Wayne D. Johnson

A meta-analysis of the effect of HIV prevention interventions on the sex behaviors of drug users in the United States

Summary: We examined the effectiveness of 33 U.S.‐based HIV intervention studies in reducing the sexual risk behaviors of drug users by reducing unprotected sex or increasing the use of male condoms. The studies, identified as of June 1998, through the HIV/AIDS Prevention Research Synthesis project, were published in 1988 or later, measured behavioral or biologic outcomes, used experimental designs or certain quasiexperimental designs, and reported sufficient data for calculating an effect size for sexual risk reduction. Of the 33 studies, 94% recruited injection drug users; 21% recruited crack users. The mean age of participants was 36 years. Almost all studies were randomized (94%), provided another HIV intervention to the comparison groups (91%), and evaluated behavioral interventions (91%). On average, interventions were conducted in 5 sessions (total, 10 hours) during 4.5 months. Interventions compared with no interventions were strong and significant (k = 3; odds ratio [OR], 0.60; 95% confidence interval [CI], 0.43‐0.85). Interventions compared with other HIV interventions showed a modest additional benefit (k = 30; OR, 0.91; 95% CI, 0.81‐1.03). When we extrapolated our result (an OR of 0.60) to a population with a 72% prevalence of risk behavior, the proportion of drug users who reduced their risk behaviors was 12.6% greater in the intervention groups than in the comparison groups. Our meta‐analysis shows that interventions can lead to sexual risk reduction among drug users and justifies providing interventions to drug users. Developing interventions with stronger effects to further reduce sexual risk behaviors among drug users must remain a high priority.

HIV Prevention Research for Men Who Have Sex with Men: A Systematic Review and Meta-analysis

Summary: A systematic review of HIV prevention reports published or distributed in the United States as of June 1998 yielded 9 rigorous controlled trials reporting intervention effects on unprotected sex for men who have sex with men. A summary measure of these effects was favorable (odds ratio, .69), statistically significant (95% confidence interval, 0.56‐0.86), and very homogeneous. This summary value indicates a 26% reduction in the proportion of men engaging in unprotected anal intercourse. The most clearly favorable effects were observed among interventions that promoted interpersonal skills, were delivered in community‐level formats, or focused on younger populations or those at higher behavioral risk. These studies demonstrate that interventions can promote risk reduction among men who have sex with men. Yet given the epidemiology of HIV in the United States, the small number of rigorous controlled intervention trials for this population is striking. Many more rigorous evaluations of HIV prevention efforts with men who have sex with men are needed to ascertain with confidence the effects of specific intervention components, population characteristics, and methodologic features.

Evaluation of an HIV prevention intervention adapted for Black men who have sex with men.

OBJECTIVES We assessed the efficacy of an HIV behavioral intervention adapted for Black men who have sex with men (MSM). METHODS We conducted serial cross-sectional surveys, 1 baseline measurement followed by initiation of an intervention and 3 follow-up measurements, among Black MSM in 3 North Carolina cities over 1 year. RESULTS We observed significant decreases in unprotected receptive anal intercourse at 4 months (by 23.8%, n=287) and 8 months (by 24.7%, n=299), and in unprotected insertive anal intercourse (by 35.2%), unprotected receptive anal intercourse (by 44.1%), and any unprotected anal intercourse (by 31.8%) at 12 months (n=268). Additionally, at 12 months, the mean number of partners for unprotected receptive anal intercourse decreased by 40.5%. The mean number of episodes decreased by 53.0% for unprotected insertive anal intercourse, and by 56.8% for unprotected receptive anal intercourse. The percentage of respondents reporting always using condoms for insertive and receptive anal intercourse increased by 23.0% and 30.3%, respectively. CONCLUSIONS Adapting previously proven interventions designed for other MSM can significantly reduce HIV risk behaviors of Black MSM.

