B
The Prevention Portfolio: Interventions to Prevent HIV Infection

After approximately two decades of research on interventions to prevent HIV infection, there is a wealth of data documenting the results of HIV prevention efforts. The majority of existing prevention strategies are behavioral interventions that try to change sexual and substance use practices that increase risk of exposure to and infection with the virus. There also are interventions that occur on the biomedical or technological level. These have the same goal of preventing new HIV infections, but make use of the advances in clinical medicine, HIV treatment, and biotechnology to lower individuals’ susceptibility to HIV infection. In addition, prevention efforts benefit from the treatment of other co-occurring diseases, such as sexually transmitted diseases (STDs), substance abuse, and mental disorders. Still other prevention interventions are societal in that they strive to change the social and environmental factors—such as policies, access to prevention services, and social norms—that contribute to individuals’ HIV risk.

All of these types of interventions, in essence, comprise a menu of options that can be used to prevent new HIV infections. Table B.1 presents a summary of the interventions currently available for HIV prevention. The following discussion of these strategies relies on reviews and meta-analyses of the behavioral and biomedical research literature, particularly the Centers for Disease Control and Prevention’s Compendium of HIV Prevention Interventions with Evidence of Effectiveness (1999) and the National Institutes of Health Consensus Statement (1997).



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No Time to Lose: Getting More from HIV Prevention B The Prevention Portfolio: Interventions to Prevent HIV Infection After approximately two decades of research on interventions to prevent HIV infection, there is a wealth of data documenting the results of HIV prevention efforts. The majority of existing prevention strategies are behavioral interventions that try to change sexual and substance use practices that increase risk of exposure to and infection with the virus. There also are interventions that occur on the biomedical or technological level. These have the same goal of preventing new HIV infections, but make use of the advances in clinical medicine, HIV treatment, and biotechnology to lower individuals’ susceptibility to HIV infection. In addition, prevention efforts benefit from the treatment of other co-occurring diseases, such as sexually transmitted diseases (STDs), substance abuse, and mental disorders. Still other prevention interventions are societal in that they strive to change the social and environmental factors—such as policies, access to prevention services, and social norms—that contribute to individuals’ HIV risk. All of these types of interventions, in essence, comprise a menu of options that can be used to prevent new HIV infections. Table B.1 presents a summary of the interventions currently available for HIV prevention. The following discussion of these strategies relies on reviews and meta-analyses of the behavioral and biomedical research literature, particularly the Centers for Disease Control and Prevention’s Compendium of HIV Prevention Interventions with Evidence of Effectiveness (1999) and the National Institutes of Health Consensus Statement (1997).

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No Time to Lose: Getting More from HIV Prevention TABLE B.1 Biomedical and Behavioral Intervention Strategies Used to Prevent New HIV Infections Type of Intervention Populations/Risk Groups Outcomes Affected Behavioral Interventions Voluntary counseling and testing General population • Decreased HIV risk behavior Prevention case management HIV-infected persons, uninfected individuals at elevated risk • Decreased sexual risk behavior • Decreased drug use-related risk behavior • Increased condom use Health education and risk reduction counseling (HERR)     • For adolescents/youth Adolescents, youth, young people at elevated risk (e.g., homeless, runaway) • Increased HIV knowledge • Increased positive attitudes toward risk reduction • Decreased sexual risk behavior • Increased condom use • Decreased drug use-related risk behavior • For injection drug users (IDUs) IDU • Decreased sexual risk behavior • Decreased drug-related risk behavior • Increased condom use • For STD clinic attenders STD clinic attenders, high-risk adults behavior • Decreased sexual risk • Increased condom use • Decreased STD incidence • Decreased drug use-related risk behavior • For men who have sex with men (MSM) Gay and bisexual men • Decreased sexual risk behavior • Increased condom use • Decreased drug use-related risk behavior • For women Women at elevated risk of infection (including sexual partners of highrisk individuals, such as IDU) • Increased HIV knowledge • Increased condom use • Decreased sexual risk behavior • Decreased drug use-related risk behavior

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No Time to Lose: Getting More from HIV Prevention Type of Intervention Populations/Risk Groups Outcomes Affected Street/community outreach High-risk persons, e.g., IDU, CSW, homeless/runaway youth • Decreased sexual risk behavior • Decreased drug use-related risk behavior • Increased condom use School-based HERR education Adolescents, youth in educational settings (who may or may not be sexually active) • Increased HIV knowledge • Increased positive attitudes toward risk reduction • Decreased sexual risk behavior • Increased condom use Prison-based HERR education Prison inmates While incarcerated: • Increased HIV knowledge • Increased positive attitudes toward risk reduction When released: • Decreased sexual risk behavior • Increased condom use • Decreased drug use-related risk behavior Interventions Associated with Treatment of Co-Occurring Conditions Treatment of sexually transmitted diseases (STD) Persons with STD infection • Decreased sexual risk behavior • Decreased susceptibility to HIV due to STD infection Substance abuse treatment IDU and other alcohol/substance abusers • Decreased number of potential sexual or drug use-related exposures to HIV caused by addiction behavior Psychiatric/mental health treatment Persons with psychological disorders or severe • Decreased number of potential sexual or drug-mental illness use related exposures to HIV caused by psychiatric disorders Biomedical and Technological Interventions Administration of zidovudine (AZT) for Pregnant HIV-infected women • Decreased vertical transmission of HIV from perinatal transmission mother to infant

