Community based hiv interventions

Community-Based HIV Intervention 1

Review of the Literature

While many advances have been made in HIV and AIDS treatment, communities still

need to be proactive in prevention and education. It is imperative that communities work

together to provide culturally-based interventions and work with researchers to implement

evidence-based interventions into community-based organizations and settings. This is

especially true in African American, Latino, injecting drug users (IDUs) and low income

communities. Since there is still no cure for HIV and AIDS, behavior change is the most

effective way to decrease infection of the virus. Community-based organizations need to find

the best prevention interventions that can help change high risk behaviors.

To halt the continuation of HIV, it is important to raise awareness through community

mobilization, education prevention and behavior change in special groups. According to Cai, Li,

and Li’s (2009) article, community-based interventions have been successful in changing risky

behavior and in prevention of HIV. In order to accurately assess the success of interventions

CAI, et al. (2009) believe special attention needs to be paid to socioeconomic and behavioral

aspects at the local level. Community volunteers and leaders as well as religious leaders should

all be included in education programs pertaining to HIV intervention and prevention.

In their research article, CAI, et al. (2009) studied community participation, program

activities and outreach strategies which they believe are necessary for a successful community

education program. One model to prevent HIV transmission was discussed. The PRECEDE-

PROCEED model for community planning and health promotion was adopted and led by public

health professionals. Discussion groups and input from community members and community

based organization assessed information. Twelve areas which accounted for 73% of reported


AIDS cases among African Americans and Latinos aged 18-39 were selected for interventions.

Horizontal outreach to residents, vertical outreach to stakeholders, strategic communications and

infrastructure development were chosen to promote behavioral change.

2,011 surveys were conducted with community residents in the first year, and 2,381

follow-up interviews were done the next year. The results showed that program awareness was

up from 5.4% in 2001 to 6.7% in 2002. Recognition of HIV/AIDS problems increased to 35.3%.

Participation in HIV prevention increased significantly.

The America Responds to AIDS (ARTA) campaign was also studied. ARTA used serial

theme education programs and was based on established theory and practice. Originally

developed as a response to the early AIDS crisis, it has evolved into the development of

objectives to combat HIV/AIDS. ARTA includes state and local health agencies and

community-based organizations. All objectives are based on public need and specific

organizations. Input from all participants was used to implement strategies. The results showed

that community-based interventions which promoted HIV/AIDS awareness and change of risky

behavior did prevent the spread of HIV/AIDS (CAI, et al., 2009).

According to Williams, Wyatt and Wingood, (2010), even though African Americans

only make up 12% of the population, they account for 51% of new HIV/AIDS cases and 48% of

all people currently living with HIV/AIDS. Williams, et al. (2009), believe that since sexual

behaviors are the most common mode of transmission, changing behavior is the key to

prevention. Therefore, they researched different prevention interventions which focused on

behavioral changes in African Americans.


In 1996 the Prevention Research Branch Division of HIV/AIDS Prevention (DHAP)

began the HIV/AIDS Prevention Research Synthesis (PRS) project to review HIV behavioral

prevention research literature to find the most effective preventions. The PRS created a

compendium where community-based organizations (CBO) would implement programs best

suited for their target populations. They found that identifying variables that influence HIV

transmissions and sexual behaviors is critical for interventions to be successful. One of the most

important variables is culture, which needs to be included in interventions. Interventions must

include core cultural and community elements (Williams, et al., 2009).

Previous HIV prevention has generally focused on safe sex with condoms. All ethnic

groups were targeted the same way. According to Williams, et al. (2009), research has shown

that different ethnic groups need to be targeted in ways that are familiar to them. Intervention

presentation strategies use videos, and models of the same race/ethnicity. The person delivering

the message should be a member of the target population and community. Curriculum content

includes cultural concepts into interventions, such as racial pride.

HIV intervention for African Americans needs to address institutional variables, which

operate on either an individual, community and health level. Individual factors include being

poor, lack of health insurance and discrimination. Community and health systems include lack

of services and lack of culturally aware providers which act as barriers. Williams, et al. (2010)

found that while evidenced-based interventions (EBI) may work with study participants, they

often do not achieve the same outcomes in real world settings. Most EBIs are conducted in

university setting and making the transition into the community is challenging.


