilitator features with characteristics of the recipient population (e.g. gender), there was no behavior change bias for men who have sex with men, younger individuals changed their behavior more than older individuals, and African-Americans changed their behavior less than other groups.

Factors associated with condom use among young adult ecstasy users

OBJECTIVE

This paper examines the prevalence of and the factors associated with condom use in a sample of 283 young adult ecstasy users.

METHODS

The study, which relied upon targeted sampling and ethnographic mapping, took place between 2002 and 2004. It entailed conducting two-hour-long, face-to-face interviews in the Atlanta, Georgia metropolitan area.

RESULTS

Condom use was inconsistent; only 35.2% of all sex acts were protected. Using multiple regression, five factors were related to condom use: race (Caucasians used condoms less than other groups), income (lower income = greater condom use), relationship status (persons involved in relationships reported less condom use than those who were not "involved"), multiple sex partners (multiple sex partners = more condom use), and condom use self-efficacy (higher efficacy level = more condom use).

CONCLUSIONS

Condom use rates were not optimal in this population. In particular, targeted interventions are needed for Caucasian ecstasy users. Intervention efforts ought to address relationship (in)fidelity as it pertains to engaging in safer sex practices, especially among persons involved in relationships. Intervention efforts also need to work to increase condom use self-efficacy.

An ecological approach to addressing HIV/AIDS in the African American community

The disproportionate impact of HIV/AIDS on African Americans is a significant public health challenge. The complex constellation of individual, social, and environmental factors influencing transmission, require ecological solutions that recognize these multiple levels of influence and actively involve communities. This article describes the formation of a community-based coalition and highlights three initiatives it has undertaken in the areas of mobile HIV testing, HIV education, and faith-based work to improve HIV services for African Americans.

From research to community-based practice--working with Latino researchers to translate and diffuse a culturally relevant evidence-based intervention: the Modelo de Intervención Psicomédica (MIP) experience

Efforts to translate, package, and diffuse HIV/AIDS research into practice have gained momentum with the Centers for Disease Control and Prevention's (CDC's) launch of three projects: the Prevention Research Synthesis Project, which identifies evidence-based interventions studies; the Replicating Effective Programs Project, which supports the translation of evidence-based interventions into materials suitable for use in local prevention programs; and the Diffusion of Effective Behavioral Interventions Project, which moves behavioral interventions into full-scale practice across the United States. This article describes the CDC's fast-track process of translation, packaging, and diffusion of an HIV intervention for Hispanic/Latino injection drug users, the Modelo de Intervención Psicomédica conducted by the Diffusion of Effective Behavioral Interventions Project in collaboration with a CBA organization and the original researchers.

Diffusion of Effective Behavioral Interventions and Hispanic/Latino populations

The national HIV/AIDS prevention program, the Diffusion of Effective Behavioral Interventions (DEBI), is described in the context of addressing Hispanics/Latinos at risk for HIV/AIDS in the United States and Puerto Rico. The eight-step DEBI model is referenced in terms of the interventions and Division of HIV/AIDS Prevention/Capacity Building Branch (DHAP/CBB) Latino Diffusion Team activities. A summary of activities and examples addressing diffusion needs for the diverse Hispanic/Latino populations is discussed. Challenges and successes in diffusion and partner collaborations are also presented, with comment on future directions such as translations and trainings to serve the needs of the Hispanic/Latino-serving community-based organizations and their communities.

A review of the Centers for Disease Control and Prevention's response to the HIV/AIDS crisis among Blacks in the United States, 1981-2009

Among US racial/ethnic groups, Blacks are at the highest risk of acquiring HIV/AIDS. In response, the Centers for Disease Control and Prevention (CDC) has launched the Heightened National Response to Address the HIV/AIDS Crisis Among African Americans, which seeks to engage public and nonpublic partners in a synergistic effort to prevent HIV among Blacks. The CDC also recently launched Act Against AIDS, a campaign to refocus attention on the domestic HIV/AIDS crisis. Although the CDC's efforts to combat HIV/AIDS among Blacks have achieved some success, more must be done to address this crisis. New initiatives include President Obama's goal of developing a National HIV/AIDS Strategy to reduce HIV incidence, decrease HIV-related health disparities, and increase access to care, especially among Blacks and other disproportionately affected populations.

A quasi-experimental evaluation of a community-based HIV prevention intervention for Mexican American female adolescents: the SHERO's program

This article describes a quasi-experimental evaluation of a community-based, culturally and ecologically tailored HIV prevention intervention for Mexican American female adolescents grounded in the AIDS risk reduction model. A total of 378 Mexican American female adolescents (mean age = 15.2) participated in either the nine-session SHERO's (a female-gendered version of the word hero) intervention or a single session information-only HIV prevention intervention. Assessment data were collected at pretest, posttest, and 2-month follow up. Significant improvements across all time points were revealed on measures of self-esteem, condom attitudes, beliefs regarding a woman's control of her sexuality, beliefs regarding sexual assault, perceived peer norms, and HIV/AIDS and STI knowledge. At posttest SHERO's participants were more likely to carry condoms and to report abstaining from vaginal sex in the previous 2 months; and at 2-month follow up they reported using condoms more often in the preceding 2 months and planned on using them more frequently in the coming 2 months. Findings support the development of community-based adolescent HIV prevention interventions that address culturally specific ecological factors.

The efficacy of HIV/STI behavioral interventions for African American females in the United States: a meta-analysis

OBJECTIVES

We evaluated the efficacy of HIV behavioral interventions for African American females in the United States, and we identified factors associated with intervention efficacy.

METHODS

We conducted a comprehensive literature review covering studies published from January 1988 to June 2007, which yielded 37 relevant studies. Data were analyzed using mixed-effects models and meta-regression.