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No Time to Lose: Getting More from HIV Prevention Type of Intervention Populations/Risk Groups Outcomes Affected Postexposure prophylaxis (PEP) for occupational HIV exposure Health care workers • Decreased number of new HIV infections caused by work-related exposure to contaminated blood Postexposure prophylaxis (PEP) for nonoccupational HIV exposure Persons with sexual or other nonoccupational exposure to HIV • Unproven efficacy in preventing HIV infection Screening of blood (and blood products) for HIV All blood products • Decreased number of new HIV infections caused by receipt of contaminated blood or blood products Antiretroviral therapy (ART) HIV-infected persons • Decreased infectiousness of HIV-infected person, possibly resulting in decreased sexual transmission of HIV to uninfected sex partners Societal Interventions Mass media General population • Increased HIV/AIDS knowledge • Increased positive attitudes toward risk reduction Condom social marketing/ behavior availability General population • Decreased sexual risk • Increased condom use Structural (policy, legal) interventions General population • Increased access to prevention services and tools (e.g., sterile injection equipment) BEHAVIORAL INTERVENTIONS There is an impressive body of evidence for the efficacy of prevention. Behavioral interventions have been shown to be capable of changing risk behaviors related to both sexual practices and substance use in populations of men who have sex with men (ACDP Research Group, 1999; Kegeles et al., 1996; Kelly et al., 1992; Valdiserri et al., 1989), injection drug users (e.g., review by Booth and Watters, 1994), young people (Jemmott et al., 1998; Rotheram-Borus et al., 1997; Stanton et al., 1996; St. Lawrence et al., 1995; Jemmott et al., 1992); heterosexual men (reviewed in Exner et al.,

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No Time to Lose: Getting More from HIV Prevention 1999), and women (Sikkema et al., 2000; Exner et al., 1997; DiClemente and Wingood, 1995) . Because behavioral interventions can be tailored to meet the prevention needs and respect the cultural diversity of different populations, they can be adapted for delivery in community settings, including specific venues (e.g., housing developments, STD clinics, schools, and prisons) where at-risk populations are located or come together (e.g., Sikkema et al., 2000; Kamb et al., 1998; NIMH Multisite HIV Prevention Trial Group, 1998; Boyer et al., 1997; Magura et al., 1994; Main et al., 1994; Cohen et al., 1991). INTERVENTIONS ASSOCIATED WITH THE TREATMENT OF CO-OCCURRING CONDITIONS Because of the epidemiological synergy between HIV/AIDS and substance abuse, mental health disorders, and STDs, it is crucial to acknowledge the benefit that treatment of these co-occurring conditions can have on the prevention of new HIV infections. There is a wealth of evidence showing that treatment of STDs can reduce individuals’ susceptibility to HIV infection, as well as reduce transmission of HIV (CDC, 1998). Further, behavioral counseling by providers during STD treatment can help to encourage risk-reducing behavior change (Cohen, 1995). Similarly, there is ample evidence that treating substance abuse disorders not only facilitates successful recovery from addiction, but is also associated with reduced HIV infections caused by substance use-related behavior (e.g., sharing injection equipment or engaging in high-risk sexual practices) (Iguchi, 1998; Shoptaw et al., 1998; Moss et al., 1994). Additionally, given that psychiatric disorders and mood disturbances have been shown to be associated with high-risk sexual behavior (Marks et al., 1998; Folkman et al., 1992) and substance use (Drake and Osher, 1997; Regier et al., 1993), treatment for these disorders can lead to reductions in HIV risk behavior. Further, given that mental illness among HIV-infected persons can contribute to poor adherence to antiretroviral therapy (Murphy et al., 1999; Cheever et al., 1998; Schulz et al., 1998), treatment of psychiatric comorbidity could improve medical adherence to antiretroviral treatments and lead to subsequent decreases in viral load and infectiousness. BIOMEDICAL AND TECHNOLOGICAL INTERVENTIONS Recent advances in antiretroviral therapies (ARTs) have resulted in the development of several highly effective protocols that can be used for prevention of HIV infection. For example, there is strong evidence that the administration of zidovudine or nevirapine to pregnant HIV-infected women greatly reduces the risk of perinatal transmission of HIV (IOM,

