Challenging Dogma - Fall 2007

...Using the social and behavioral sciences to improve the practice of public health.

Friday, December 14, 2007

REP Adult Secondary HIV Prevention Interventions: Their Failure to Address Sexual Risk Taking Among HIV- Infected Population- Jessica Ripton

Approximately 33% of HIV-infected individuals from diverse populations across the U.S. continue to engage in unprotected sexual intercourse (1). Nationally, unprotected sexual intercourse with an infected partner continues to be the leading transmission category among men who have sex with men (MSM) at 67% and unprotected heterosexual contact accounts for 80% of all infections among women (2). In response to continued sexual risk taking, HIV prevention strategies have expanded to include secondary prevention interventions, which are prevention interventions aimed at reducing transmission risk behavior among HIV positive individuals. Researchers, local health providers and government agencies recognize the need to quickly implement interventions that have shown effectiveness in reducing transmission risk behavior in randomized controlled trials. Such interventions are commonly referred to as evidence-based. The goal of the Center for Disease Control (CDC) Replicating Effective Programs (REP) is to package evidence-based behavioral interventions in an accessible language and format to be used to guide prevention providers in replicating effective risk-reduction programs in their own settings and communities (3). Three of the thirteen evidence-based behavioral interventions currently included in the CDC’s REP focus on reducing sexual risk behavior among HIV-infected populations. Two of the interventions focus on adult populations, while the third focuses on HIV-infected youth. This paper will concentrate on the REP behavioral intervention designed for HIV-infected adults, as the issues specific to HIV-infected youth merit a separate investigation.

The secondary prevention behavioral interventions included in REP for adults have contributed significantly to the field of HIV prevention; however, several limitations will impact the effective replication of these interventions in HIV-positive communities throughout the nation. Both interventions focus on either providing individuals with information on how to reduce sexual risk taking or building skills and strategies to reduce sexual risk taking. Yet neither intervention attempts to uncover the complex reasons why the sexual risk taking continues. This paper will address the following fundamental limitations of the REP secondary prevention interventions: 1) Social Cognitive Theory’s emphasis on skill and education-based behavior change doesn’t address the root cause(s) of continued sexual risk; 2) the interventions fail to assess how multiple psychosocial issues such as limited access to care, lack of stable housing and lack of social support impact sexual risk taking and; 3) despite strong evidence that HIV infected population experience high level of psychological distress, neither intervention addresses underlying mental health issues which may have initially put these individuals at greater risk of HIV infection and will likely continue to impact their sexual risk behavior.

REP & Evidence-Based Secondary Prevention Interventions

The CDC’s Division of HIV/AIDS Prevention (DHAP) has been working to make research–based HIV/AIDS prevention interventions available to communities since 1996 through technical assistance programs such as REP (4). Briefly, REP works in partnership with two other technology transfer projects in DHAP: Prevention Research Synthesis (PRS) and Diffusion of Effective Behavioral Interventions (DEBI). The programs work to identify evidence based interventions and prepare packages of materials for dissemination to HIV prevention agencies and providers (4). As noted previously, two of the thirteen REP programs focus on HIV-infected adults: Healthy Relationships and Partnership for Health. The following section will briefly describe the initial intervention studies where efficacy was determined.

Healthy Relationships is a behavioral intervention grounded in Social Cognitive Theory designed to assist people living with HIV to reduce HIV- transmission risk behavior through group sessions emphasizing the importance of building behavioral skills, enhancing self-efficacy for practicing risk reduction behaviors, promoting intentions to change risk behaviors, and developing strategies for behavior change. This study involved a randomized clinical trial design with a study population that included 230 HIV-positive men and 98 HIV-positive women from diverse backgrounds recruited from AIDS services and Infection Disease Clinics in Atlanta, Georgia. The study found significantly less unprotected intercourse and greater condom use at 6 month follow-up for the intervention arm (5).

In contrast, Partnership for Health is a behavioral intervention based on a social cognitive model that used brief provider-delivered counseling using either a gain-framed message (emphasizing the positive consequences) or a loss-framed message (emphasizing the negative consequences) on issues to reduce sexual risk taking among females and males at six large HIV clinics in California (6). The randomized controlled evaluation study found that at follow-up (up to 7 months after the intervention) the patients who reported two or more partners at baseline unprotected anal and vaginal intercourse (UAV) was reduced by 38% for those patients who received the loss-framed message counseling, but no significant changes were seen in those who received the gain-framed messages (6).

