Mary M. Mullins

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 behavioral interventions in reducing HIV risk sex behaviors and incident sexually transmitted disease in black and Hispanic sexually transmitted disease clinic patients in the United States: a meta-analytic review.

Objectives: Interventions targeting sexually transmitted disease (STD) clinic patients provide an important opportunity to modify high-risk sex behaviors related to HIV/STD transmission. Identifying efficacious interventions for blacks and Hispanics is urgently needed because these 2 groups are disproportionately affected by the HIV/STD epidemics. Goal: This meta-analysis evaluates the efficacy of behavioral interventions in reducing unprotected sex and incident STD among black and Hispanic STD clinic patients. Study Design: Comprehensive searches, including electronic databases (1988–2004), hand searches of journals (January 2004 to June 2005), reference lists of articles, and contacts with researchers, identified 18 randomized, controlled trials meeting the selection criteria. Results: Interventions significantly reduced unprotected sex (odds ratio [OR] = 0.77; 95% confidence interval [CI] = 0.68–0.87; 14 trials; N = 11,590) and incident STD (OR = 0.85; 95% CI = 0.73–0.998; 13 trials; N = 16,172). Conclusions: Behavioral interventions provide an efficacious means of HIV/STD prevention for blacks and Hispanics who attend STD clinics.

Interventions to Promote Linkage to and Utilization of HIV Medical Care Among HIV-diagnosed Persons: A Qualitative Systematic Review, 1996–2011

This qualitative systematic review examined interventions that promote linkage to or utilization of HIV care among HIV-diagnosed persons in the United States. We conducted automated searches of electronic databases (i.e., MEDLINE, EMBASE, PsycINFO, CINAHL) and manual searches of journals, reference lists, and listservs. Fourteen studies from 19 published reports between 1996 and 2011 met our inclusion criteria. We developed a three-tier approach, based on strength of study design, to evaluate 6 findings on linkage to care and 18 findings on HIV care utilization. Our review identified similar strategies for the two outcomes, including active coordinator’s role in helping with linking to or utilizing HIV care; offering information and education about HIV care; providing motivational or strengths-based counseling; accompanying clients to medical appointments and helping with appointment coordination. The interventions focused almost exclusively on individual-level factors. More research is recommended to examine interventions that address system and structural barriers.ResumenEsta revisión sistemática cualitativa examinó intervenciones que promueven el coneción a o la utilización del cuidado del VIH entre personas diagnosticadas con el VIH en los Estados Unidos. Condujimos búsquedas automatizadas de bases de datos electrónicas (es decir, MEDLINE, EMBASE, PsycINFO, CINAHL) y búsquedas manuales de revistas, listas de la referencia y listservs. Catorce estudios desde 19 informes publicados entre 1996 y 2011 cumplieron nuestros criterios de inclusión. Desarrollamos un enfoque de tres niveles, basado en la fuerza del diseño de estudio, para evaluar 6 conclusiones sobre el coneción al cuidado médico y 18 conclusiones en la utilización de cuidado del VIH. Nuestra revisión identificó estrategias similares para los dos resultados, incluyendo el papel activo del coordinador en ayudando con el coneción a o utilización del cuidado del VIH; ofreciendo de información y educación sobre cuidado del VIH; proporcionando consejería motivacional o basada en fortalezas; acompañando clientes a sus citas médicas; y ayudando con coordinación de las citas. Las intervenciones se concentraron casi exclusivamente en factores de nivel individual. Más investigación es recomendado para examinar intervenciones que se dirigen a barreras sistémicas y estructurales.

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.

Are couple-based interventions more effective than interventions delivered to individuals in promoting HIV protective behaviors? A meta-analysis

