HIV/AIDS Prevention
Danuta Kasprzyk
Daniel Montaño
Update on Sexually
Transmitted Infections (STIs)
September 29, 2009
Some Definitions…
• Efficacy
– How well an intervention works under ideal
circumstances
• Effectiveness
– How well an intervention works in the real
world
• Impact = Effectiveness x Reach
Prevention
• Prevention works
• New paradigms, old practices?
• Combination Prevention
– The overall combination of prevention
practices in a synchronized system of
prevention programs
• Programs that target multiple levels, groups, and
individuals with multiple types of approaches
– The combination of behavioural and
biomedical approaches
Behavioral Interventions in Relation to
Coverage and Intensity
(Adapted from Mertens et al. WHO)
Low
Intensity
Mass media campaigns
Risk reduction info
Radio Dramas
Social marketing
Condom supplies
Clinical services
Workshops
Small media
School-based programs
Community attachment
Peer communication
Community development
Support groups
Group
counseling
High
Intensity
Policy
Structural intervention
Face to face counseling
Low Coverage
High Coverage
Prevention
•
•
•
•
•
•
Prevention works
New paradigms, old practices?
Combination Prevention
Behavioral counselling works
Works when combined with STD treatment
Examples of such approaches and
programs
– Manzwa
– Makasa
– Project RESPECT
JAMA 1998; 280:1161-67
HIV Prevention: STD treatment
and prevention counseling
• Sexually transmitted disease treatment
– Project RESPECT (RCT)
• 3 arm intervention
• Conducted in STD clinics with STD patients
• Arms 1-2: Interactive counseling based on
behavioral models focusing on constructs (i.e.
attitude, norm, self-efficacy) related to behavior
change
– Short one session counseling (Arm 2)
– Three session counseling (Arm 3)
• Arm 3: usual care, and usual discussion
HIV Prevention: Behavioral Intervention
• Behavior change works
– Behavioral counseling in STD or primary care
clinics works
– Community and individual interventions work to
change individuals and groups
• To encourage consistent condom use
• To encourage monogamy
• To encourage abstinence or delay of sexual
onset
• To encourage testing for STDs and HIV
BEFORE having sex, then committing to
monogamy
HIV Prevention: Behavioral Intervention
• Increasing knowledge is not enough
• Behavioral change works
– Motivating behavioral change works among
targeted groups such as adolescents, drug
users, gay and bisexual men, and
heterosexuals
– Health and sex education in schools
• Early
• Explicit
• Engaging and interactive, NOT preachy
• Abstinence only education does not work
Percentage of behavior change among women and men
who have heard of AIDS and have ever had sex
90
No change in sexual
behaviour
80
Stopped sex
70
60
Began using a
condom
50
Restricted to one
partner
40
Fewer partners
30
Other
20
10
0
Never
married
men
Currently
married
men
Formerly
married
men
Never
married
women
Currently
married
women
Formerly
married
women
Data source: Zimbabwe Demographic and Health Survey 1994
VCT review: Principal findings
• Voluntary Counselling and Testing is another form
of prevention intervention
• Does it work?
• A review done by WHO shows that it is not
consistent
• Though clear impact on specific risk behaviours
for individuals and couples in some studies
• Impact generally stronger for those who test
positive but not exclusively
• Impact generally stronger for those who test and
receive counselling as a couple
Source: K. O’Reilly, WHO
VCT review: Principal findings
• Few studies looked for primary biological
outcomes;
• Even fewer found an effect for one
• Strongest of these studies had high rates of
previous testing, perhaps muting the effect
• Quality and rigor of most studies examined
was weak
• Negative consequences were rare in general,
though a little higher for those couple
counselled (though still rare)
• No studies reported increase in risk
behaviours, even for negatives
Source: K. O’Reilly, WHO
Prevention with positives in VCT
• Voluntary counseling and testing
– The largest behavior change occurs among
individuals who have just found out they are HIV +
– Maintenance of safe sex behavior difficult
• 1/3 individuals have unprotected sex after they find out
their status
– VCT less effective for individuals who find they are
HIV negative
• May be due to multiple factors (e.g., partner choice)
• Weak studies
• More research needed
What do we know about discordance?
