Evaluation Framework for HIV Prevention and Care Activities in the Enhanced Comprehensive HIV Prevention Planning Project, 2010-2013

OBJECTIVE

The Enhanced Comprehensive HIV Prevention Planning (ECHPP) project was a demonstration project implemented by 12 U.S. health departments (2010-2013) to enhance HIV program planning in cities with high AIDS prevalence, in support of National HIV/AIDS Strategy goals. Grantees were required to improve their planning and implementation of HIV prevention and care programs to increase their impact on local HIV epidemics. A multilevel evaluation using multiple data sources, spanning multiple years (2008-2015), will be conducted to assess the effect of ECHPP on client outcomes (e.g., HIV risk behaviors) and impact indicators (e.g., new HIV diagnoses).

METHODS

We designed an evaluation approach that includes a broad assessment of program planning and implementation, a detailed examination of HIV prevention and care activities across funding sources, and an analysis of environmental and contextual factors that may affect services. A data triangulation approach was incorporated to integrate findings across all indicators and data sources to determine the extent to which ECHPP contributed to trends in indicators.

RESULTS

To date, data have been collected for 2008-2009 (pre-ECHPP implementation) and 2010-2013 (ECHPP period). Initial analysis of process data indicate the ECHPP grantees increased their provision of HIV testing, condom distribution, and partner services programs and expanded their delivery of prevention programs for people diagnosed with HIV.

CONCLUSION

The ECHPP evaluation (2008-2015) will assess whether ECHPP programmatic activities in 12 areas with high AIDS prevalence contributed to changes in client outcomes, and whether these changes were associated with changes in longer-term, community-level impact.

Shifting Resources and Focus to Meet the Goals of the National HIV/AIDS Strategy: The Enhanced Comprehensive HIV Prevention Planning Project, 2010-2013

In September 2010, CDC launched the Enhanced Comprehensive HIV Prevention Planning (ECHPP) project to shift HIV-related activities to meet goals of the 2010 National HIV/AIDS Strategy (NHAS). Twelve health departments in cities with high AIDS burden participated. These 12 grantees submitted plans detailing jurisdiction-level goals, strategies, and objectives for HIV prevention and care activities. We reviewed plans to identify themes in the planning process and initial implementation. Planning themes included data integration, broad engagement of partners, and resource allocation modeling. Implementation themes included organizational change, building partnerships, enhancing data use, developing protocols and policies, and providing training and technical assistance for new and expanded activities. Pilot programs also allowed grantees to assess the feasibility of large-scale implementation. These findings indicate that health departments in areas hardest hit by HIV are shifting their HIV prevention and care programs to increase local impact. Examples from ECHPP will be of interest to other health departments as they work toward meeting the NHAS goals.

Health Department HIV Prevention Programs That Support the National HIV/AIDS Strategy: The Enhanced Comprehensive HIV Prevention Planning Project, 2010-2013

OBJECTIVE

The Enhanced Comprehensive HIV Prevention Planning project was the first initiative of the Centers for Disease Control and Prevention (CDC) to address the goals of the National HIV/AIDS Strategy (NHAS). Health departments in 12 U.S. cities with a high prevalence of AIDS conducted comprehensive program planning and implemented cost-effective, scalable HIV prevention interventions that targeted high-risk populations. We examined trends in health department HIV prevention programs in these cities during the project.

METHODS

We analyzed the number of people who received partner services, condoms distributed, and people tested for HIV, as well as funding allocations for selected HIV prevention programs by year and by site from October 2010 through September 2013. We assessed trends in the proportional change in services and allocations during the project period using generalized estimating equations. We also conducted thematic coding of program activities that targeted people living with HIV infection (PLWH).

RESULTS

We found significant increases in funding allocations for HIV testing and condom distribution. All HIV partner services indicators, condom distribution, and HIV testing of African American and Hispanic/Latino populations significantly increased. HIV tests associated with a new diagnosis increased significantly among those self-identifying as Hispanic/Latino but significantly decreased among African Americans. For programs targeting PLWH, health department activities included implementing new program models, improving local data use, and building local capacity to enhance linkage to HIV medical care, retention in care, and treatment adherence.

CONCLUSIONS

Overall, these findings indicate that health departments in areas with a high burden of AIDS successfully shifted their HIV prevention resources to scale up important HIV programs and make progress toward NHAS goals.

