Transcript Behavioral Interventions Sexual Transmission

Men who have sex with men:
Changing Behavior
HIV prevalence in selected high risk groups:
Mexico-U.S. Border States
16
15.5%
14.5%
14
12
10
8
5%
6
3%
4
1%
2
0
MSM
Male CSW
Female CSW
IDU
Pregnant women
Sources: CENSIDA, Viani et al, in press; Patterson et al, in press; Strathdee et al, in prep
HIV Prevalence, Risk Behaviors, and Access to Care Among
MSM in San Diego, California and Tijuana, Mexico
Juan D. Ruiz, M.D., Dr.P.H. Office of AIDS California Department of
Health Services 2002
• Latino MSM aged 18 to 29 in Tijuana, Mexico
and San Diego, CA (about 250 from each site)
– Tijuana sample: Mainly from public park reputed for
prostitution (N=249)
– San Diego sample: Mainly from gay bars/dance clubs
(N=125)
• Data
– Standardized questionnaire (English or Spanish) on
HIV risk behavior, attitudes, and access to care
– blood sample for HIV antibody testing
MSM HIV Testing and Access to
Prevention and Care (Ruiz, 2002)
• Report ever receiving HIV prevention information
– Tijuana: 141/249 = 56.6%
– San Diego: 96/125 = 76.8%
• Report ever testing for HIV antibodies:
– Tijuana: 115/249 = 46.2%
– San Diego: 78/125 = 62.4%
• HIV seroprevalence:
– Tijuana: 47/249 = 18.9%
– San Diego:
44/125 = 35.2%
Of those who tested positive and reported a previous positive
test, over 70% reported ever using AIDS drug therapy
MSM Sexual Behavior with Females
(UVI = unprotected vaginal intercourse; UAI =
unprotected anal intercourse) (Ruiz. 2002)
• Over 10 sex partners
in life
• UVI, lifetime
• UVI, last 4 months
• UAI, lifetime
• UAI, last 4 months
• Exchange partner,
lifetime
• Sex partner from
across the border,
lifetime
35.3%
6.4%
77.5%
36.8%
43.4%
8.0%
43.0%
13.6%
18.1%
3.2%
32.9%
5.6%
39.4%
27.2%
MSM Sexual Behavior with Males
(UAI = unprotected anal intercourse) (Ruiz, 2002)
• Over 10 sex partners in
life
• Insertive UAI, lifetime
• Ins. UAI, last 4 months
• Receptive UAI, lifetime
• Rec. UAI, last 4 months
• Exchange partner,
lifetime
• Sex partner from across
the border, lifetime
Tijuana
San Diego
26.9
60.0
70.7%
76.0%
27.3%
49.6%
28.1%
76.0%
12.0%
40.8%
32.9%
22.4%
45.4%
75.2%
MSM Drug Using Behaviors
(Ruiz, 2002)
• Injected drugs
– Lifetime
– Last 4-months
• Shared needles/works
– Life time
– Last 4-months
Tijuana
San Diego
41.4%
7.2%
25.3%
3.2%
37.3%
4.8%
24.1%
3.2%
• Used drug during sex in
38.2%
the last 4 months
–
–
–
–
Alcohol
Marijuana
Methamphetamine
Ecstasy
31.2%
27.3% [
8.8%
16.9%
4.0%
4.8%
1.6%
Conclusions Ruiz 2002 Study
• Risk behaviors of Latino MSM differed between sites
• Tijuana MSM were more likely to report engaging in
risky sexual behavior with females and risky drug using
behaviors
• San Diego MSM were more likely to report engaging in
risky sexual behaviors with males
• MSM at both sites engage in risky sexual behaviors with
both men and women from the opposite side of the U.S.Mexico border
• Difficult to generalize results because of sampling
scheme
HIV Prevalence,
Unrecognized
Infection, and
HIV Testing
Among Men
Who Have Sex
with Men --- Five
U.S. Cities, June
2004--April
2005 Vol 54, No
MM24;59
Issues MSM
•
•
•
•
•
•
Hidden population
Stigma
Bisexual
Discrimination
Internalized homophobia
Married and fear of identification
What changes should we promote
among MSM
• Refrain from unprotected anal intercourse,
and ideally, from other practices that
involve sexual fluid exchange
• Consistent use of condoms during
intercourse
• Adoption of sexual practices that do not
permit entry of sexual fluids
Identifying Clients at Greatest
Risk
• Homosexually active men who continue to
have high-risk sex are at imminent risk for
contracting or transmitting HIV infection
Theories and Models of
Behavior Change
•
•
•
•
•
•
•
•
Health Belief Model
Cognitive/Information Processing
Theory of Reasoned Action
Social Cognitive (Learning) Theory
Social Support Theories
Behavior Modification
Parallel Self-Management Model
Transtheoretical or “Stages of Change” Model
Theories and
intervention
approaches to
healthbehavior
change in
primary care
Elder, JP, Ayala
G, Harris S.
