Dale Stratford

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, womens 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.

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.

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

Abstract 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.

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.

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.

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.

Addressing Poverty and HIV Using Microenterprise: Findings from Qualitative Research to Reduce Risk among Unemployed or Underemployed African American Women

Introduction. Microenterprise programs are widely used to improve health outcomes among women internationally. However, there is little information on applicability to American women living in poverty. We conducted formative research to identify activities that are viable and attractive, that may produce income to address some proportion of economic need and could be incorporated in the development of a micro-enterprise HIV-prevention intervention to reduce HIV/STD transmission among unemployed or underemployed African American women at risk for HIV. Methods. Focus groups were convened with young African American women and community leaders in two southern states. Interviews with women participating in the focus groups were also convened. Results. Findings suggest an intervention should incorporate activities to increase self-esteem, enhance employability and job sustainability to decrease financial dependence. This research serves as the foundation for developing a novel approach to HIV prevention in the U.S. that may directly address poverty as a social determinant of health.

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.

Introduction to Special Supplement: Monitoring and Evaluation of HIV Counseling, Testing and referral (CTR) and HIV Testing Services:

1 Renee Stein, Tanisha S. Grimes, and Dale Stratford are with the Division of HIV/AIDS Prevention, National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention (NCHHSTP), Centers for Disease Control and Prevention (CDC), Atlanta, GA. Robert Malow is with the College of Health and Urban Affairs, Florida International University, North Miami, FL. Freya Spielberg is with the Research Triangle Institute, Research Triangle Park, NC. David R. Holtgrave Department of Health, Behavior and Society and Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD Address correspondence to Renee Stein, PhD, MPH, Division of HIV/AIDS Prevention, National Center for HIV, STD, and TB Prevention, Centers for Disease Control and Prevention, 1600 Clifton Road NE, Mail Stop E-59, Atlanta GA 30333; E-mail: arf7@cdc.gov Stein et al. Introduction to Special Supplement