To solve this problem, community-based research (CBPR) was proposed. This was a

collaborative approach designed to create structures for participation of communities,

representatives of organizations and researchers to improve health and well-being. The CBPR

combines culturally and practiced-based evidence and indigenous research methods (Williams, et

al., 2009).

The flaw to this research is that CBOs have not been formally evaluated and do not have

the scientific basis to adapted supported interventions. Also, if CBOs do not have access and a

good rapport to the target population, interventions may not be accepted or endorsed. For

interventions to be successful, it is essential that community agencies and partners are included

in all stages of development and civic organizations need to be included. Interventions need to

be adapted specifically to fit the community they are to be implemented in. To have successful

prevention of HIV/AIDS in African American communities, all workers need to work together to

develop cultural HIV interventions and work on changing behaviors. Prevention strategies

should also focus on HIV re-infection and transmission to non-infected partners (Williams, etc.

al. 2010).

The introduction of Highly Active Anti Retroviral Treatment (HAART) has increased the

life expectancy of people living with HIV and AIDS. However according to a research article by

Raymond (2005), HIV injecting drug users (IDUs) are not yet receiving the full benefit of this

treatment. There are several theories as to why this is. One theory of thought is that

communities do not provide ample interventions for IDUS. IDUs are discriminated against

because by doing drugs they are therefore criminals and not looked upon as favorably as others

suffering from HIV and AIDS (Raymond, 2005).


Biologists believe it is because illicit drugs prey on the immune system. For example, it

has been long believed that cocaine makes HIV replicate at an increased rate. However, clinical

data received from the Women and Infants Transmission Study (WITS) which included a group

of HIV African American and Latino women who were drug users, found a contradiction to this

theory. The results found no difference from non-drug using HIV women in CD4 cell

percentage, HIV viral load, or survival. They did find that drug users experienced more AIDS

opportunistic infections such as tuberculosis and pneumonia (Raymond, 2005).

The Journal of AIDS reported in 2004, that even though AIDS defining illnesses have

decreased with the use of HAART, these decreases were lower in HIV-IDUs. The death of

IDUS is higher than non drug users. It is hypothesized that this may not be necessarily due to

drug use, but rather to less access to HIV treatment. According to Raymond, (2005), HIV

positive IDUs have less access to care, quality of care and adherence. This reflects lack of

system care such as housing and treatment for drug addiction. Because illicit drugs are illegal

IDUs face a stigma and prejudice ranging from disapproval, police harassment, loss of jobs,

custody of children and imprisonment. Communities need to provide HIV drug users with more

substance abuse counseling, treatment, mental health care, housing and support.

Delayed testing and treatment has been found to have extremely negative consequences

for HIV-IDUS. Raymond, (2005) indicates a study in Baltimore which found that HIV-IDUs

who began HAART when their CD4 cell count was over 350, had survival rates comparable to

HIV negative IDUs. Other studies have shown that HIV-IDUs who received HAART responded

as well as HIV non drug users (Raymond, 2005). These results show that HIV-IDU’s need more

community-based programs, hospitals and clinics. Health care workers and staff need to be


familiar with drug users’ needs and harm reduction models. Community-based programs also

need to be linked to hospitals, clinics, substance abuse programs and correctional facilities. The

limits in these studies are that higher deaths among HIV-IDU’s may be from drug use rather than

HIV and AIDS complications.

While HAART treatment for HIV is an effective treatment, getting HIV patients to

adhere to the medication poses challenges (Mocalino, G. E., Hogan, J. W., Mitty, J. A.,

Bazerman, L. B., Delong, A. K., Loewenthal, H., Caliendo, A. M., and Fanigan, T. P., (2007).

In their article, Mocalino, et al. (2007), detail a study on a randomized trial of community-based,

modify directly observed therapy (MDOT) for HIV positive drug users. This study focused on

adherence and benefits of MDOT.

According to Mocalino, et al. (2007), the study was conducted as an open-label,

randomized, single center trial. Participants were selected from HIV primary care clinics, which

were active users of cocaine, heroin and alcohol misuse and were also non-resistant to a once

daily regimen. Participants were randomly chosen to receive either MDOT or standard of care

(SOC) stratified by HAART therapy for a minimum of two weeks. SOC participants could also

receive any adherence interventions and could cross over to the MDOT arm if their therapy

wasn’t working. MDOT participants were given their own prescriptions. An outreach social

worker observed and transported participants every day for the first three months and then lesser

days over the next nine months.