Limitations of Social Cognitive Theory
Both interventions are based on Social Cognitive Theory (SCT). SCT is rooted in an earlier theory of Albert Bandura’s called Social Learning Theory, which was based in behaviorism and was focused on how individuals learn through experience (7). SCT evolved when Bandura began to shift his focus to the concept of self efficacy and the role it plays in the process of behavior change. In addition to individual characteristics like self-efficacy, SCT also proposes that behavior change is a function of environmental factors and the interactive process between an individual’s behavior based on internal and external cues and the response the behavior elicits from society (7). While SCT clearly considers the individual’s interaction with environmental factors, it remains largely focused on the individual’s capacity to enact behavior change through self-efficacy. SCT, however, arguably does not expressly consider how self-efficacy can be limited by environmental factors, such as lack of affordable housing, access to care, ability to pay for medication, and other socioeconomic factors. Moreover, SCT seems to lend itself to interventions that are designed to provide individuals with information and skills or strategies to enact behavior change without addressing underlying issues that impact individual’s ability to negotiate sexual risk reduction. In their article on HIV prevention among Asian Pacific Islander (API) MSM, Choi et al. (8) argue that existing social cognitive theories have limited use in addressing the larger environmental factors affecting HIV risk because they are individual-focused models that ignore the individual’s wider social context. Choi et al. referenced how API MSM’s negative experience with cultural expectations, parent and family silence about sex, stigmatization and racism make it harder to practice safe sex (8). These issues could be considered “fundamental causes” of unsafe sexual behavior much in the way Link and Phelan (9) attributed social conditions as fundamental causes of major diseases. Link and Phelan argued that in order to understand risk factors we must contextualize the risk and examine how individuals come to be exposed to the risk (9). HIV prevention programs that fail to contextualize risk factors, assess the wider social environment, and identify the fundamental causes of sexual risk taking may be largely ineffective in the long term.

SCT in the context of both Healthy Relationships and Partnership for Health, leads to a reliance on individual based behavior change strategies. In Healthy Relationships, the intervention focused on increasing self-efficacy through targeted skill-building around issues of serostatus disclosure and negotiating sexual risk reductions. The intervention was administered in small groups and relied heavily on skill-based behavioral change (5). The brief provider messages used in the intervention for Partnership for Health were based on information regarding the health benefits of safer sex or health disadvantages of continued sexual risk taking. The brief provider messages were delivered at all visits except those that dealt with acute illness (6). Both interventions were successful at decreasing transmission risk behavior, but it can’t be determined if that decrease will be sustained. Information and skill-building interventions among HIV-infected populations undoubtedly impact behavior, but that impact is only as great as the individual’s ability to use the information or skill. An individual’s ability to use the information or the skill is not solely based on self-efficacy and secondary behavioral interventions need to do a better job identifying the fundamental causes of continued sexual risk taking.

Lack of Assessment of Multiple Psychosocial Issues
This paper uses the term psychosocial issues to broadly define a variety of psychological, social and economic issues impacting HIV-infected individuals such as mental health concern, socioeconomic concerns and lack of social support. In their article, Reif et al (10) state that HIV infected populations often experience multiple psychosocial needs and stressors, but often these needs are not met and HIV-infected individual are without the needed financial assistance, psychiatric care and social support (10). In multivariate logistic regression analyses, the author found that unmet needs in terms of benefits (Social Security, health insurance and prescription drug plan) and social support were associated with being less likely to be taking any HIV medication (10). The article suggests that those HIV infected individuals with unmet psychosocial needs may have worse health outcomes than those whose psychosocial needs are met. While there is no mention of a connection between unmet psychosocial needs and increased HIV transmission risk behavior, it may be that a similar relationship exists between numerous unmet psychosocial needs and increased transmission risk behavior. Using multivariate logistic regression models, Stall et al (11) found that a greater number of psychosocial health problems among MSM (polydrug use, depression, childhood sexual abuse (CSA), partner violence) were significantly and positively associated with high-risk sexual behavior and HIV infection indicating HIV prevention program need to address broader health concerns. The research of both Reif et al and Stall et al strongly suggest that reliance on traditional intervention models that focus solely on sexual risk may be unable to fully explain and address continued sexual risk taking in HIV-infected individuals.