• Behaviour change is greater in serodiscordant
couples
• In SSA, transmission within serodiscordant couples
is large component of continuing transmission
– In Kenya, estimated at 40%
– Zambia: 50-90% of infections occur in stable relationships
• With appropriate counselling and testing, this may
be reduced
• Problem is that only about 10% of individuals
coming in for VCT come in with partner
• Follow-up services for all those found to have HIV
are crucial
– Including prevention: counselling, disclosure, partner
notification; family planning and PMTCT; psychosocial
support and behavioral counselling
Prevention with positives
• 30-50% of married HIV + people from various
studies in Uganda have HIV - spouses
• Understanding of HIV Discordance is low
– Only 12% of HIV-infected people initiating ART
knew that discordance could exist (TASO)
– Clients did not understand need for partner
testing with low uptake of partner VCT at facilities
(3-12%)
• During first six months on ART:
– Increase of sexual desire among clients, but also
increase in safer sexual practices
Source: A. Coutinho, TASO, Uganda
Prevention with positives
• Routine HIV Testing in all medical settings
• Opt-out testing
– Routine testing:
• Ambulatory and primary care clinics, ERs, hospitals
– Recommendation:
• How often does it occur
• Couples testing as requirement before
marriage
– This is not a requirement anywhere in the world
– Why?
Behavioral Theory Works
• Meta-analysis of 96 data sets on 2 leading
theories
– Theory of reasoned action
– Theory of planned behavior
• Tested associations between models’ key
variables
– Condom use associated with intentions
– Intentions associated with
• Attitude, Normative influence, Self-efficacy, Perceived control
– Attitude associated with specific behavioural
beliefs
– Norm associated with specific normative beliefs
Behavioral Theory Works
• Meta-analysis by Albarracin of 354 HIV-prevention
interventions
• Effective interventions include:
– Educational information
– Attitudinal arguments
– Behavioral skills arguments
– Behavioral skills training
• Least effective interventions:
– Attempt to induce fear
• Active (person-to-person contact) interventions
more effective than passive (materials distributed)
Behavioral Theory Works
• Meta-analysis by Albarracin of condom use
interventions
• More successful achieving immediate
knowledge and motivation change than behavior
change
• Immediate motivation change decays, while
behavior change increases over time
• More effective if engage audience with activity
(e.g. role-playing)
• Expert intervention facilitators more effective
than lay facilitators
Diffusion of Innovation Theory
(Rogers, 1985)
• New trends (innovations) are introduced
by a small segment of opinion leaders in
the population
• Once they are visibly endorsed and
modeled by opinion leaders, new trends
(innovations) diffuse through the
population, influencing others
CPOL Behavioral Intervention
• Developed and tested in US in among gay
men in gay bars – where HIV prevalence
was highest at that time
• Uses Community Popular Opinion Leaders
– Deliver persuasive messages to peers to encourage behavior
change
– Opinions and behavior diffuse through community to become
norm
• Rationale for using CPOL intervention:
– Evolves from within community
– Reaches large numbers
– Few resources
Behavioral Interventions in Relation to
Coverage and Intensity
(Adapted from Mertens et al. WHO)
Low
Intensity
CPOL intervention
High
Intensity
Low Coverage
High Coverage
Participants who ‘ever had sex’
N = 4,263
Males
(52%)
Age at first
sex
18.3
Females
(48%)
18.0
Age of first
partner
16.8
22.8
Median lifetime
partners
3
2
Ever had
transactional sex
11%
5%
Know how to use
condom
87%
58%
Overall: 16% had concurrent partners in past 12 months
How did we do it?