ABSTRACT Despite several advantages to bringing couples together to learn how to protect themselves and new-born children from the risk of HIV infection, most interventions are designed for individuals or groups, not for dyads. This meta-analysis provides a direct test of whether couple-based interventions are more effective in promoting HIV protective behaviors than interventions delivered to individuals. We conducted systematic searches of five electronic databases and 60 journals. Eligible studies were controlled trials or prospective cohort designs; evaluated a couple-based intervention compared to an individual-level intervention; assessed at least one HIV prevention outcome (e.g., protective sex, drug use, HIV testing, medication adherence, and sexually transmitted infections [STI]); and were published between 1988 and 2014. Fifteen interventions, including 21,882 participants from China, Kenya, Rwanda, Tanzania, Trinidad, Zambia, and the USA, were evaluated. The results of random-effects models showed statistically significant intervention effects for protective sex (OR = 1.60, 95% CI = 1.21, 2.11), HIV testing (OR = 1.79, 95% CI = 1.31, 2.45), and Nevirapine uptake (OR = 1.51, 95% CI = 1.02, 2.24). The evidence demonstrates the usefulness of couple-based interventions in protecting individuals, partners, and new-born children from the risk of HIV transmission and infection.

Identifying Best Practices for Increasing Linkage to, Retention, and Re-engagement in HIV Medical Care: Findings from a Systematic Review, 1996-2014.

A systematic review was conducted to identify best practices for increasing linkage, retention and re-engagement in HIV care (LRC) for persons living with HIV (PLWH). Our search strategy consisted of automated searches of electronic databases and hand searches of journals, reference lists and listservs. We developed two sets of criteria: evidence-based to identify evidence-based interventions (EBIs) tested with a comparison group and evidence-informed to identify evidence-informed interventions (EIs) tested with a one-group design. Eligible interventions included being published between 1996 and 2014, U.S.-based studies with a comparison or one-group designs with pre-post data, international randomized controlled trials, and having objective measures of LRC-relevant outcomes. We identified 10 best practices: 5 EBIs and 5 EIs. None focused on re-engagement. Providers and prevention planners can use the review findings to identify best practices suitable for their clinics, agencies, or communities to increase engagement in care for PLWH, ultimately leading to viral suppression.ResumenUna revisión sistemática se realizó para identificar las mejores prácticas para aumentar la vinculación, la permanencia y el regreso hasta atención médica del VIH (VPR) para las personas que viven con el VIH (PVVS). La estrategia de búsqueda consistió en búsquedas automatizadas de bases de datos electrónicas y búsquedas manuales en revistas, listas de referencias y listas de correo electrónico. Hemos desarrollado dos juegos de criterios: “basadas en evidencias” para identificar las intervenciones basadas en la evidencia y probadas con un grupo de comparación (IBEs), y “informadas por evidencias” para identificar las intervenciones informadas por evidencias y probadas con un diseño empleando un solo grupo (IIEs). Intervenciones elegibles incluyeron siendo publicados entre 1996 y 2014, estudiados en los Estados Unidos con un grupo de comparación o uno grupo con datos pre-post, ensayos internacionales controlados aleatorios, y que tienen medidas objetivas de resultados VPR-relevantes. Se identificaron 10 mejores prácticas: 5 IBEs y 5 IIEs. Ninguno se centró en un regreso hasta atención médica. Los proveedores y los planificadores de prevención pueden utilizar los resultados de la revisión para identificar las mejores prácticas adecuadas para sus clínicas, agencias, o comunidades para aumentar la participación en la atención médica para las PVVS, en última instancia conduciendo a la supresión viral.

A Systematic Review of Interventions for Reducing HIV Risk Behaviors among People Living with HIV in the United States, 1988–2012

Objective:To conduct a systematic review to examine interventions for reducing HIV risk behaviors among people living with HIV (PLWH) in the United States. Methods:Systematic searches included electronic databases from 1988 to 2012, hand searches of journals, reference lists of articles, and HIV/AIDS Internet listservs. Each eligible study was evaluated against the established criteria on study design, implementation, analysis, and strength of findings to assess the risk of bias and intervention effects. Results:Forty-eight studies were evaluated. Fourteen studies (29%) with both low risk of bias and significant positive intervention effects in reducing HIV transmission risk behaviors were classified as evidence-based interventions (EBIs). Thirty-four studies were classified as non-EBIs due to high risk of bias or nonsignificant positive intervention effects. EBIs varied in delivery from brief prevention messages to intensive multisession interventions. The key components of EBIs included addressing HIV risk reduction behaviors, motivation for behavioral change, misconception about HIV, and issues related to mental health, medication adherence, and HIV transmission risk behavior. Conclusion:Moving evidence-based prevention for PLWH into practice is an important step in making a greater impact on the HIV epidemic. Efficacious EBIs can serve as model programs for providers in healthcare and nonhealthcare settings looking to implement evidence-based HIV prevention. Clinics and public health agencies at the state, local, and federal levels can use the results of this review as a resource when making decisions that meet the needs of PLWH to achieve the greatest impact on the HIV epidemic.