Review and meta-analysis of HIV prevention intervention research for heterosexual adult populations in the United States

Summary: A meta‐analysis was performed to examine the effects of 14 behavioral and social interventions for heterosexual adults on their adoption of safer sex behaviors or incidence of sexually transmitted diseases (STDs). The intervention studies were identified through a systematic search and review strategy. Data were extracted and combined by using well‐defined methods and appropriate statistical techniques. For inclusion in this article, studies had to be based in the United States, written in English, first reported between 1988 and 1996, and aimed at reducing sex‐related HIV risks. In addition to measuring behavioral or STD incidence outcomes, studies also had used experimental or quasi‐experimental designs with control or comparison groups and reported sufficient outcome data to allow calculation of odds ratios. The meta‐analytic results show statistically significant effects in reducing sex‐related risks (10 studies; odds ratio [OR], 0.81; 95% confidence interval [CI], 0.69‐0.95), particularly non‐use of condoms (8; OR, 0.69; 95% CI, 0.53‐0.90). The interventions also had significant effects in reducing STD infections (6 studies; OR, 0.74; 95% CI, 0.62‐0.89). These analyses indicate that science‐based prevention interventions have positive effects among populations at risk through heterosexual transmission and that these positive effects are found with biologic and self‐reported behavioral measures.

Accessing Social Networks With High Rates of Undiagnosed HIV Infection: The Social Networks Demonstration Project

OBJECTIVES We evaluated the use of social networks to reach persons with undiagnosed HIV infection in ethnic minority communities and link them to medical care and HIV prevention services. METHODS Nine community-based organizations in 7 cities received funding from the Centers for Disease Control and Prevention to enlist HIV-positive persons to refer others from their social, sexual, or drug-using networks for HIV testing; to provide HIV counseling, testing, and referral services; and to link HIV-positive and high-risk HIV-negative persons to appropriate medical care and prevention services. RESULTS From October 1, 2003, to December 31, 2005, 422 recruiters referred 3172 of their peers for HIV services, of whom 177 were determined to be HIV positive; 63% of those who were HIV-positive were successfully linked to medical care and prevention services. The HIV prevalence of 5.6% among those recruited in this project was significantly higher than the approximately 1% identified in other counseling, testing, and referral sites funded by the Centers for Disease Control and Prevention. CONCLUSIONS This peer-driven approach is highly effective and can help programs identify persons with undiagnosed HIV infection in high-risk networks.

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.

An Online Randomized Controlled Trial Evaluating HIV Prevention Digital Media Interventions for Men Who Have Sex with Men

Background As HIV infection continues unabated, there is a need for effective interventions targeting at-risk men who have sex with men (MSM). Engaging MSM online where they meet sexual partners is critical for HIV prevention efforts. Methods A randomized controlled trial (RCT) conducted online among U.S. MSM recruited from several gay sexual networking websites assessed the impact of 2 HIV prevention videos and an HIV prevention webpage compared to a control condition for the study outcomes HIV testing, serostatus disclosure, and unprotected anal intercourse (UAI) at 60-day follow-up. Video conditions were pooled due to reduced power from low retention (53%, n = 1,631). No participant incentives were provided. Principal Findings Follow-up was completed by 1,631 (53%) of 3,092 eligible men. In the 60 days after the intervention, men in the pooled video condition were significantly more likely than men in the control to report full serostatus disclosure (‘asked and told’) with their last sexual partner (OR 1.32, 95% CI 1.01–1.74). Comparing baseline to follow-up, HIV-negative men in the pooled video (OR 0.70, 95% CI 0.54–0.91) and webpage condition (OR 0.43, 95% CI 0.25–0.72) significantly reduced UAI at follow-up. HIV-positive men in the pooled video condition significantly reduced UAI (OR 0.38, 95% CI 0.20–0.67) and serodiscordant UAI (OR 0.53, 95% CI 0.28–0.96) at follow-up. Conclusions/Significance Findings from this online RCT of MSM recruited from sexual networking websites suggest that a low cost, brief digital media intervention designed to engage critical thinking can increase HIV disclosure to sexual partners and decrease sexual risk. Effective, brief HIV prevention interventions featuring digital media that are made widely available may serve as a complementary part of an overall behavioral and biomedical strategy for reducing sexual risk by addressing the specific needs and circumstances of the target population, and by changing individual knowledge, motivations, and community norms. Trial Registration ClinicalTrials.gov NCT00649701

A protocol for the analytical aspects of a systematic review of HIV prevention research.