There is little direct research on how psychosocial issues may impact transmission risk behavior among HIV-infected population; however, there is certainly evidence to suggest that such a connection is possible and merits investigation. Secondary prevention interventions like Healthy Relationships and Partnership for Health tend to be so focused on sexual risk taking that they de-emphasis other issues that are important to HIV-infected populations. Both interventions would benefit from taking a more holistic approach to sexual risk taking. A holistic approach would provide information and skill-building, as in Healthy Relationships and Partnership for Health, but would also include a thorough assessment of barriers to using the information or the skills.

Lack of Assessment of Underlying Mental Health Issues
Numerous studies have examined posttraumatic stress disorder (PTSD) and depression rates among HIV-infected populations and found them to be higher than rates among the general population and higher than individuals suffering from other chronic diseases (12; 13; 14). Within HIV infected sub-groups, MSM and minority women are at increased risk for PTSD (13), which may be attributable to both higher rates of stressful life events and childhood sexual abuse in these groups (14). Despite the strong evidence to support interventions aimed at assessing and treating mental health issues within HIV-infected populations, neither Health Relationships or Partnership for Health incorporated mental health assessment and referrals into the intervention. Given what is known about the prevalence of mental health disorders in HIV infected populations, this omission seems almost unbelievable. Prevention information and skill-building may have little impact on the sexual risk behavior of an HIV infected individual suffering from untreated anxiety disorder. It could be argued that the assessment of mental health status should be the first step in all secondary prevention programs. HIV-infected individuals with untreated mental health disorders may not be able to fully use the brief provider messages on risk reduction or the skill-building on risk reduction to enact sustained behavior change. An intervention that focuses solely on transmission risk behavior dismisses the important and complex role mental health disorders play in sexual risk taking and overall HIV disease progression.

Incorporating Mental Health Assessment in Interventions
In Healthy Relationships, the intervention would have benefited from having some individual counseling where the patient could discuss issues specific to their experience. Prior to the individual counseling session, patients could be asked to complete a brief mental health screening assessment. The counselor could use the results of the mental health screening assessment to inform the individual counseling sessions and when appropriate provide referrals for follow-up mental health services. Partnership for Health included brief provider message at all non-acute medical visits. However, it may have been more effective for providers to use some of the visits to address other issues that may impact the lives of their HIV-infected patients. Several of the brief interventions could have focused on assessing unmet mental health needs and developing a plan to access appropriate treatment services. By making small adjustments to overall interventions, both Healthy Relationships and Partnership for Health could address the mental health concerns of the patients, which may decrease their sexual risk taking and improve their overall health outcomes.

The critique of the REP behavioral interventions is not intended to be dismissive of their innovation or importance; rather, the intention is to illuminate areas that require further research. As the quest for a biomedical intervention (i.e. microbicides, vaccine, and post-exposure prophylaxis) suffers considerable set backs in clinical trials, the need for effective, targeted and diverse behavioral interventions is urgent. Moreover, these needed interventions must make an impact on the sexual risk taking in those groups most impacted by the epidemic. To accomplish this within high risk HIV-infected sub-groups (i.e. communities of color and MSM), research must tailor behavioral interventions to address major factors impacting continued transmission risk behavior. Interventions that fail to consider the complex social realities of HIV-infected populations will fail to develop holistic approaches and may run the risk of dismissing important issues that impact overall health. It may be that HIV prevention within infected populations requires multiple interventions to address the root causes of continued sexual risk taking. Researchers have begun to call for a more diverse array of prevention intervention within an integrated approach that considers and equally emphasizes social, psychological, medical and economic realities of HIV-infected individuals.

In their article assessing secondary HIV prevention interventions, Gordon et al note that the vast majority of the interventions have been limited to variants SCT, which typically highlight cognitive behavioral skill-building without incorporating contextual factors (15). Further, the authors argue that interventions should target multiple levels of prevention and calls for researchers to shift secondary HIV prevention towards a more complex social-ecological model (15). The ecological model of health promotion offers three advantages over the individualistically-orientated behavior change models as summarized by Choi et al: 1) deemphasizes the importance of the individual on behavior change, 2) examines both individual and environmental influences for unhealthy behavior, and 3) promotes the use of environmental approaches in prevention programs (8). The ecological model would involve the assessment of risk on multiple levels and would be better equipped to determine the fundamental causes of continued sexual risk taking.