• Identified popular opinion leaders in each
growth point (CPOLs)
• Recruited about 683 CPOLs to participate
in the intervention (15% of target
population)
• Trained CPOLs as risk reduction behavior
change experts to lower risk behavior in
each growth point
– 4 weekly sessions
– Booster/reunion sessions every 3 months
thereafter
CPOL Training
• Session 1: Information
–
–
–
–
Motivation of CPOLs
Epidemiology of STD/HIV
Risk reduction steps
Building skills with condoms
• Session 2: Health promotion
– Characteristics of effective health promotion messages
• Sensitizing others to threat
• Identifying specific changes needed to lower risk
• Suggesting strategies for implementing changes
using self as example
• Personally endorsing the value and benefits of
change
CPOL Training
• Session 3: Effective conversations
–
–
–
–
Trainers model conversation examples
CPOLs role play initiating conversations
Feedback, rehearsal
Homework: CPOLs identify four individuals for practice
conversations in the next week
• Session 4: Review of conversation practice
– Review outcomes of conversational attempts
• Discuss successes
• Problem solve difficulties (person, place, content, timing)
– Behavioral contract for ten more conversations
– Motivate CPOLs – emphasize their important role
CPOLs in action
How did we do it?
• Created environmental cues that help
CPOLs initiate conversations about risk
reduction
• Repeated the baseline survey 12 and 24
months after CPOL cohorts were trained
in each growth point to assess changes
produced by the CPOLs
• Conducted parallel Process Evaluation for
additional community monitoring
Results: STI Incidence
Results: Unprotected sex
CPOL Trial Conclusions
• Control arm participants received STD
testing, HIV and STD prevention counseling,
and treatment for treatable STDs
• Intervention arm participants received all
that, as well as the CPOL intervention
• Both arms of the Trial showed a 50%
reduction in the risk outcomes selected
• The CPOL intervention did not have an
additional behavioral effect for the two study
outcomes chosen
CPOL Intervention
Is considered community
level intervention
In practice CPOL
Intervention:
- Consists of multiple
individual conversations
- Community change is
composite of individuals
influencing friends
What happens in
this process?
CPOL Model
Identify and Train
Opinion Leaders
CPOL Conversations
Change in Perception
Of
Normative Behavior
Behavior Change In
Community
Integrated Behavioral Model, Montaño & Kasprzyk, 2008
IBM Goals
• Design survey to measure IBM mediators
• Conduct qualitative elicitation interviews to identify
underlying issues/beliefs for each IBM mediator
regarding:
– Condom use with different partners, transactional sex,
monogamy, talking to partners about sex, sex in context
of alcohol use
• Develop culturally appropriate IBM mediator
measures
• Assess how well IBM explains behavioral
intentions
• Identify specific mediators and their component
beliefs for targeted intervention messages
Zichire
ethnographers
on site at village
borehole
Typical rural homestead
Rural household activities
Final IBM Survey
• Content analysis yielded lists of items
– For each mediator, for each behavior
• Measured mediators for each behavior
–
–
–
–
–
–
–
–
5 point scales
Behavioral intention/motivation
Direct attitude: 3 semantic differential items
Indirect attitude: 9-14 behavioral beliefs
Subjective norm: 4-6 normative beliefs
Perceived Control direct: 1 semantic differential item
Self-efficacy direct: 1 item
Self-efficacy indirect: 6-11 self-efficacy beliefs
• Condom Stereotypes Scale
– Myths – 6 beliefs
– Morals – 5 beliefs
Integrated Behavioral Model Testing
• To determine which mediators are most
highly associated with Behavioral Intention
• Simple correlations between Behavioral
Intention and Mediators
• Those most strongly correlated should be
the focus of interventions
• Strongly correlated mediators should be
further explored for design of specific
persuasive messages
Condom Use
with
Spouse:
Males
Experiential
Attitude
Attitude
Instrumental Attitude = .38
