Gail E Kennedy

The Efficacy of Behavioral Interventions in Reducing HIV Risk Behaviors and Incident Sexually Transmitted Diseases in Heterosexual African Americans

Objective:To conduct a meta-analytic review of HIV interventions for heterosexual African Americans to determine the overall efficacy in reducing HIV-risk sex behaviors and incident sexually transmitted diseases and identify intervention characteristics associated with efficacy. Methods:Comprehensive searches included electronic databases from 1988 to 2005, handsearches of journals, reference lists of articles, and contacts with researchers. Thirty-eight randomized controlled trials met the selection criteria. Random-effects models were used to aggregate data. Results:Interventions significantly reduced unprotected sex (odds ratio = 0.75; 95% confidence interval = 0.67, 0.84; 35 trials; N = 14 682) and marginally significantly decreased incident sexually transmitted diseases (odds ratio = 0.88; 95% confidence interval = 0.72, 1.07; 10 trials; N = 10 944). Intervention characteristics associated with efficacy include cultural tailoring, aiming to influence social norms in promoting safe sex behavior, utilizing peer education, providing skills training on correct use of condoms and communication skills needed for negotiating safer sex, and multiple sessions and opportunities to practice learned skills. Conclusion:Interventions targeting heterosexual African Americans are efficacious in reducing HIV-risk sex behaviors. Efficacious intervention components identified in this study should be incorporated into the development of future interventions and further evaluated for effectiveness.

Linking family planning with HIV/AIDS interventions: a systematic review of the evidence.

Objective:To conduct a systematic review of the literature and examine the effectiveness, optimal circumstances, and best practices for strengthening linkages between family planning and HIV interventions. Design:Systematic review of peer-reviewed articles and unpublished program reports (‘promising practices’) evaluating interventions linking family planning and HIV services. Methods:Articles were included if they reported post-intervention evaluation results from an intervention linking family planning and HIV services between 1990 and 2007. Systematic methods were used for searching, screening, and data extraction. Quality assessment was conducted using a 9-point rigor scale. Results:Sixteen studies were included in the analysis (10 peer-reviewed studies and six promising practices). Interventions were categorized into six types: family planning services provided to HIV voluntary counseling and testing (VCT) clients, family planning and VCT services provided to maternal and child health clients, family planning services provided to people living with HIV, community health workers provided family planning and HIV services, VCT provided to family planning clinic clients, and VCT and family planning services provided to women receiving postabortion care. Average study design rigor was low (3.25 out of 9). Most studies reported generally positive or mixed results for key outcomes; no negative results were reported. Conclusion:Interventions linking family planning and HIV services were generally considered feasible and effective, though overall evaluation rigor was low.

Sexual and reproductive health services for people living with HIV: a systematic review.

Abstract People living with HIV often have unmet needs for sexual and reproductive health (SRH) services. We present results of a systematic review of studies offering SRH services targeted to people living with HIV. Studies were selected from a broader SRH and HIV linkages review. Inclusion criteria included: (1) peer-reviewed journal articles with a pre–post or multiple-arm study design; (2) reported post-intervention evaluation data; and (3) published 1 January 1990 through 31 December 2007. Nine studies were identified with an average rigour score of 5.1 out of 9. Services included family planning (one study), sexually transmitted infection (STI) services (two studies), combined family planning and STI services (three studies) and multiple services (three studies). The review identified mostly positive effects on the outcomes measured, including condom and contraceptive use and quality of services. Yet gaps remain in the research to establish the best approaches for addressing needs and choices of people living with HIV. There is a need for high-quality intervention studies to determine the most successful and cost-effective strategies for providing SRH services to people living with HIV.

International collaboration in conducting systematic reviews: The Cochrane Collaborative Review Group on HIV Infection and AIDS

Summary: To make sound health care decisions, policy makers, providers and researchers need access to relevant research findings. The role of systematic reviews is increasingly acknowledged as an important contribution in evidence‐based health care decision making, and several review efforts, including that of the international Cochrane Collaboration, are under way. The Cochrane Collaborative Review Group on HIV Infection and AIDS (CRG on HIV/AIDS), conducts systematic reviews on the prevention and the treatment of HIV infection and AIDS and is guided by the Cochrane Collaborations principles, which include minimizing potential bias, ensuring quality in the review process, keeping reviews up to date, and enhancing collaboration. The CDC HIV/AIDS Prevention Research Synthesis (PRS) project is working closely with the CRG on HIV/AIDS to produce Cochrane reviews of behavioral prevention interventions and on development and maintenance of a centralized, cumulative electronic database of HIV/AIDS behavioral prevention studies. Systematic reviews can play an important role in advancing evidence‐based policy and practice in HIV/AIDS prevention and care.