Assessments were conducted at screening, baseline, one month and then every two

months afterward. Assessments consisted of a questionnaire and venipuncture. Participants


were given incentives during assessments. The types of incentives given were not specified in

the article. Of the 87 participants, 43 received SOC and 44 received MDOT (Mocalino, 2007).

The results showed that after one month, SOC participants missed at least one dose

compared to MDOT participants. The three month evaluation showed similar results. HIV

seropositive drug users on MDOT were more likely to achieve HIV PVL suppression than those

receiving SOC. HAART participants on MDOT also were hospitalized less than SOC

participants. Therefore, there was an overall monetary savings on the MDOT arm (Mocalino,

2007).

One limitation to the study was that participants consisted of both drugs users and alcohol

abusers, so the effects between the two groups could not be evaluated. Another limitation is the

study’s endpoint was at three months, which means long-term effectiveness could not be

calculated. The overall results showed that MDOT should be included into adherence

interventions whose participants are failing therapy. However, more studies are needed to

specify which populations would benefit the most and also what the long-term benefits would be.

For community-based interventions to be effectively implemented there needs to be

better ways for scientists, researchers, policy makers, analysts and decision makers to discuss

and exchange HIV prevention and interventions. In his article, Holtgrave (2004) discusses his

framework for scientists, analysts and decision makers to better communicate prevention

interventions for HIV through technology transfer which also includes cost effective analysis.

Community-based organizations have faced several barriers in adopting science-based HIV

prevention interventions in the form of workshop-style training, supportive documentation and

on-site technical assistance. According to Holtgrave (2004), these barriers include: lack of


financial, human and resources to deliver intensive HIV prevention interventions; lack of

resources to fund enrollment incentives to participants; high staff turnover; lack of training; lack

of science-based interventions that are specifically adapted to particular communities.

Little research has been conducted on the most effective methods of delivering HIV

prevention intervention technical assistance to community organizations. It is important for

policy makers to know how effective interventions will be and their cost. Scientists working on

HIV prevention and interventions generally do not provide their findings in a format that can be

inputted into programmatic and policy decision making. Holtgrave’s (2004), framework

provides tools of analytic techniques which can be used, such as research synthesis, Meta

analysis and economic evaluation methods. According to Holtgrave (2004), dialogue between

scientists and policy analysts is important. There also needs to be dialogue between policy

analysts and decision makers to discuss problems in interventions. Holtgrave’s (2004),

framework shows the importance of using scientific results in a technological format to help

policy analysts and decision makers to find the best prevention interventions.

Another article by Bauer, Kilbourne, Neuman, Pincus and Stall (2007), discusses the best

strategies to implement evidenced-based interventions for HIV from academic settings to

community-based settings. Although many effective interventions have been developed for HIV

in academic settings, very few have been successfully disseminated into community-based

organizations. Bauer et al. (2007) describe different strategies that can help with this transfer.

The first strategy is to determine when an organization is ready to implement an intervention.

The second strategy is to work with senior leaders and providers to overcome barriers to

adaptation.


At the time of this article, no implementation frameworks had been specified on how to

implement and adapt interventions to fit community-based organizations. Because of this most

community-based organizations do not implement evidence-based interventions. Bauer et al.,

(2007) study and focus on Replicating Effective Programs (REP) which specifically outlines how

to implement evidence-based interventions into community-based settings through a framework

of strategies which include packaging, training, and technical assistance.

The REP framework, developed by the U.S. Centers for Disease Control and Prevention

(CDC) in 1996 is based on literature review and community input. The REP framework has four

phases. These phases consist of identifying the need for interventions for a particular population,

researching whether the intervention has been successful in similar settings, and identifying

barriers to implementation. After these phases have been completed, an intervention package is

drafted along with training and technical assistance plans. According to Bauer et al. (2007), the

REP package is better than other intervention toolkits because it provides specific details and

options for adaptation for different community-based organizations and settings. As of 2007, the

CDC had funded over 500 prevention organizations (Bauer. et al., 2007).

Once implemented, the REP interventions are thoroughly evaluated by collecting data

through interviews of providers and consumers, checking to see that core elements of the

intervention were implemented, patient-level outcomes are assessed and whether the intervention

was effective. After evaluations are completed the REP framework maintains and makes

changes as needed.