RESULTS

Overall, behavioral interventions had a significant impact on reductions in HIV-risk sex behaviors (odds ratio [OR] = 0.63; 95% confidence interval [CI] = 0.54, 0.75; n = 11 239; Cochrane Q(32) = 84.73; P < .001) and sexually transmitted infections (STIs; OR = 0.81; 95% CI = 0.67, 0.98; n = 8760; Cochrane Q(16) = 22.77; P = .12). Greater intervention efficacy was observed in studies that specifically targeted African American females used gender- or culture-specific materials, used female deliverers, addressed empowerment issues, provided skills training in condom use and negotiation of safer sex, and used role-playing to teach negotiation skills.

CONCLUSIONS

Behavioral interventions are efficacious at preventing HIV and STIs among African American females. More research is needed to examine the potential contribution of prevention strategies that attend to community-level and structural-level factors affecting HIV infection and transmission in this population.

Common factors in effective HIV prevention programs

We propose a set of common factors in evidence-based interventions (EBI) for HIV prevention, which cut across theoretical models of behavior change. Three existing literatures support this agenda: (1) Common factors in psychotherapy; (2) core elements from the Centers for Disease Control and Prevention EBIs; and (3) component analyses of EBI. To stimulate discussion among prevention researchers, we propose a set of common factors at the highest level of abstraction that describe what all effective programs do: (1) establish a framework to understand behavior change; (2) convey issue-specific and population-specific information necessary for healthy actions; (3) build cognitive, affective, and behavioral self-management skills; (4) address environmental barriers to implementing health behaviors; and (5) provide tools to develop ongoing social and community support for healthy actions. A focus on common factors will enhance research on new HIV prevention interventions, encourage collaboration among researchers, provide guidelines for adapting EBI, and simplify and speed the adoption of EBI for providers.

Adapting effective narrative-based HIV-prevention interventions to increase minorities' engagement in HIV/AIDS services

Disparities related to barriers to caring for HIV-positive and at-risk minorities continue to be a major public health problem. Adaptation of efficacious HIV-prevention interventions for use as health communication innovations is a promising approach for increasing minorities' utilization of HIV health and ancillary services. Role-model stories, a widely-used HIV-prevention strategy, employ culturally tailored narratives to depict experiences of an individual modeling health-risk reduction behaviors. This article describes the careful development of a contextually appropriate role model story focused on increasing minorities' engagement in HIV/AIDS health and related services. Findings from interviews with community members and focus groups with HIV-positive minorities indicated several barriers and facilitators related to engagement in HIV health care and disease management (e.g., patient-provider relationships) and guided the development of role-model story narratives.

Toward a multi-level, ecological approach to the primary prevention of sexual assault: prevention in peer and community contexts

Although sexual assault prevention programs have been increasingly successful at improving knowledge about sexual violence and decreasing rape-supportive attitudes and beliefs among participants, reducing sexually assaultive conduct itself remains an elusive outcome. This review considers efforts to support change for individuals by creating prevention strategies that target peer network and community-level factors that support sexual violence. To this end, the article examines successful ecological prevention models from other prevention fields, identifies the components of multilevel prevention that appear critical to efficacy and discusses their application to existing and emerging sexual violence prevention strategies.

The diffusion of a community-level HIV intervention for women: lessons learned and best practices

Abstract Early in the HIV/AIDS epidemic in the United States, relatively few women were diagnosed with HIV infection and AIDS. Today, the epidemic represents a growing and persistent health threat to women in the United States, especially young women and women of color. In 2005, the leading cause of HIV infection among African American women and Latinas was heterosexual contact. In addressing HIV prevention needs among women, community-level strategies are needed to increase consistent condom use by women and their partners and to change community norms to support safer sex behaviors. The Real AIDS Prevention Project (RAPP) is a community-based HIV prevention intervention for women and their partners. RAPP is based on a community mobilization model that involves a combination of activities, including street outreach, one-on-one discussions called stage-based encounters, role model stories, community networks, and small group activities. The objectives of RAPP are to increase consistent condom use by women and their partners and change community norms associated with perceptions of condom use and high-risk behaviors in an effort to make safer sex practice more acceptable. This paper describes the Centers for Disease Control and Prevention (CDC) Division of HIV/AIDS Prevention (DHAP) effort to nationally diffuse RAPP from March 2003 through May 2007 and lessons learned from that diffusion experience. The paper specifically discusses (1) collaborating and planning with researchers, (2) a diffusion needs assessment that was designed to assess prior implementation experiences among select agencies, (3) developing the intervention package, (4) developing and piloting training for community-based organizations (CBOs), (5) a rollout of national trainings for health departments and community-based organizations interested in implementing RAPP, and (6) ongoing quality assurance activities and the provision of technical assistance and support. RAPP has been proven effective in reducing HIV transmission risk behaviors and improving communication and negotiation skills necessary for African American women and Latinas to reduce their risk for HIV infection and improve their overall health status.

From brochures to videos to counseling: exposure to HIV-prevention programs

This research tested the prediction that reading a preventive brochure leads people to watch a preventive video, and that watching this video in turn leads to an increase in the likelihood of participating in a preventive counseling session. A sample of men and women from a southeastern community in the United States was recruited for a general health survey with the objective of examining participation in HIV-prevention interventions. Unobtrusive measures of exposure to HIV-prevention brochures, an HIV-prevention video, and an HIV-prevention counseling session were obtained. Findings indicated that reading the brochures increased watching the video and that watching the video increased participation in the counseling session. The association between exposure to the video and exposure to the counseling was mediated by expectations that the counseling would be useful. Findings are discussed in terms of the need to ensure exposure to interventions to achieve intervention effectiveness.