Linda S. Kay

Best-Evidence Interventions: Findings From a Systematic Review of HIV Behavioral Interventions for US Populations at High Risk, 2000-2004

OBJECTIVES The Centers for Disease Control and Preventions HIV/AIDS Prevention Research Synthesis Team conducted a systematic review of US-based HIV behavioral intervention research literature from 2000 through 2004 to identify interventions demonstrating best evidence of efficacy for reducing HIV risk. METHODS Standard systematic review methods were used. Each eligible study was reviewed on the basis of Prevention Research Synthesis Team efficacy criteria that focused on 3 domains: study design, implementation and analysis, and strength of evidence. RESULTS Eighteen interventions met the criteria for best evidence. Four targeted HIV-positive individuals. Of those targeting populations at risk for HIV, 4 targeted drug users, 6 targeted adults at risk because of heterosexual behaviors only, 2 targeted men who have sex with men, and 2 targeted youths at high risk. Eight interventions focused on women, and 13 had study samples with more than 50% minority participants. Significant intervention effects included increased condom use and reductions in unprotected sexual intercourse, number of sexual partners, injection drug use or needle sharing, and newly acquired sexually transmitted infections. CONCLUSIONS Most of the best-evidence interventions are directly applicable for populations in greatest need of effective prevention programs; however, important gaps still exist.

The Efficacy of HIV/STI Behavioral Interventions for African American Females in the United States: A Meta-Analysis

OBJECTIVES We evaluated the efficacy of HIV behavioral interventions for African American females in the United States, and we identified factors associated with intervention efficacy. METHODS We conducted a comprehensive literature review covering studies published from January 1988 to June 2007, which yielded 37 relevant studies. Data were analyzed using mixed-effects models and meta-regression. RESULTS Overall, behavioral interventions had a significant impact on reductions in HIV-risk sex behaviors (odds ratio [OR] = 0.63; 95% confidence interval [CI] = 0.54, 0.75; n = 11 239; Cochrane Q(32) = 84.73; P < .001) and sexually transmitted infections (STIs; OR = 0.81; 95% CI = 0.67, 0.98; n = 8760; Cochrane Q(16) = 22.77; P = .12). Greater intervention efficacy was observed in studies that specifically targeted African American females used gender- or culture-specific materials, used female deliverers, addressed empowerment issues, provided skills training in condom use and negotiation of safer sex, and used role-playing to teach negotiation skills. CONCLUSIONS Behavioral interventions are efficacious at preventing HIV and STIs among African American females. More research is needed to examine the potential contribution of prevention strategies that attend to community-level and structural-level factors affecting HIV infection and transmission in this population.

A profile of U.S.-based trials of behavioral and social interventions for HIV risk reduction.

Summary: We describe 99 (experimental and certain quasi‐experimental) U.S.‐based trials, reported or published since 1988, of behavioral and social interventions that measured prespecified behavioral and biologic outcomes and aimed to reduce risk for HIV infection. Studies identified through June 1998 by the HIV/AIDS Prevention Research Synthesis project were grouped into 4 risk behavior areas: drug‐related (k [number of studies] = 48), heterosexual youth (k = 24), heterosexual adult (k = 17), and same‐sex (k = 10). We compared the studies in the 4 areas by variables key to the development, evaluation, and transfer of interventions. Participants comprised injection drug users (43% of studies), drug users out of treatment (29%), African Americans (18%), clinic patients (18%), youth in schools (10%), and drug users in treatment (10%). Most studies were randomized (85%), provided another intervention to the control or comparison groups (71%), and evaluated behavioral interventions (92%). On average, interventions were conducted in 5 sessions (total, 8 hours) during 3 months. The theoretical basis of the intervention was not noted in 57% of the reports. At least one variable from each of the 3 outcome classifications was measured in 8% of the studies: behavioral, biologic, and psychosocial. Distinct profiles exist for the 4 risk areas. Addressing gaps in research and reporting would be helpful for analytical and program activities. This sizable portfolio of evaluated interventions contributes to effectiveness reviews and to considerations of transfer to program practice.