Routine HIV screening in two health-care settings--New York City and New Orleans, 2011-2013

Approximately 16% of the estimated 1.1 million persons living with human immunodeficiency virus (HIV) in the United States are unaware of their infection and thus unable to benefit from effective treatment that improves health and reduces transmission risk. Since 2006, CDC has recommended that health-care providers screen for HIV all patients aged 13-64 years unless prevalence of undiagnosed HIV infection in their patients has been documented to be <0.1%. This report describes novel HIV screening programs at the Urban Health Plan (UHP), Inc. in New York City and the Interim Louisiana Hospital (ILH) in New Orleans. Data were provided by the two programs. UHP screened a monthly average of 986 patients for HIV during January 2011-September 2013. Of the 32,534 patients screened, 148 (0.45%) tested HIV-positive, of whom 147 (99%) received their test result and 43 (29%) were newly diagnosed. None of the 148 patients with HIV infection were previously receiving medical care, and 120 (81%) were linked to HIV medical care. The ILH emergency department (ED) and the urgent-care center (UCC) screened a monthly average of 1,323 patients from mid-March to December 2013. Of the 12,568 patients screened, 102 (0.81%) tested HIV-positive, of whom 100 (98%) received their test result, 77 (75%) were newly diagnosed, and five (5%) had acute HIV infection. Linkage to HIV medical care was successful for 67 (74%) of 91 patients not already in care. Routine HIV screening identified patients with new and previously diagnosed HIV infection and facilitated their linkage to medical care. The two HIV screening programs highlighted in this report can serve as models that could be adapted by other health-care settings.

"The anticipation alone could kill you": past and potential clients' perspectives on HIV testing in non-health care settings

HIV testing in non-health care settings is an effective strategy for increasing the proportion of persons aware of their infection. We conducted 21 focus groups with 186 past and potential clients in five U.S. cities to explore attitudes and experiences related to HIV counseling and testing in non-health care settings. Qualitative analysis yielded several key themes. HIV-related stigma and fear emerged as a main theme throughout the discussions. Knowing one's HIV status quickly and accurately was of primary importance; HIV prevention counseling was secondary. Participants prioritized a supportive, nonjudgmental environment with adequate privacy and confidentiality. Provision of immediate emotional support, medical information, and linkage services to HIV-infected clients were considered essential. Staff with HIV-specific skills to address clients' emotional and informational needs was considered a strength of non-health care testing programs. Frequently, however, participants compared non-health care settings unfavorably to health care settings regarding privacy, competency, confidentiality, and test accuracy. Recommendations for enhancing counseling and testing services in non-health care settings are discussed.

Sexual and drug use risk behaviors of long-haul truck drivers and their commercial sex contacts in New Mexico

OBJECTIVES

Long-haul truck drivers and their commercial sex contacts (CCs) have been associated with the spread of sexually transmitted infections (STIs) in the developing world. However, there is a paucity of information about the STI risk behaviors of these populations in the U.S. We conducted a qualitative phase of a two-phase study to gather information about STI-related risk behaviors in drivers and their CCs in New Mexico.

METHODS

Between July and September 2004, we conducted face-to-face unstructured and semistructured qualitative interviews at trucking venues, health department facilities, and a community-based organization to solicit information on sexual behavior and condom and illicit drug use. The interviews were audiotaped, transcribed, reviewed for quality control, and then coded and analyzed for emerging themes using NVivo software.

RESULTS

Thirty-three long-haul truck drivers and 15 CCs completed the interview. The truck drivers were mostly male and non-Hispanic white with a mean age of 41 years. The majority of the CCs were female, the largest percentage was Hispanic, and the mean age was 36 years. Data suggested risky sexual behavior and drug use (i.e., inconsistent condom use, illicit drug use including intravenous drug use, and the exchange of sex for drugs) that could facilitate STI/human immunodeficiency virus (HIV) and hepatitis virus transmission. Results also showed a low knowledge about STIs and lack of access to general health care for both populations.

CONCLUSIONS

Additional studies are needed to further assess risk and inform the development of prevention interventions and methods to provide STI/HIV and other medical services to these populations.

HIV transmission in a state prison system, 1988-2005

INTRODUCTION

HIV prevalence among state prison inmates in the United States is more than five times higher than among nonincarcerated persons, but HIV transmission within U.S. prisons is sparsely documented. We investigated 88 HIV seroconversions reported from 1988-2005 among male Georgia prison inmates.