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No Time to Lose: Getting More from HIV Prevention 1999; Connor et al., 1994). Similarly, recent evidence suggests that treating HIV-infected persons with low or undetectable viral load have reduced infectiousness to seronegative sexual partners (Quinn et al., 2000). Much more evidence is needed, however, to confirm these findings. Antiretroviral therapy has also been shown to be effective (and is recommended) for reducing the likelihood of infection after occupational exposures (e.g., needle sticks) to HIV (CDC, 1996). Using such treatment may be effective for preventing infection from nonoccupational (e.g., sexual) exposure to HIV, although no data currently exist regarding the effectiveness of this intervention (CDC, 1998). Additionally, the development of sensitive HIV antibody screening assays have been shown to be highly effective in ensuring a blood supply that is virtually free of HIV infection risk (IOM, 1995). SOCIETAL INTERVENTIONS Societal prevention interventions show remarkable efficacy in preventing new HIV infections. Such approaches can be highly cost-effective because they can inexpensively reach large numbers of at-risk individuals (Holtgrave et al., 1998; Pinkerton and Holtgrave, 1998). The social marketing of condoms is an example of a societal intervention that has been proven effective for HIV prevention, particularly in developing countries (Ford et al., 1996; Bhave et al., 1995; Ford and Norris, 1993; Ngugi et al., 1988). Condom social marketing seeks to increase the popularity of condoms using advertising and mass media, as well as to increase access to condoms by making them widely available to the general public through community health facilities, promotional events, and other mechanisms (Andreasen, 1995). With combined increases in condom advertising and availability, these campaigns promote the idea that condom use is an attractive, positive behavior, all the while reducing the barriers to engaging in this behavior. Typically, condom social marketing results in increased rates of community level condom use, thereby providing benefit to the multiple goals of HIV and STD prevention. A nationwide condom advertising and availability program has never occurred in the United States (Bedimo et al., in review). However, smaller-scale studies of condom social marketing in selected areas show such programs are met with great receptivity by individuals, can be very cost effective, and are easy to implement (Cohen et al., 1991; Bedimo et al., in review). While these types of campaigns should not replace individual and community-level risk reduction interventions, they can be strong complements to the prevention efforts made by those more intensive programs (Bedimo et al., in review). Both individual-level and population-

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No Time to Lose: Getting More from HIV Prevention based interventions should be used to prevent the further spread of HIV (Kelly, 1999). Similarly, prevention social marketing has been effective in reducing risk behavior in both industrialized countries, such as Switzerland (Dubois-Arber et al., 1997), and developing countries, such as Thailand (Nelson et al., 1996). In the United States, the only AIDS-related nationwide mass media campaign to date was “America Responds to AIDS” (ARTA). Conducted from October 1987 to July 1990, ARTA was a five-phased multimedia (e.g., multilingual mailings, public service announcements on television and radio stations, and posters) campaign designed to increase public awareness of and knowledge about HIV/AIDS. A smaller-scale social marketing effort, the Prevention Marketing Initiative, was implemented by the CDC in 1994 and was directed at adolescents in five cities. This initiative was successful in obtaining positive behavioral risk-reduction outcomes among adolescents, such as increases in carrying condoms and reductions in the number of unprotected sexual acts (U.S. Conference of Mayors, 1994; Kennedy et al., 2000). Broader implementation of such programs in the United States could potentially reach those risk populations who have limited or sporadic access to HIV prevention messages. Further, educational components of such campaigns can help to reduce the stigma and negative attitudes associated with HIV/AIDS, substance abuse, and sexuality. There also is striking evidence in support of policy interventions that increase individuals’ access to prevention services and tools. For example, needle-exchange programs have been widely demonstrated to be effective in reducing substance use-related risk behaviors (such as needle sharing) without increasing overall prevalence of substance use in either adults or youth (e.g., IOM, 1995; Valleroy et al., 1995). Unfortunately, societal interventions are underutilized in the United States due to social attitudes and policy barriers opposing their implementation. These barriers are addressed in greater detail in Chapter 7. REFERENCES USED IN THE COMPLILATION OF THE TABLE OF BIOMEDICAL AND BEHAVIORAL INTERVENTIONS AIDS Community Demonstration Projects. 1999. Community-level HIV intervention in 5 cities: Final outcome data from the CDC AIDS Community Demonstration Projects. American Journal of Public Health 89(3):336–345. Andreasen AR. 1995. Marketing Social Change. San Francisco: Jossey-Bass. Bedimo AL, Pinkerton SD, Cohen DA, Gray B, Farley TA. In review. Cost-savings of a condom social marketing program. American Journal of Public Health. Bhave G, Lindan CP, Hudes ES, Desai S, Wagle U, Tripathi SP, Mandel JS. 1995. Impact of an intervention on HIV, sexually transmitted diseases, and condom use among sex workers in Bombay, India. AIDS 9 (Suppl 1):S21–S30.

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