Injunctive Norm, others = .36
Injunctive Norm, partner = .45
Perceived Norm
Descriptive Norm
Perceived Control = .39
Personal Agency
Self-Efficacy = .52
Intention to
Perform the
Behavior
Condom Use
with
Steady
Partner:
Males
Experiential
Attitude
Attitude
Instrumental Attitude = .44
Injunctive Norm, others = .30
Injunctive Norm, partner = .56
Perceived Norm
Descriptive Norm
Perceived Control = .41
Personal Agency
Self-Efficacy = .61
Intention to
Perform the
Behavior
Condom Use
with
Casual
Partner:
Males
Experiential
Attitude
Attitude
Instrumental Attitude = .38
Injunctive Norm, others = .33
Injunctive Norm, partner = .44
Perceived Norm
Descriptive Norm
Perceived Control = .41
Personal Agency
Self-Efficacy = .57
Intention to
Perform the
Behavior
Condom Use
with
Commercial
Sex
Worker
Partner:
Males
Experiential
Attitude
Attitude
Instrumental Attitude = .18
Injunctive Norm, others = .31
Injunctive Norm, partner = . 15
Perceived Norm
Descriptive Norm
Perceived Control = .23
Personal Agency
Self-Efficacy = .43
Intention to
Perform the
Behavior
Condom Use
with
Spouse:
Females
Experiential
Attitude
Attitude
Instrumental Attitude = .37
Injunctive Norm, others = .34
Injunctive Norm, partner = .46
Perceived Norm
Descriptive Norm
Perceived Control = .36
Personal Agency
Self-Efficacy = .54
Intention to
Perform the
Behavior
Condom Use
with
Steady
Partner:
Females
Experiential
Attitude
Attitude
Instrumental Attitude = .49
Injunctive Norm, others = .32
Injunctive Norm, partner = .56
Perceived Norm
Descriptive Norm
Perceived Control = .44
Personal Agency
Self-Efficacy = .70
Intention to
Perform the
Behavior
Intervention Targets: Summary
Protective Behavior
Condom use Spousal
Partner
Condom use Steady
Partner
Condom use Casual
Partner
Condom use CS
Partner
Attitude
M
F
Norm
M
F
PBC
M
F
 
SE
M F
 
       




Implications for Interventions
• Many interventions implicitly target IBM
mediators
– Mediators’ relationship to behavior seldom
systematically identified
– Mediators rarely explicitly targeted
• Examine mediators that are significantly
related
• Breakdown to behavioral, normative,
perceived control, self-efficacy beliefs
• How do you translate this to messages?
Participants who ‘ever had sex’
N = 4,148
Males
(51.4%)
Age at first sex
18.3
16.8
3
Females
(48.6%)
18.0
22.8
2
Ever had
transactional sex
11%
5%
Know how to use
condom
87%
58%
Age of first partner
Median lifetime
partners
16% had concurrent partners in the past year
Participants who ‘ever had sex’
• Overall: 25% drank in the past 30 days
– 11% get drunk 5 or more times a month
• Overall: 16% had concurrent partners in past 12
months
– 25% men; 7% women
• Individuals with concurrent relationships were:
– Younger at first sex (17 vs. 18)
– Had more total number of partners on average
– Drank for a greater number of days per month;
7 days compared to 2 days
– More likely to get drunk; 42% compared to 13%
Participants with concurrent relationships:
• Were significantly more likely to have
trichomoniasis gonorrhea, syphilis, and HIV
• Had higher HIV prevalence 30% compared to 24%
in those who did not have concurrent partners
• Not more likely to have HSV2, chlamydia
• Overall, condom use rates with main or steady
partners are low (only 5-8% used consistently)
• Overall, condom use motivations with main or
steady partners are also low
• But, individuals with concurrent partners are
significantly more likely to say if they don’t use
condoms with main partners that they are at risk for
STD and HIV acquisition
Sub-sample Analysis
All sexually active men
IBM Comparisons for attitudinal, normative,
personal agency beliefs
Comparisons made between:
- those with concurrent partners
- to those without concurrent partners
Participant Characteristics
•
•
•
•
•
•
2169 men total
540 men had concurrent partnerships
Mean age: 22.76 years
Had the same number of years of schooling
Significantly younger at first sex (17 vs. 18)
Significantly higher median number of
partners:
– Lifetime: 7 partners (vs. 3)
Individual Indicator Analysis
• Identify key beliefs underlying each IBM
construct