METHODS

We analyzed medical and administrative data to describe seroconverters' HIV testing histories and performed a case-crossover analysis of their risks before and after HIV diagnosis. We sequenced the gag, env, and pol genes of seroconverters' HIV strains to identify genetically-related HIV transmission clusters and antiretroviral resistance. We combined risk, genetic, and administrative data to describe prison HIV transmission networks.

RESULTS

Forty-one (47%) seroconverters were diagnosed with HIV from July 2003-June 2005 when voluntary annual testing was offered. Seroconverters were less likely to report sex (OR [odds ratio] = 0.02, 95% CI [confidence interval]: 0-0.10) and tattooing (OR = 0.03, 95% CI: <0.01-0.20) in prison after their HIV diagnosis than before. Of 67 seroconverters' specimens tested, 33 (49%) fell into one of 10 genetically-related clusters; of these, 25 (76%) reported sex in prison before their HIV diagnosis. The HIV strains of 8 (61%) of 13 antiretroviral-naïve and 21 (40%) of 52 antiretroviral-treated seroconverters were antiretroviral-resistant.

DISCUSSION

Half of all HIV seroconversions were identified when routine voluntary testing was offered, and seroconverters reduced their risks following their diagnosis. Most genetically-related seroconverters reported sex in prison, suggesting HIV transmission through sexual networks. Resistance testing before initiating antiretroviral therapy is important for newly-diagnosed inmates.

Randomized controlled trial of an intervention to prevent adherence failure among HIV-infected patients initiating antiretroviral therapy

OBJECTIVE

Compare the efficacy of a multicomponent social support intervention to standard-of-care counseling on medication adherence among HIV-infected patients initiating antiretroviral therapy.

DESIGN

Randomized controlled trial. Generalized estimating equations tested for differences in the percentage of participants achieving 90% adherence.

MAIN OUTCOME MEASURES

Pill-taking, electronically monitored over 6 consecutive months; plasma viral load (VL), assessed at 3 and 6 months following initiation of therapy.

RESULTS

Of 226 participants who were randomized and began the trial, 87 (38%) were lost to the study by 6 months. The proportion of adherent participants declined steadily over time, with no time by group interaction. Sustained adherence was associated with increased odds of achieving an undetectable VL (OR=1.78; 95% CI=1.01, 3.13). In intention-to-treat analyses, a larger proportion of the intervention group than the control group was adherent (40.15% vs. 27.59%, p=.02) and achieved an undetectable VL p=.04). However, the majority of participants who remained on study experienced some reduction in VL (>or=1-log drop or undetectable), regardless of experimental condition.

CONCLUSION

The multicomponent social support intervention significantly improved medication adherence over standard-of-care counseling; evidence for improved virologic outcomes was inconsistent. Early discontinuation of care and treatment may be a greater threat to the health of HIV patients than imperfect medication-taking.

Addressing poverty as risk for disease: recommendations from CDC's consultation on microenterprise as HIV prevention

In March 2006, the Centers for Disease Control and Prevention (CDC) convened a consultation meeting to explore microenterprise as a potential human immunodeficiency virus (HIV)/acquired immunodeficiency syndrome (AIDS) prevention intervention. The impulse to link microenterprise with HIV/AIDS prevention was driven by the fact that poverty is a significant factor contributing to the risk for infection. Because increasingly high rates of HIV infection are occurring among women, particularly among poor African American women in the southern United States, we focused the consultation on microenterprise as an intervention among that population. In the international arena, income generated by microenterprise has contributed to improving family and community health outcomes. This article summarizes the contributions made to the consultation by participants from the diverse fields of microenterprise, microfinance, women's studies, and public health. The article ends with recommendations for HIV/AIDS prevention and, by implication, addressing other public health challenges, through the development of multifaceted intervention approaches.