Developing a Comprehensive Search Strategy for Evidence Based Systematic Reviews

Objective: As the health care field moves towards evidence-based practice, it becomes ever more critical to conduct systematic reviews of research literature for guiding programmatic activities, policy-making decisions, and future research. Conducting systematic reviews requires a comprehensive search of behavioral, social, and policy research to identify relevant literature. As a result, the validity of the systematic review findings and recommendations is partly a function of the quality of the systematic search of the literature. Therefore, a carefully thought out and organized plan for developing and testing a comprehensive search strategy should be followed. Methods: The comprehensive search strategies, including automated and manual search techniques, were developed, tested, and implemented to locate published and unpublished citations to build a database of HIV/AIDS and STD literature for the CDC’s HIV Prevention Research Synthesis Project. The search incorporates various automated and manual search methods to decrease the chance of missing pertinent information. The automated search was implemented in MEDLINE, EMBASE, PsycINFO, Sociological Abstracts and AIDSLINE some of the key databases for biomedical, psychological, behavioral science, and public health literature. These searches utilized indexing, keywords including truncation, proximity, and phrases. The manual search method includes physically examining journals (hand searching), reference list checks, and researching key authors. Results: Using automated and manual search components, the PRS search strategy retrieved 17,493 HIV/AIDS/STD prevention focused articles for the years 1988-2005. The automated search found 91% and the manual search contributed 9% of the articles reporting on HIV/AIDS or STD interventions with behavior/biologic outcomes. Among the automated search citations, 48% were found in one database only (20% MEDLINE, 18% PsycINFO, 8 % EMBASE, 2% Sociological Abstracts). Conclusions: A comprehensive base of literature requires searching multiple databases and methods of manual searching in order to locate all relevant citations. Understanding the project needs, the limitations of different electronic databases, and other methods for developing and refining a search are vital in planning an effective and comprehensive search strategy. Reporting standards for literature searches as part of the broader push for procedurally transparent and reproducible systematic reviews is not only advisable, but good evidence-based practice.

Efficacy of HIV/STI Behavioral Interventions for Heterosexual African American Men in the United States: A Meta-Analysis

This meta-analysis estimates the overall efficacy of HIV prevention interventions to reduce HIV sexual risk behaviors and sexually transmitted infections (STIs) among heterosexual African American men. A comprehensive search of the literature published during 1988–2008 yielded 44 relevant studies. Interventions significantly reduced HIV sexual risk behaviors and STIs. The stratified analysis for HIV sexual risk behaviors indicated that interventions were efficacious for studies specifically targeting African American men and men with incarceration history. In addition, interventions that had provision/referral of medical services, male facilitators, shorter follow-up periods, or emphasized the importance of protecting family and significant others were associated with reductions in HIV sexual risk behaviors. Meta-regression analyses indicated that the most robust intervention component is the provision/referral of medical services. Findings indicate that HIV interventions for heterosexual African American men might be more efficacious if they incorporated a range of health care services rather than HIV/STI-related services alone.

Identification of Evidence-Based Interventions for Promoting HIV Medication Adherence: Findings from a Systematic Review of U.S.-Based Studies, 1996–2011