Summary: Quantitative analysis can reveal the consistency of intervention effects across studies, as well as the variation of effects according to study‐level characteristics. After consulting with project experts in methods and content, and reviewing the literatures on research synthesis and on HIV prevention, we developed a systematic protocol of analytical methods for synthesis of behavioral and biologic outcome data from HIV intervention studies. This protocol included procedures for identifying eligible studies; defining, characterizing, and prioritizing outcomes; abstracting and calculating estimates of effect; adjusting for baseline distributions and intraclass correlation; transforming estimates to a common metric; summarizing effects; examining differences in effectiveness among groups of studies; and translating these results into terms useful to HIV prevention practitioners and researchers. We applied these procedures to transform outcome data reported in many different statistical formats into odds ratios that could be combined and compared across studies. We analyzed data on behaviors related to sexual risk for HIV infection (unprotected sex, condom use, and number of partners) as well as data on biologic outcomes (incidence of HIV and other sexually transmitted infections). This framework may be useful for meta‐analyses of prevention research in other fields, particularly when primary research features diverse outcome measures and methods of analysis.

Social oppression, psychological vulnerability, and unprotected intercourse among young Black men who have sex with men.

OBJECTIVE Young Black men who have sex with men (YBMSM) are at extraordinarily high risk for HIV infection. Given their dual minority identity, they experience multiple forms of social oppression-racism, homophobia, and poverty. This study tested a model for how these forces contribute to their sexual risk behavior. METHOD YBMSM (n = 1,289) from 2 Texas cities completed a 1-time assessment of sexual behaviors and psychosocial variables. Structural equation modeling was used to characterize relationships among variables. RESULTS Experiences of racism, homophobia, and socioeconomic distress were all associated with unprotected anal intercourse (UAI) either directly or indirectly in a manner largely consistent with Díazs (1997, 1998) model of the effects of social oppression. Racism, homophobia, and socioeconomic distress were each associated with specific psychological vulnerabilities, which were in turn associated with participation in difficult sexual situations (e.g., in a public setting), and then UAI. The effects of racism were largely mediated by depressive symptoms and participation in difficult sexual situations. Homophobia was mediated by depressive symptoms, social support, and internalized homophobia. The effects of socioeconomic distress were partially mediated by decreased social support and greater participation in difficult sexual situations. Socioeconomic distress also had a significant direct effect on UAI not explained by the proposed mediators. CONCLUSIONS Social oppression contributes to YBMSMs psychological vulnerabilities, participation in difficult sexual situations, and their UAI. Interventions to reduce sexual risk in YBMSM should address socioeconomic disadvantage, homophobia, and racism, as well as the psychological challenges that social oppression creates for them.

Formulating the Stress and Severity Model of Minority Social Stress for Black Men Who Have Sex with Men

Despite drastic declines in HIV in the United States (US) (Holtgrave, Hall, Rhodes, & Wolitski, 2008), communities of color and men who have sex with men (MSM) are still disproportionately infected. Nationally, MSM comprise 48% of people living with HIV (CDC, 2008a For MSM of all age groups, 35% of new infections were in black MSM (CDC, 2008b). Epidemiological studies of MSM demonstrate that rates of HIV infection have been greater for black MSM as compared with other racial or ethnic groups of MSM (Harawa et al., 2004; Lemp et al., 1994; Mansergh et al., 2002; CDC, 2001). In fact, between 2001 and 2004, black MSM were the only subgroup of blacks for whom new HIV diagnoses actually increased rather than decreased (CDC, 2005a). HIV seroprevalence rates of black MSM in the US have been shown analogous to those in some resource-limited countries (CDC, 2002; CDC, 2005b).