HIV continues to disproportionably impact communities of color and MSM (3). Research must be committed to determining how and why HIV impacts those communities and exploring how HIV prevention programs may address multiple levels of risk. This critique of the REP secondary prevention interventions suggests that risk is impacted by a variety of individual and environmental factors that are not adequately addressed by interventions based on SCT. Examining those communities most affected by HIV forces us to confront how poverty, racism and homophobia contribute to increased HIV risk and will likely continue to impact transmission risk behavior. By replicating evidence-based interventions in MSM or communities of color that fail to account for poverty, racism and homophobia, researchers will find it difficult to initiate and sustain healthy behavior change. To better combat the transmission of HIV, research must focus on a new generation of secondary prevention interventions largely based on the ecological model.

1. Kalichman SC, Rompa D, Cage M. Sexually transmitted infections among HIV seropositive men and women. Sex Transm Infect. 2000 Oct;76(5):350-4.
2. CDC. CDC HIV/AIDS fact sheet: A glance at HIV/AIDS among men who have sex with men. November, 2007. Available at:
3. CDC, Replicating Effective Programs Plus. Atlanta, GA: US Department of Health and Human Services. Accessed November, 2007. Available at:
4. Eke AN, Neumann MS, Wilkes AL, Jones PL. Preparing effective behavioral interventions to be used by prevention providers: the role of researchers during HIV Prevention Research Trials. AIDS Educ Prev. 2006 Aug;18(4 Suppl A):44-58.
5. Kalichman, S.C., Rompa, D., Cage, M., DiFonzo, K., Simpson, D., Austin, J., Luke, W., Buckles, J., Kyomugisha, F., Benotsch, E., Pinkerton, S., and Graham, J. (2001). Effectiveness of an intervention to reduce HIV transmission risks in HIV-positive people. American Journal of Preventive Medicine 21(2), 84-92.
6. Richardson J.L., Milam J., McCutchan A., Stoyanoff S., Bolan R., Weiss J., Kemper C., Larsen R.A., Hollander H., Weismuller P., Chou C.P., and Marks G. Effect of brief provider safer-sex counseling of HIV-1 seropositive patients: A multi-clinic assessment. AIDS 2004;18:1179-1186.
7. Mark Edberg. Essentials of Health Behavior: Social and Behavioral Theory in Public Health. Sudbury, MA: Jones and Bartlett Publishers, 2007.
8. Choi K, Yep GA, Kumekawa E. HIV prevention among Asian and Pacific Islander men who have sex with men: a critical review of theoretical models and directions for future research. AIDS Education and Prevention 1998; 10(Supplement A):19-30.
9. Link BG, Phelan J. Social conditions as fundamental causes of disease. Journal of Health and Social Behavior 1995; 35(extra issue):80-94.
10. Reif S, Whetten K, Lowe K, Ostermann J. Association of unmet needs for support services with medication use and adherence among HIV-infected individuals in the southeastern United States. AIDS Care. 2006 May;18(4):277-83.
11. Stall R, Mills TC, Williamson J, Hart T, Greenwood G, Paul J, Pollack L, Binson D, Osmond D, Catania JA. Association of co-occurring psychosocial health problems and increased vulnerability to HIV/AIDS among urban men who have sex with men. Am J Public Health. 2003 Jun;93(6):939-42.
12. Koopman C, Gore-Felton C, Azimi N, O'Shea K, Ashton E, Power R, De Maria S, Israelski D, Spiegel D. Acute stress reactions to recent life events among women and men living with HIV/AIDS. Int J Psychiatry Med. 2002;32(4):361-78.
13. Kelly B, Raphael B, Judd F, Perdices M, Kernutt G, Burnett P, Dunne M, Burrows G. Posttraumatic stress disorder in response to HIV infection. Gen Hosp Psychiatry. 1998 Nov;20(6):345-52.
14. Kimerling R, Calhoun KS, Forehand R, Armistead L, Morse E, Morse P, Clark R, Clark L. Traumatic stress in HIV-infected women. AIDS Educ Prev. 1999 Aug;11(4):321-30.
15. Gordon CM, Forsyth AD, Stall R, Cheever LW. Prevention interventions with persons living with HIV/AIDS: state of the science and future directions. AIDS Educ Prev. 2005 Feb;17(1 Suppl A):6-20.

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  • At December 18, 2007 at 8:43 AM , Anonymous Nicole M said...

    That was a very well written and very interesting critique on addressing HIV prevention interventions!

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