A systematic review was conducted to identify evidence-based interventions (EBIs) for increasing HIV medication adherence behavior or decreasing HIV viral load among persons living with HIV (PLWH). We conducted automated searches of electronic databases (i.e., MEDLINE, EMBASE, PsycINFO, CINAHL) and manual searches of journals, reference lists, and listservs. Interventions were eligible for the review if they were U.S.-based, published between 1996 and 2011, intended to improve HIV medication adherence behaviors of PLWH, evaluated the intervention using a comparison group, and reported outcome data on adherence behaviors or HIV viral load. Each intervention was evaluated on the quality of study design, implementation, analysis, and strength of findings. Of the 65 eligible interventions, 10 are EBIs. The remaining 55 interventions failed to meet the efficacy criteria primarily due to null findings, small sample sizes, or low retention rates. Research gaps and future directions for development of adherence EBIs are discussed.ResumenSe realizó una revisión sistemática para identificar intervenciones eficaces en aumentando comportamientos para tomar medicinas para VIH en manera prescrita (adherencia a medicamentos) o disminuyendo la carga viral de VIH detectada en la sangre (carga viral) entre personas viviendo con VIH. Realizamos búsquedas automatizadas de bases de datos electrónicas (es decir MEDLINE, EMBASE, PsycINFO, CINAHL) y búsquedas manuales de revistas, listas de referencia, y listservs. Las intervenciones fueron elegibles para la revisión, si fueron basadas en los EEUU, publicadas entre 1996 y 2011, intentaron mejorar los comportamientos de personas viviendo con VIH en tomar sus medicinas en manera prescrita, evaluaron la intervención usando un grupo de comparación, y reportaron los datos de resultados de los comportamientos de adherencia a medicamentos o carga viral del VIH. Se evaluó cada intervención sobre la calidad del diseño del estudio, implementación, análisis y validez de los resultados. De las 65 intervenciones elegibles, 10 fueron intervenciones identificadas como eficaz. Las 55 intervenciones que sobraron no cumplieron con los criterios de eficacia, principalmente debido a retención baja, tamaños de muestra pequeños o nulos resultados. Hoyos en los estudios y direcciones futuras para el desarrollo de intervenciones eficaces en aumentando adherencia a medicamentos se discuten.

Prevention Campaigns for Hard-to-Reach Populations at Risk for HIV Infection: Theory and Implementation

Using applied behavioral science techniques that have been successful in other areas of health promotion, community-level campaigns were implemented in 5 cities to prevent HIV infection among hard-to-reach, at-risk populations: men who have sex with men but do not self-identify as gay; women who engage in sex for money or drugs; injecting drug users (IDUs); female sex partners of IDUs; and youth in high-risk situations. Communication materials presented positive role models for risk-reducing behaviors, and peer networks prompted and reinforced the behavior change process. This article describes the first year of intervention experience and documents the practical application of theoretical concepts of persuasion and learning. The use of theory and data to develop 188 educational messages is illustrated and training methods and experiences are reported for 150 peer leaders, 104 other community networkers, and 22 outreach workers. These activities are feasible and appear to offer an effective, general approach for diverse, special populations.

A Comparison of the Interactive Systems Framework (ISF) for Dissemination and Implementation and the CDC Division of HIV/AIDS Prevention's Research-to-Practice Model for Behavioral Interventions

Translating evidence-based HIV/STD prevention interventions and research findings into applicable HIV prevention practice has become an important challenge for the fields of community psychology and public health due to evidence-based interventions and evidence-based practice being given higher priority and endorsement by federal, state, and local health department funders. The Interactive Systems Framework (ISF) for Dissemination and Implementation and the Division of HIV/AIDS Prevention (DHAP) Research-to-Practice model both address this challenge. The DHAP model and the ISF are each presented with a brief history and an introduction of their features from synthesis of research findings through translation into intervention materials to implementation by prevention providers. This paper describes why the ISF and the DHAP model were developed and the similarities and differences between them. Specific examples of the use of the models to translate research to practice and the subsequent implications for support of each model are provided. The paper concludes that the ISF and the DHAP model are truly complementary with some unique differences, while both contribute substantially to addressing the gap between identifying effective programs and ensuring their widespread adoption in the field.

Heuristics, Biases, and Environmental Health Risk Analysis

Human behavior both harms and benefits the natural environment, and in turn, environmental changes can significantly impact human health. Therefore, the study of human decision making, which guides much of human behavior, is highly relevant to the management of environmental health risks. This chapter examines the important relationship between one area of behavioral decision making (cognitive heuristics and biases) and environmental health risk management.