Developing WHO guidelines with pragmatic, structured, evidence-based processes: A case study

Abstract Many guidelines, including those produced by the World Health Organisation (WHO), have failed to adhere to rigorous methodological standards. Operational examples of guideline development processes may provide important lessons learned to improve the rigour and quality of future guidelines. To this end, this paper describes the process of developing WHO guidelines on prevention and care interventions for adults and adolescents living with HIV. Using a pragmatic, structured, evidence-based approach, we created an organising committee, identified topics, conducted systematic reviews, identified experts and distributed evidence summaries. Subsequently, 55 global HIV experts drafted and anonymously submitted guideline statements at the beginning of a conference. During the conference, participants voted on statements using scales evaluating appropriateness of the statements, strength of recommendation and level of evidence. After review of voting results, open discussion, re-voting and refinement of statements, a draft version of the guidelines was completed. A post-conference writing team refined the guidelines based on pre-determined guideline writing principles and incorporated external comments into a final document. Successes and challenges of the guideline development process were identified and are used to highlight current issues and debates in developing guidelines with a focus on implications for future guideline development at WHO.

Validation of AIDS-related mortality in Botswana

BackgroundMortality data are used to conduct disease surveillance, describe health status and inform planning processes for health service provision and resource allocation. In many countries, HIV- and AIDS-related deaths are believed to be under-reported in government statistics.MethodsTo estimate the extent of under-reporting of HIV- and AIDS-related deaths in Botswana, we conducted a retrospective study of a sample of deaths reported in the government vital registration database from eight hospitals, where more than 40% of deaths in the country in 2005 occurred. We used the consensus of three physicians conducting independent reviews of medical records as the gold standard comparison. We examined the sensitivity, specificity and other validity statistics.ResultsOf the 5276 deaths registered in the eight hospitals, 29% were HIV- and AIDS-related. The percentage of HIV- and AIDS-related deaths confirmed by physician consensus (positive predictive value) was 95.4%; however, the percentage of non-HIV- and non-AIDS-related deaths confirmed (negative predictive value) was only 69.1%. The sensitivity and specificity of the vital registration system was 55.7% and 97.3%, respectively. After correcting for misclassification, the percentage of HIV- and AIDS--related deaths was estimated to be in the range of 48.8% to 54.4%, depending on the definition.ConclusionImprovements in hospitals and within government offices are necessary to strengthen the vital registration system. These should include such strategies as training physicians and coders in accurate reporting and recording of death statistics, implementing continuous quality assurance methods, and working with the government to underscore the importance of using mortality statistics in future evidence-based planning.

The Cochrane HIV/AIDS review group and evidence-based practice in nursing.

The nursing profession has long recognized the importance of research and the incorporation of research findings into the clinical environment. The paradigm shift from traditional and intuition-driven practice to evidence-based practice can be witnessed in all areas of health care. Models for change to evidencebased practice help guide nurses and other health care professionals through a systematic process incorporating research findings into the clinical setting. This practice is more likely to occur in environments that value the integration of new knowledge and provide resources to access this information (Rosswurm & Larrabee, 1999). Nurses, physicians, public health practitioners, policy makers, and consumers are deluged with unmanageable amounts of information about the best approaches to prevention, treatment, and health care delivery. The development of comprehensive HIV/ AIDS-care programs has been based and revised on numerous clinically based observations since the outset of the pandemic. With the exponential increases in scientific knowledge about most diseases and HIV/ AIDS in particular, many practitioners often turn to journal review articles, which are usually narrative reviews. These articles may be useful reminders of the main issues and published evidence, but they are notoriously prone to bias, with concluding remarks often at odds with the evidence discussed in the article. This is because such review articles are rarely performed in a structured and explicit way (Cook, Sackett, & Spitzer, 1994). To address this problem, a movement called evidencebased health care has arisen that seeks to have practitioners and consumers make informed decisions based on the best available scientific evidence. These systemic reviews and evidence-based practice have become invaluable tools for nurses and other health care practitioners. The Cochrane Collaboration seeks to provide systematic reviews of all health care interventions since the first randomized controlled trial (RCT) was conducted in 1948. How nurses may contribute to and access this database, specifically the HIV/AIDS Review Group, will be discussed.