Reporting Quality of Search Methods in Systematic Reviews of HIV Behavioral Interventions (2000-2010): Are the Searches Clearly Explained, Systematic and Reproducible?.

Systematic reviews are an essential tool for researchers, prevention providers and policy makers who want to remain current with the evidence in the field. Systematic review must adhere to strict standards, as the results can provide a more objective appraisal of evidence for making scientific decisions than traditional narrative reviews. An integral component of a systematic review is the development and execution of a comprehensive systematic search to collect available and relevant information. A number of reporting guidelines have been developed to ensure quality publications of systematic reviews. These guidelines provide the essential elements to include in the review process and report in the final publication for complete transparency. We identified the common elements of reporting guidelines and examined the reporting quality of search methods in HIV behavioral intervention literature. Consistent with the findings from previous evaluations of reporting search methods of systematic reviews in other fields, our review shows a lack of full and transparent reporting within systematic reviews even though a plethora of guidelines exist. This review underscores the need for promoting the completeness of and adherence to transparent systematic search reporting within systematic reviews.

Effects of integrated interventions on transmission risk and care continuum outcomes in persons living with HIV: Meta-analysis, 1996-2014

Background:Reducing HIV infection and improving outcomes along the continuum of HIV care are high priorities of the US National HIV/AIDS strategy. Interventions that target multiple problem behaviors simultaneously in an integrated approach (referred to as integrated interventions) may improve prevention and care outcomes of persons living with HIV (PLWH). This systematic review and meta-analysis examines the effects of integrated interventions. Methods:A systematic review, including both electronic and hand searches, was conducted to identify randomized controlled trials (RCTs) published between 1996 and 2014 that were designed to target at least two of the following behaviors among PLWH: HIV transmission risk behaviors, HIV care engagement, and medication adherence. Effect sizes were meta-analyzed using random-effects models. Results:Fifteen RCTs met the inclusion criteria. Integrated interventions significantly reduced sex without condoms [odds ratio (OR) = 0.74, 95% confidence interval (CI) = 0.59, 0.94, P = 0.013, 13 effect sizes] and had marginally significant effects on improving medication adherence behaviors (OR = 1.35, 95% CI = 0.98, 1.85, P = 0.063, 12 effect sizes) and undetectable viral load (OR = 1.46, 95% CI = 0.93, 2.27, P = 0.098, seven effect sizes). Significant intervention effects on at least two outcomes were seen in RCTs tailored to individual needs, delivered one on one, or in settings wherein PLWH received services or care. Conclusion:Integrated interventions produced some favorable prevention and care continuum outcomes in PLWH. How to incorporate integrated interventions with other combination HIV prevention strategies to reach the optimal impact requires further research.

Evaluating the Evidence for More Frequent Than Annual HIV Screening of Gay, Bisexual, and Other Men Who Have Sex With Men in the United States: Results From a Systematic Review and CDC Expert Consultation:

The Centers for Disease Control and Prevention (CDC) recommended in 2006 that sexually active gay, bisexual, and other men who have sex with men (MSM) be screened for human immunodeficiency virus (HIV) at least annually. A workgroup comprising CDC and external experts conducted a systematic review of the literature, including benefits, harms, acceptability, and feasibility of annual versus more frequent screening among MSM, to determine whether evidence was sufficient to change the current recommendation. Four consultations with managers of public and nonprofit HIV testing programs, clinics, and mathematical modeling experts were conducted to provide input on the programmatic and scientific evidence. Mathematical models predicted that more frequent than annual screening of MSM could prevent some new HIV infections and would be more cost-effective than annual screening, but this evidence was considered insufficient due to study design. Evidence supports CDC’s current recommendation that sexually active MSM be screened at least annually. However, some MSM might benefit from more frequent screening. Future research should evaluate which MSM subpopulations would benefit most from more frequent HIV screening.