Rebecca Firestone

Reducing HIV Risk among Transgender Women in Thailand: A Quasi-Experimental Evaluation of the Sisters Program

Transgender women are particularly at risk of HIV infection, but little evidence exists on effective HIV prevention strategies with this population. We evaluated whether Sisters, a peer-led program for transgender women, could reduce HIV risks in Pattaya, Thailand. The study used time-location sampling to recruit 308 transgender women in Pattaya into a behavioral survey in 2011. Coarsened exact matching was used to create statistically equivalent groups of program participants and non-participants, based on factors influencing likelihood of program participation. Using multivariable logistic regression, we estimated effects of any program participation and participation by delivery channel on: condom use at last sex; consistent condom and condom/water-based lubricant use in the past 3 months with commercial, casual, and regular partners; and receipt of HIV testing in the past 6 months. Program coverage reached 75% of the population. In a matched sub-sample (n = 238), participation in outreach was associated with consistent condom/water-based lubricant use with commercial partners (AOR 3.22, 95% CI 1.64–6.31). Attendance at the Sisters drop-in center was associated with receiving an HIV test (AOR 2.58, 95% CI 1.47–4.52). Dedicated transgender-friendly programs are effective at reducing HIV risks and require expansion to better serve this key population and improve HIV prevention strategies.

Do community-based strategies reduce HIV risk among people who inject drugs in China? A quasi-experimental study in Yunnan and Guangxi provinces

BackgroundHIV transmission among people who inject drugs (PWID) is high in Yunnan and Guangxi provinces in southwest China. To address this epidemic, Population Services International (PSI) and four cooperating agencies implemented a comprehensive harm reduction model delivered through community-based drop-incenters (DiC) and peer-led outreach to reduce HIV risk among PWID.MethodsWe used 2012 behavioral survey data to evaluate the effectiveness of this model for achieving changes in HIV risk, including never sharing needles or syringes, always keeping a clean needle on hand, HIV testing and counseling (HTC), and consistent condom use. We used respondent-driven sampling to recruit respondents. We then used coarsened exact matching (CEM) to match respondents during analysis to improve estimation of the effects of exposure to both DiC and outreach, only DiC, and only outreach, modeled using multivariable logistic regression.ResultsWe found a significant relationship between participating in both peer-led DiC-based activities and outreach and having a new needle on hand (odds ratio (OR) 1.53, p < .05) and consistent condom use (OR 3.31, p < .001). We also found a significant relationship between exposure to DiC activities and outreach and HIV testing in Kunming (OR 2.92, p < .01) and exposure to peer-led outreach and HIV testing through referrals in Gejiu, Nanning, and Luzhai (OR 3.63, p < .05).ConclusionsA comprehensive harm reduction model delivered through peer-led and community-based strategies reduced HIV risk among PWID in China. Both DiC activities and outreach were effective in providing PWID behavior change communications (BCC) and HTC. HTC is best offered in settings like DiCs, where there is privacy for testing and receiving results. Outreach coverage was low, especially in Guangxi province where the implementation model required building the technical capacity of government partners and grassroot organizations. Outreach appears to be most effective for referring PWID into HTC, especially when DiC-based HTC is not available and increasing awareness of DiCs where PWID can receive more intensive BCC interventions.

Effectiveness of a combination prevention strategy for HIV risk reduction with men who have sex with men in Central America: a mid-term evaluation