– Behavioral beliefs underlying attitude
– Normative beliefs underlying perceived norm
– Self-efficacy beliefs underlying self-efficacy
• Analytic procedure
– Separate analysis for each construct with each
behavior (especially monogamy)
– Correlations of beliefs with monogamy behavior
– Comparisons of mediators between men
Monogamy Behavioral Expectations/Intentions
Monogamy
Expectations
% strongly agree
Non
r
Concurrent
Concurrent
Motivation to stick to one partner
95%
76%
Expectation main partner is monogamous
65%*
66%*
Spouse expects monogamy
98%*
96%*
Your self standard re: monogamy w spouse
98%
85%
Your spouse has other partners besides you
23%
13%
Steady partner (SP) expects monogamy
96%
90%
Your self standard re: monogamy w SP
96%
79%
Your SP has other partners besides you
18%
22%
* Non Significant
Behavioral Beliefs with Monogamy Behavior
Monogamy
Behavioral Beliefs
% strongly agree
Non
concurrent
Concurrent
13%
22%
Not be sexually satisfied
3%
9%
Does not fit into our culture
6%
10%
Difficult because you have high sex drive
3%
10%
Difficult since traditional for multiple partners
9%
14%
Makes men less manly
6%
10%
You will not get HIV
61%*
63%*
Something you cannot commit to
9%
22%
Would get sick
4%
7%
Would lose prestige or standing in community
4%
7%
Not get variety in sex partners you need
* Non Significant
Normative Beliefs with Monogamy Behavior
Monogamy
% strongly agree
Non
concurrent
Concurrent
Your family
96%
92%
Your closest friends
95%
88%
Your church
97%
86%
Your culture
97%
94%
Radio shows or dramas
96%*
94%*
Spouse
98%*
96%*
Normative Influence Beliefs
* Non Significant
Self-Efficacy with Monogamy Behavior
Monogamy
Self-Efficacy Beliefs
% strongly agree
Non
concurrency
Concurrency
Talking about it with partner
90%
76%
Trust partner is also monogamous
88%
77%
You and partner being apart a lot
80%
63%
Partner did not want sex as often as you
82%
61%
You spot a beautiful girl
81%
66%
CSWs entice you
86%
79%
Wife or steady partner being pregnant
85%
74%
Implications for Interventions
• These types of analyses allow one to
identify specific beliefs/mediators most
highly associated with motivations or
behaviors
• Intervention messages can be designed to
focus on these beliefs using communication
media most appropriate to the target
audience
• In addition, other mediators that differentiate
those with concurrency versus none, can
also be targets of interventions (alcohol
use)
Summary: Intervention Targets
• Attitudinal beliefs that differentiate men who
do not have concurrent partnerships, from
those who do:
– Are important to target in intervention messages
– May be most important to target first
• Interventions should include additional
beliefs differentiating these men such as,
– Normative beliefs
– Convince men their spouse, families, friends, churches
all support behavioral strategies to avoid concurrency
– Self-efficacy beliefs can also be targeted
Implications for Interventions
• Broader applications using communication
techniques can be used to change beliefs most
highly associated with motivations or behaviors
• Intervention messages using mass media, small
print media, the internet, interpersonal,
provider/patient, etc. (any communication
medium) can be designed to focus on these
beliefs
• Beliefs more universally held lend themselves to
mass media approaches
• Beliefs held by specific audience segments should
lead to tailored intervention messages probably
implemented using a more personal
communications strategy, i.e. counselors,
providers, among others
ACKNOWLEDGEMENTS
Funded by: NIAAA, NIMH
Battelle Team:
Lisa Cubbins, PhD (PI – NIAAA grant: Alcohol Study)
April Greek, PhD
ZiCHIRe Team:
Mufuta Tshimanga, MD, MPH, director Zichire
Godfrey Woelk, PhD (Co-PI POL intervention)
Philani Moyo and Ethnography Team
Reggie Mutsindiri and Nurses Team
Patrick Mateta and Lab Team
Walter Chikanya and Intervention Team
Pesenai Chatikobo and Process Evaluation Team
Rachel Gatsi and Transcription Team
Gay Hendrikse and Admin Staff
Gift Mutepfe and Driving Team
All CPOL/Alcohol Study Participants