American Journal
of Preventive
Medicine
Volume 17, Issue 4
, November 1999,
Pages 275-284
Elements Critical to HIV Risk
Behavior Change
• Risk Education
• Threat personalization
• Practical understanding of
factors responsible for risk
and behavior changes
needed to reduce risk
• Accurate appraisal of
personal level of risk based
upon one’s own behavior
Elements Critical to HIV Risk
Behavior Change Continued
• Perceived efficacy of
change
• Belief that one is
personally capable of
implementing risk
reduction behavior
changes and that these
changes if made, will
have protective value
Elements Critical to HIV Risk
Behavior Change Continued
• Intention to act
• Risk reduction behavioral
skills acquisition
• Commitment to initiate personal
action to reduce risk
• Acquisition and ability to
skillfully perform behavioral
skills needed to effect risk
reduction (including condom
use, safer sex guidance,
assertiveness skills to refuse
coercions, self-management
skills needed to implement
cognitive and environmental
changes to reduce risk
vulnerability
Elements Critical to HIV Risk
Behavior Change Continued
• Cognitive problemsolving skills for change
implementation and
maintenance
• Reinforcement of
behavior change efforts
• Planning strategies for
implementation of
action if obstacles are
encountered or lapses
occur
• Self-reinforcement
and social supports
needed to sustain
behavior changes over
time
Counselor Characteristics and
Attitudes
•
•
•
•
•
Positive regard for clients
Comfort discussing sex and drug use
Ability to form an advocacy alliance
Strong reinforcement skills
Listening skills
Types of interventions
• Media campaigns (general vs. targeted)
• Advantage:
– Reach large numbers of individuals
• to dispel myths about how HIV is transmitted
• to fight stigma and discrimination towards at-risk
populations subjected to stigma and/or PLWHAs
• Disadvantage:
– Need to develop new messages to avoid message
burnout
Examples of Media Campaigns
• Côte d’Ivoire, television soap operas on AIDS
promoting condom use (Shapiro et al., 2003)
– most appealing to viewers who engaged in risky behaviour
• Unintended consequences: Promotion of the female
condom in San Francisco led to its uptake among
men having sex with men, despite that efficacy of the
product had not been established for anal sex (Gibson
et al., 1999).
• Integrated campaigns such as those implemented in
Switzerland (Kocher, 1996) have been the exception
rather than the rule
Individual News Items can
have a big impact on risk
behavior
Media Campaign for MSM
in San Francisco
Media Campaign for
MSM in San Francisco
Media Campaign for MSM in San Francisco
Internet
• Powerful media tool for disseminating HIV/AIDS
education and prevention messages
• Advantages
– Low cost
– Access hard to reach populations
– Avoid stigma
• Disadvantages
– Not specific to positives
– Anonymous
– Technology not available to all
Individual-level interventions
• Advantages
– Target problems unique to individual
– Ideally, interventions are based on behavioral theories that guide
their development, implementation and evaluation.
• Disadvantages
– Often require highly skilled interventionists
– Delivery and standardization are complex, hence interventions tend
to be expensive.
– Utility and sustainability in resource-poor settings may be limited.
Group-based interventions
• Advantages
– Ability to intervene with more than one person
at a time
– Participants can problem-solve and role-play
with others
• Disadvantages
– Costs not always lower compared to
interventions involving individual
• Due to costs to screen/locate eligible participants to
form groups
Examples
• MSM small groups, mix of positive and negatives,
produced significant improvements (Johnson et al.,
2002)
• Social Cognitive Theory based intervention to reduce
sexual risks among HIV-infected individuals
(Kalichman et al. 2001).
– Groups: five-session group-based, safer sex intervention
condition vs. social support group condition,
– Participants in the risk reduction intervention condition had
significantly lower rates of unprotected sex, fewer total sex
acts, fewer HIV-uninfected partners and a larger percentage
of sex acts involving condom use at six-month follow-up,
compared to the control condition.
Community-level interventions
• Advantages
– Reach large numbers of vulnerable individuals
– Potential to change the behaviour of whole groups
by providing education, increasing motivation and
creating new social norms.
• Disadvantages
– Requires detailed knowledge of community
– Messages become stale unless changed
Example
• Community Popular Opinion Leader Model
(C-POL) (Kelly et al. 1992; 1997)
– Developed and tested an intervention for MSM
based on the ideas of Rogers (1985), which
suggested that behavioural innovations often
originate among a subgroup of individuals who
are the community’s popular opinion leaders.