BackgroundDespite over a decade of research and programming, little evidence is available on effective strategies to reduce HIV risks among Central American men who have sex with men (MSM). The Pan-American Social Marketing Organization (PASMO) and partners are implementing a HIV Combination Prevention Program to provide key populations with an essential package of prevention interventions and services: 1) behavioral, including interpersonal communications, and online outreach; 2) biomedical services including HIV testing and counseling and screening for STIs; and 3) complementary support, including legal support and treatment for substance abuse. Two years into implementation, we evaluated this program’s effectiveness for MSM by testing whether exposure to any or a combination of program components could reduce HIV risks.MethodsPASMO surveyed MSM in 10 cities across Guatemala, El Salvador, Nicaragua, Costa Rica, and Panama in 2012 using respondent-driven sampling. We used coarsened exact matching to create statistically equivalent groups of men exposed and non-exposed to the program, matching on education, measures of social interaction, and exposure to other HIV prevention programs. We estimated average treatment effects of each component and all combined to assess HIV testing and condom use outcomes, using multivariable logistic regression. We also linked survey data to routine service data to assess program coverage.ResultsExposure to any program component was 32% in the study area (n = 3531). Only 2.8% of men received all components. Men exposed to both behavioral and biomedical components were more likely to use condoms and lubricant at last sex (AOR 3.05, 95% CI 1.08, 8.64), and those exposed to behavioral interventions were more likely to have tested for HIV in the past year (AOR 1.76, 95% CI 1.01, 3.10).ConclusionsPASMO’s strategies to reach MSM with HIV prevention programming are still achieving low levels of population coverage, and few men are receiving the complete essential package. However, those reached are able to practice HIV prevention. Combination prevention is a promising approach in Central America, requiring expansion in coverage and intensity.

The BetterBirth Program: Pursuing Effective Adoption and Sustained Use of the WHO Safe Childbirth Checklist Through Coaching-Based Implementation in Uttar Pradesh, India

The BetterBirth Program relied on carefully structured coaching that was multilevel, collaborative, and provider-centered to motivate birth attendants to use the WHO Safe Childbirth Checklist and improve adherence to essential birth practices. It was scaled to 60 sites as part of a randomized controlled trial in Uttar Pradesh, India. The BetterBirth Program relied on carefully structured coaching that was multilevel, collaborative, and provider-centered to motivate birth attendants to use the WHO Safe Childbirth Checklist and improve adherence to essential birth practices. It was scaled to 60 sites as part of a randomized controlled trial in Uttar Pradesh, India. Shifting childbirth into facilities has not improved health outcomes for mothers and newborns as significantly as hoped. Improving the quality and safety of care provided during facility-based childbirth requires helping providers to adhere to essential birth practices—evidence-based behaviors that reduce harm to and save lives of mothers and newborns. To achieve this goal, we developed the BetterBirth Program, which we tested in a matched-pair, cluster-randomized controlled trial in Uttar Pradesh, India. The goal of this intervention was to improve adoption and sustained use of the World Health Organization Safe Childbirth Checklist (SCC), an organized collection of 28 essential birth practices that are known to improve the quality of facility-based childbirth care. Here, we describe the BetterBirth Program in detail, including its 4 main features: implementation tools, an implementation strategy of coaching, an implementation pathway (Engage-Launch-Support), and a sustainability plan. This coaching-based implementation of the SCC motivates and empowers care providers to identify, understand, and resolve the barriers they face in using the SCC with the resources already available. We describe important lessons learned from our experience with the BetterBirth Program as it was tested in the BetterBirth Trial. For example, the emphasis on relationship building and respect led to trust between coaches and birth attendants and helped influence change. In addition, the cloud-based data collection and feedback system proved a valuable asset in the coaching process. More research on coaching-based interventions is required to refine our understanding of what works best to improve quality and safety of care in various settings. (After publication of this article, the impact results of the BetterBirth intervention were published in the New England Journal of Medicine [volume 377, pages 2313-2324, doi: 10.1056/NEJMoa1701075]. The results showed that the intervention had no significant effect on maternal or perinatal mortality or maternal morbidity, despite having positive effects on essential birth practices.)