REP has shown to be effective in implementing HIV interventions into community-based

settings. The downside to REP is that it had not yet been evaluated for its effectiveness in


reducing HIV/AIDS, patient outcome or costs as of 2007. No studies of the long-term effects of

REP beyond implementations had been done either. More studies that evaluate long-term

outcomes and sustainability of REP needs to be conducted.

As mentioned in other articles, behavioral interventions are the most effective way to

reduce risk and transmission of HIV. However, successfully implementing interventions from

research settings into community-based organizations are often faced with complications. This

is due mostly to the fact that clinical settings often do not have the funding and resources to

deliver, monitor and evaluate community-based interventions. According to an article by

Copenhaven and Lee (2007), AIDS complacency has posed problems to interventions. The

introduction of HIV medications, have made people complacent and the threat of HIV/AIDS is

not necessarily seen as the threat it was once was. Another problem is that targeted individuals

tend to recount prevention information if they view it as redundant.

Analysis of randomized and controlled trials (RCTs) found that IDUs responded better in

community-based interventions when the focus was on sex and drug related risks equally.

Copenhaver and Lee (2007) developed the Community-Friendly Health Recovery Program

(CHRP), which showed successful outcomes with enhanced HIV-knowledge, motivation,

behavioral skills, and reduction in at risk sex and drug behaviors. A study was conducted to

check whether the intervention effects decayed over time and whether the intervention should be

repeated at a follow-point.

The CHRP intervention was conducted at a methadone facility as a manual guided

behavioral intervention which consisted of four 50 minute group sessions. These sessions’

targeted sex and drug related HIV risks and were led by two trained facilitators, using cognitive


remediation strategies. 226 participants participated in the initial intervention, and 62 subjects

participated in a repeated follow-up intervention. Participants did not receive compensation or

any incentives. The follow-up rate was lower than similar interventions where participants

received incentives. No differences were found in regards to pre and post intervention measures

such as HIV knowledge, behavior, attitudes and drug use (Copenhaver and Lee, 2007).

To assess participants’ sex and drug HIV risk behaviors, the Risk Assessment Battery

(RAB) was used. The RAB also assessed participants’ HIV knowledge, motivation and

behavior. The results of the study showed that a positive effect was found for the intervention,

HIV risk group, and sex and drug risk reduction. HIV participants showed greater high HIV risk

improvement at immediate post-intervention. Decay over time was analyzed to see if outcomes

diminished. Results showed no evidence of decay in risk reduction at follow-up. However there

was a gradual decline in some areas in high HIV risk groups. Participants who had children at

home, has less decay (Copenhaven and Lee, 2007). Therefore it is suggested that future

interventions should enhance social support. Also future studies should also analyze the impact

of family and social support on risk reduction outcomes. More decay was noticed in sex-related

risk groups, but follow-up interventions did lessen the decay. The limitations to the study were

that participants did not receive incentives or compensation. Also, this study was limited to one

group, without control groups to compare outcomes. Further studies should have a separate

control group to better track results.

As mentioned in previous articles, the issue of adapting evidence-based interventions into

community-based organizations is not always successful. In their article, Kao, Rosales, and

Veniegas (2009) study how different community organizations adapt HIV prevention


interventions and how these changes affect the core elements of the interventions. The CDC

stresses the importance of keeping core elements of interventions intact when transferring them

from research settings to community-based settings. To ensure this, the CDC released three

versions of HIV prevention intervention guidance to help community agencies in planning and

implementing interventions. These guides outline core elements of evidence-based interventions

and also describe adaptation, resource requirements, recruitment, policies, standards, monitoring

and evaluations for interventions.

To help community-based organizations adapt interventions, the CDC state that agencies

adapting interventions need to conduct formative evaluations to define the target population,

culture behaviors and HIV risk factors. The CDC also encourages agencies to develop

intervention implementation plans, provide leadership, solicit feedback from staff, provide

training, ensure fidelity to core elements and monitor client responsiveness.

Kao, et al. (2009), conducted a study which consisted of interviews with staff who were

implementing evidence-based HIV prevention interventions. Participants were eligible for the

study if they were employed by an organization that provided HIV prevention interventions.

Thirty-four participants who worked in twenty-two different organizations participated in the

study. Twenty-one were female, ten were male and three were transgendered. Participants were

of mixed backgrounds and worked at the agencies from anywhere to six months to over 10 years

(Kao, et al., (2009).