• Currently being tested in many countries
Intervention Settings
• Integration of HIV prevention counseling in
Social and Health Care Settings
– STD clinics (HIV-negative MSM)
– HIV treatment Clinics (HIV+ MSM)
• Community Outreach Settings
– Bars, Bath houses
Why Focus on HIV-Positives?
• New infections are acquired via direct or indirect contact
with HIV+ persons
• The U.S. Centers for Disease Control have named this a
priority
• HIV+ individuals are living longer with access to ARVs in
many countries
• Some HIV+ persons continue to have unprotected sex,
share drug paraphernalia, etc.
• There are fewer HIV+ than HIV-negatives, therefore
prevention resources can be better targeted
Interventions among HIV+ populations to
reduce HIV transmission
• Biomedical:
– Increase access and adherence to ARVs to reduce
morbidity/mortality and potentially decrease HIV transmission
– Treat ulcerative STDs (e.g., syphilis, chancroid, HSV-2)
– Integrating therapyfor HIV and drug abuse treatment (e.g. using
sublingual methadone)
– Therapeutic HIV vaccines: (under development)
Interventions among HIV+ MSM
reduce transmission
• MSM Sex workers
– Client- and location-oriented (e,g. truck stops)
– Economic based – microcredit interventions
(e.g. Zambia, Calcutta)
– Structural interventions (e.g., 100% condom campaigns)
• MSM Injection drug users
– Drug abuse treatment programs
– Needle exchange programs (NEPs)
– Outreach and network-oriented interventions
AIDS
Community
Demonstration
Project
Mpowerment
Project
Behavioral
Selfassertiveness
Skills
Popular Opinion
Leader
Intervention for
MSM
AIDS Prevention Program
(Valdiserri, et al., AIDS 3, 21-26,
1989)
Drugs and Sex
• Methamphetamine
• Alcohol
• Polydrug use
Meth users at greater risk
Non-injection heterosexual meth users:
• Have significantly more sex partners
• Engage in more anal sex
• Are less likely to use condoms
• Are twice as likely to have sex with a prostitute or
in exchange for drugs
• Are four times more likely to have sex with an
intravenous drug user (IDU)
Study Questions
• Can active methamphetamine users benefit
from a safer sex intervention?
• Does the addition of maintenance sessions
result in better retention of behavioral
improvements?
• Does amount of meth used effect ability to
improve behavior?
• Do females differ from males in their ability
to improve?
Baseline Assessment
FASTLANE
Four 90-minute one-onone counseling sessions.
Maintenance
Four 90-minute one-onone counseling sessions.
Diet and Exercise
Four 90-minute one-onone counseling sessions
Month 6 Assessment
Four Monthly
sessions to problem
solve and reinforce
learning
Month 12 Assessment
Month 18 Assessment
Four Monthly 90minute diet and
exercise sessions
FASTLANE Counseling Modules*
Module Topic
Description
1
Context of
Unsafe Sex
Develop insights into motivations/triggers of
unsafe sex and meth use. Set plan and goals for
safer sex.
2
Condom Use
MI and skill-building to induce behavior
change. Match counseling to individual’s stage
of change.
3
Negotiation of
Safer Sex
MI to explore current negotiation behavior.
Skill-building exercises to move participants
into action.
4
Social Support
Enhance positive social supports; minimize
negative influences in relation to safer sex
goals.
*incorporating motivational interviewing (MI) and social cognitive theory
Sample Selection
Inclusion Criteria:
• HIV-negative
• Heterosexual men and women
• > 18 years old
• Had unprotected vaginal, anal, or oral sex with at
least one opposite sex partner in the past two
months.
• Used meth at least twice in the past two months.
Change in Self-Efficacy for Negotiation
of Safer Sex
Self-Efficacy for Negotiation
Control
Maintenance
No Maintenance
24
23
No Maintenance, Maintenance>Control p<0.01
22
21
20
19
18
0
6
12
Time (Months)
18
Change in Intentions to Practice Safer
Sex
31
30
29
Control
Maintenance
No Maintenance
28
27
26
25
No Maintenance, Maintenance>Control p<0.01
24
0
6
12
18
Change In Protected Sex
Control
Total Protected Sex
25
Maintenance
No Maintenance
No Maintenance, Maintenance>Control p<0.01
20
15
10
5
0
0
6
12
Time (Months)
18
Conclusions
• Heterosexual active methamphetamine
users can reduce high risk sexual behavior
• Those who used more meth improved less
• Males and females did not differ in amount
of improvement