Overview and implementation of an intervention to prevent adherence failure among HIV-infected adults initiating antiretroviral therapy: lessons learned from Project HEART

Project HEART, an acronym for Helping Enhance Adherence to Retroviral Therapy, was a prospective, controlled study to develop, implement, and evaluate a clinic-based behavioural intervention to prevent adherence failure among HIV-infected adults beginning their first highly active antiretroviral therapy (HAART) regimen (N = 227). In this paper, we describe the conceptualisation of the Project HEART adherence intervention, characteristics of the participants, and lessons learned implementing HEART in an inner-city clinic setting. A multi-component intervention, HEART combined enhanced education, reminders, adherence feedback, social support and adherence-focused problem solving in an integrated manner to address common cognitive, motivational, and social barriers to adherence. Unique components of the intervention included use of participant-identified adherence support partners and a standardized adherence barriers assessment to develop and implement individualised adherence plans. Lessons learned regarding the feasibility of using participant-identified support partners were as follows. Few participants eligible for the study had trouble identifying a support partner. Over 90% of support partners attended at least one intervention visit. Support partners were most available and amenable to participate early in the initiation of therapy. Participants' experiences as the 'supported' partner were generally positive. Though many participants faced barriers not easily addressed by this intervention (for example, housing instability), formally integrating support partners into the intervention helped to address many other common adherence barriers. Family and friends are an under-utilised resource in HIV medication adherence. Enlisting the help of support partners is a practical and economical approach to adherence counselling.

Social organization of sexual-economic networks and the persistence of HIV in a rural area in the USA

In order to determine why high rates of HIV transmission have persisted in a rural area despite community-wide HIV prevention since the mid-1980s, qualitative information was collected about the contexts and social organization of risk behaviour for HIV transmission from residents of a southern Florida community with high HIV prevalence. Original data were collected during 1995-1997 using individual interviews, observations, focus groups, and print media. The research findings were recently reviewed by community members, and the relevance of the data in the present day context was confirmed. We identified risk behaviours including multiple sex partners within heterosexual networks that cross socioeconomic strata and include adults and young people, sex workers, men who have sex with men, prison inmates, truckers, and migrant workers. Crack cocaine was an important feature of some networks. Financial support from multiple male or female sex partners was often part of a personal economic strategy and overlaid traditional social support networks. This type of relationship appears to be historically integrated into the economic fabric of the community and is not likely to receive social censure. Sexual reciprocity may explain, in part, why HIV transmission is rising among women in rural southern communities that have depressed economies.

Integration of a participatory research strategy into a rural health survey

The Glades Health Survey, a population-based survey of tuberculosis and HIV infection, provides a model for building community-research partnerships with local health departments in ethnically diverse communities. The survey was initiated without broad community participation; a year and a half of organizing established community leadership of the project. Essential factors in the success of the project included a shared objective, direct confrontation of fears about research, inclusion of all socioeconomic and racial/ethnic groups, and community participation in performing the research. These activities led to establishment of a community-based organization that received funding for HIV counseling and testing and HIV prevention case management.

Highway cowboys, old hands, and Christian truckers: risk behavior for human immunodeficiency virus infection among long-haul truckers in Florida

This paper reports the results of ethnographic research to describe risk for human immunodeficiency virus (HIV) infection among long-haul truck drivers and the contexts and factors that influence risk and protective behaviors. Drivers were selected using purposive and snowball sampling at trucking-related businesses along major truck routes in Florida. Interview information was used to categorize truckers' levels of potential risk, describe behavioral characteristics of each group, identify sex partners, and assess perceptions of the risk of HIV infection. One-third of the 71 men interviewed had frequent sexual intercourse on the road with multiple partners, but few ever used condoms. Commercial sex workers were their most frequent partners for on-the-road sex. The risk was compounded by occupational conditions, which motivated truckers to drive long hours, often using drugs to stay alert. Sex, alcohol, and drugs were perceived as quick, effective stress relievers during downtime on long, lonely trips. Despite their high-risk behaviors, truckers tended to consider themselves at low risk for HIV infection and expressed a number of misconceptions regarding HIV transmission. For example, many truckers did not associate HIV risk with heterosexual contact or think that condoms were effective in preventing HIV transmission. In addition, many truckers maintained strong homophobic and anti-government opinions that reinforced their suspicion of safe-sex messages. These findings suggest that high-risk sexual behavior is common among long-haul truckers in the US, who may be at risk for HIV infection primarily because of unprotected sexual intercourse with multiple sex partners. Also, drug use may be associated with HIV risk behavior. The authors recommend establishing prevention programs that are developed by and for truckers, determining HIV seroprevalence rates of truckers, addressing drug and alcohol abuse among truckers, and altering industry policy that keeps truckers on the road too long for their own and others' safety.