Kao, et al. (2009), stated that semi-structured interviews were conducted with study

participants. The interviews were based upon research on the adoption of evidence-based HIV

prevention programs. Afterwards, the interviews were transcribed, entered electronically and


then coded. The results showed that agency staff adapted activities and delivery methods of

interventions as recommended by the CDC. Most of the study participants said that they used

pilots and made changes after assessing and getting feedback from intervention participants.

Some made changes on cultural issues. For example, if they showed a video about heterosexuals

to homosexuals, participants said that they couldn’t relate to the video. Thus they would change

to a video that showed homosexuals. Other participants often made changes to include

incentives.

According to Kao, et al. (2009), none of the staff who made changes consulted with a

technical assistance provider or other expert. Seven participants stated that reinvention during

the implementation stage was required by their funders. Some staff reported making changes

during maintenance for quality assurance. These were mostly efforts made to improve activities

and delivery methods. Few of these participants piloted their adaptations before commencing

with full implementation as recommended by the CDC. Also reinventions did sometimes change

the core elements of the interventions which the CDC cautions against.

The results are that continuous measurements of fidelity are needed. Any adaptations to

interventions need to be recorded and these records should be included in periodic reports by

agencies to funders, so that changes can be accessed. This will help the effectiveness of future

prevention interventions (Kao, et al. (2009). Piloting and technical assistance is also important

during the pre-implementation phase. Re-invented interventions should be evaluated to

demonstrate their ability to reduce HIV risk.

The limitations to the study include interview questions that did not address as to specific

program adaptations, or why changes were made. Since there was no program monitoring, or


fidelity assessment, the reliability of the study participants cannot be verified. Also, the study

should have included participants at varying levels in the organizations, to see if the results and

interviews varied by different positions. The article was also confusing, in that in one part Kao,

et al. (2009) stated that all adaptations were within CDC guidelines with most using pilots first.

However, it was later stated that some adaptations were not CDC approved and participants did

not use pilots.

In the final analysis, combining all the information of the reviewed articles shows that

even though treatments such as HAART have been proven effective in prolonging the lives of

people who have HIV and AIDS, community-based interventions still need to be implemented.

It is also important that more research is done to help implement successful evidence-based

prevention interventions into community-based organizations and settings. In order for these

interventions to be successful, they need to focus on behavioral change and be custom tailored to

their specific target populations. This includes incorporating cultural aspects so that participants

are more willing to participate and adhere. Most of the research has shown that community-

based interventions have been successful with lowering high risk behaviors when implemented

successfully.


References

Bauer, M. S., Kilbourne, A. M., Neuman, M. S., Pincus, H. A., and Stall, R. (2007).

Implementing evidence-based interventions in health care: application of the replicating

effective programs framework. Implementation Science. 2:42, p42.

CAI, H., Li, Q., Li, Y. (2009). Community-based intervention for AIDS prevention.

International Journal of Health and Science. 2:4, p226.

Copenhaven, M., Lee, I. (2007). Examining the decay of HIV risk reduction outcomes following

a community-friendly intervention targeting injection drug users in treatment. Journal of

Psychoactive Drugs. 39.3, p223.

Holtgrave, D., R. (2004). The role of quantitative policy analysis in HIV prevention technology

Transfer. Public Health Reports. 119.1. P19

Kao, U. H., Rosales, R., and Veniegas, R. C. (2009). Adapting HIV prevention evidence-based

interventions in practice settings and interview study. Implementation Science. 4. P76

Mocalino, G. E., Hogan, J. W., Mitty, J. A., Bazerman, L. B., DeLong, A. K., Loewenthal, H.,

Caliendo, A. M., Fanigan, T. P. (2007). A Randomized clinical trial of community-based

directly observed therapy as an adherence intervention for HAART among substance

users. AIDS. 21.11, p1473-1477.

Raymond, D. (2005). HIV Care and Treatment as Harm Reduction. The Body. Retrieved from


http://www.thebody.com/content/art14382.html?ts=pf

Williams, J. K., Wyatt, G. E., Wingood, G. (2010). The Four Cs of HIV Prevention with African

Americans: Crisis, Condoms, Culture, and Community. CUR HIV/AIDS Rep, 7:185-193

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