The effectiveness of social marketing in global health: a systematic review

Social marketing is a commonly used strategy in global health. Social marketing programmes may sell subsidized products through commercial sector outlets, distribute appropriately priced products, deliver health services through social franchises and promote behaviours not dependent upon a product or service. We aimed to review evidence of the effectiveness of social marketing in low- and middle-income countries, focusing on major areas of investment in global health: HIV, reproductive health, child survival, malaria and tuberculosis. We searched PubMed, PsycInfo and ProQuest, using search terms linking social marketing and health outcomes for studies published from 1995 to 2013. Eligible studies used experimental or quasi-experimental designs to measure outcomes of behavioural factors, health behaviours and/or health outcomes in each health area. Studies were analysed by effect estimates and for application of social marketing benchmark criteria. After reviewing 18 974 records, 125 studies met inclusion criteria. Across health areas, 81 studies reported on changes in behavioural factors, 97 studies reported on changes in behaviour and 42 studies reported on health outcomes. The greatest number of studies focused on HIV outcomes (n = 45) and took place in sub-Saharan Africa (n = 67). Most studies used quasi-experimental designs and reported mixed results. Child survival had proportionately the greatest number of studies using experimental designs, reporting health outcomes, and reporting positive, statistically significant results. Most programmes used a range of methods to promote behaviour change. Programmes with positive, statistically significant findings were more likely to apply audience insights and cost-benefit analyses to motivate behaviour change. Key evidence gaps were found in voluntary medical male circumcision and childhood pneumonia. Social marketing can influence health behaviours and health outcomes in global health; however evaluations assessing health outcomes remain comparatively limited. Global health investments are needed to (i) fill evidence gaps, (ii) strengthen evaluation rigour and (iii) expand effective social marketing approaches.

Integration of the Opportunity‐Ability‐Motivation behavior change framework into a coaching‐based WHO Safe Childbirth Checklist program in India

To evaluate whether integration of the Opportunity‐Ability‐Motivation plus Supplies (OAMS) framework into coaching improved the delivery of essential birth practices in a low‐resource setting.

Intensive Group Learning and On-Site Services to Improve Sexual and Reproductive Health Among Young Adults in Liberia: A Randomized Evaluation of HealthyActions

Combining intensive group learning and provision of on-site reproductive health services through an existing alternative basic education program increased use of contraception and HIV testing and counseling among young out-of-school Liberians. Combining intensive group learning and provision of on-site reproductive health services through an existing alternative basic education program increased use of contraception and HIV testing and counseling among young out-of-school Liberians. ABSTRACT Introduction: Young Liberians, particularly undereducated young adults, face substantial sexual and reproductive health (SRH) challenges, with low uptake of contraceptive methods, high rates of unintended pregnancy, and low levels of knowledge about HIV status. The purpose of this study was to assess the impact of a 6-day intensive group learning intervention combined with on-site SRH services (called HealthyActions) among out-of-school young adults, implemented through an existing alternative education program, on uptake of contraception and HIV testing and counseling (HTC). Methods: The intervention was implemented among young women and men ages 15–35 who were enrolled in alternative basic education learning sites in 5 counties of Liberia. We conducted a randomized evaluation to assess program impact. Baseline data were collected in January–March 2014, and endline data in June–July 2014. Key outcomes of condom use, contraceptive use, and HTC were estimated with difference-in-difference models using fixed effects. All analyses were conducted in Stata 13. Results: We assessed outcomes for 1,157 learners at baseline and 1,052 learners at endline, across 29 treatment and 26 control sites. After adjusting for potential confounders, learners in the HealthyActions intervention group were 12% less likely to report never using a condom with a regular partner over the last month compared with the control group (P = .02). Female learners who received HealthyActions were 13% more likely to use any form of modern contraception compared with learners in control sites (P<.001), with the greatest increase in the use of contraceptive implants. Learners in HealthyActions sites were 45% more likely to have received HTC (P<.001). Conclusion: Providing intensive group learning in a supportive environment coupled with on-site health services improved SRH outcomes among participating learners. The focus of HealthyActions on participatory learning for low-literacy populations presents an adaptable solution for health programming across Liberia and the region.