Secondary HIV Prevention: Novel Intervention Approaches to Impact Populations Most at Risk

This paper reviews recent secondary prevention interventions designed to reduce sexual risk behaviors among people living with HIV/AIDS (PLWHA). A summary of findings from previous meta-analyses and narrative reviews of interventions is provided. Next, novel HIV prevention approaches for PLWHA are reviewed. The review reports on the efficacy of interventions delivered in primary care settings or by technology-formats, interventions that also address mental health difficulties, and programs to address particular at-risk populations (eg, men who have sex with men). A critique of recent interventions for people living with HIV/AIDS is provided as well as suggestions for future research.     

Drug treatment as HIV prevention: a research update

Drug use continues to be a major factor fueling the global epidemic of HIV infection. This article reviews the current literature on the ability of drug treatment programs to reduce HIV transmission among injection and noninjection drug users. Most data come from research on the treatment of opiate dependence and provide strong evidence on the effectiveness of medication-assisted treatment for reducing the frequency of drug use, risk behaviors, and HIV infections. This has been a consistent finding since the epidemic began among diverse populations and cultural settings. Use of medications other than methadone (such as buprenorphine/naloxone and naltrexone) has increased in recent years with promising data on their effectiveness as HIV prevention and as new treatment options for communities heavily affected by opiate use and HIV infection. However, few treatment interventions for stimulant abuse and dependence have shown efficacy in reducing HIV risk. The cumulative literature provides strong support of drug treatment programs for improving access and adherence to antiretroviral treatment. Drug users in substance abuse treatment are significantly more likely to achieve sustained viral suppression, making viral transmission less likely. Although there are challenges to implementing drug treatment programs for maximum impact, the scientific literature leaves no doubt about the effectiveness of drug treatment as an HIV prevention strategy.     

Managing HIV/AIDS in correctional settings

Approximately one quarter of people living with HIV/AIDS in the United States pass through the correctional system, resulting in a burden of infection on the correctional health care system that has challenged correctional and public health officials. The HIV epidemic behind bars results from the high prevalence of HIV risk behaviors among those incarcerated: illicit drug use, untreated mental illness, prostitution, homelessness, and poverty. Challenges to HIV care in correctional settings include management of comorbid conditions, remoteness from HIV care sites, organizational constraints, and access to effective therapies. Despite these challenges, prisoners with HIV have derived considerable benefit from HIV detection and treatment. In order to achieve parity in HIV outcomes among vulnerable populations, effective prison-release programs that incorporate effective case management with effective drug treatment and adherence strategies are required to extend the benefit of highly active antiretroviral therapy as prisoners transition back to community settings.     

Methadone maintenance as HIV risk reduction with street-recruited injecting drug users

OBJECTIVE: To compare changes in HIV risk behaviors between street-recruited opiate injectors who entered and remained in methadone maintenance treatment and those who did not. METHODS: Three hundred sixteen participants were interviewed at baseline, received outreach interventions, and were interviewed again 6 months later. RESULTS: Significant (p <.001) reductions in HIV-related risk behaviors, including frequency of injecting, injecting with used (dirty) needles, and sharing injection paraphernalia, were demonstrated. Participants (31%) who entered and remained in methadone maintenance treatment for at least 90 days before follow-up showed a significantly greater reduction in heroin injections than those who did not. They did not show a greater reduction in using dirty needles or sharing other injection paraphernalia. CONCLUSIONS: These findings suggest that although methadone maintenance may reduce injection frequency, it does not reduce other HIV-related risk behaviors above and beyond what can be accomplished through outreach interventions. Treatment facilities and outreach intervention programs should collaborate to provide a comprehensive approach to reducing HIV risk behaviors among drug injectors both in and out of drug treatment.     

Give them prizes, and they will come: contingency management for treatment of alcohol dependence

This study evaluated the efficacy of a contingency management (CM) procedure that provided opportunities to win prizes as reinforcers. At intake to outpatient treatment, 42 alcohol-dependent veterans were randomly assigned to receive standard treatment or standard treatment plus CM, in which they earned the chance to win prizes for submitting negative Breathalyzer samples and completing steps toward treatment goals. Eighty-four percent of the CM participants were retained in treatment for an 8-week period compared with 22% of the standard treatment participants (p < .001). By the end of the treatment period, 69% of those receiving CM were still abstinent, but 61% of those receiving standard treatment had used alcohol (p < .05). These results support the efficacy of this CM procedure. Participants earned an average of $200 in prizes. This CM procedure may be suitable for use in standard treatment settings because prizes can be solicited from the community.     

Management of Cryptococcal Meningitis in Sub-Saharan Africa

Cryptococcal meningitis (CM) is a common form of meningitis in sub-Saharan Africa due to the high prevalence of HIV/AIDS. This report outlines the management of CM with a focus on resource-limited settings. Sections covered include epidemiology and diagnosis, pharmacotherapy, management of complications, timing of antiretrovirals, and primary and secondary prevention of CM. Emphasis has been given to recent articles and landmark trials, and opinion is given from the authors’ own experiences.     

Drug Treatment as HIV Prevention: Expanding Treatment Options

Research conducted during the first 20 years of the AIDS epidemic provided a solid foundation of data supporting methadone treatment as HIV prevention. Drug users in methadone treatment were consistently found to reduce the frequency of drug use, risk behaviors, and infections. These data have been consistent over time and across cultural settings and have been used to promote the expansion of drug treatment as a prevention intervention. More recently, data have emerged suggesting the prevention potential of medication-assisted treatments other than methadone (buprenorphine/naloxone and naltrexone). Still, with a few notable exceptions, global drug treatment coverage for opiate injectors remains remarkably low and only a few treatment interventions for stimulant use have shown efficacy in reducing HIV risk. Importantly, more recent data provide support for the role of drug treatment programs in improving access and adherence to antiretroviral treatment and that injection drug users in substance abuse treatment are more likely to achieve sustained viral suppression. While important challenges remain in maximizing its impact, the scientific literature provides strong evidence of the efficacy of drug treatment as an HIV prevention strategy.     

The impact of an integrated treatment on HIV risk behavior among homeless youth: a randomized controlled trial

While many studies provide useful information on the risk behaviors in which homeless youth engage, few prior studies evaluate Human Immunodeficiency Virus (HIV) risk related reduction strategies. In this study, homeless youth (n = 180) were recruited from a drop-in center and randomly assigned to one of two conditions, either an integrated individual cognitive-behavioral treatment and HIV prevention intervention that focused on skills building and education or to treatment as usual. All youth were assessed at entry into the program and at 3 and 6 month follow-up points. Findings showed an interaction between treatment condition, age and time. In the interaction, youth assigned to the integrated treatment reported greater condom usage than youth assigned to treatment as usual, with younger youth assigned to treatment as usual showing no change in condom use. The number of sexual partners reported by youth in both treatment conditions was also reduced over time. However, youth in both conditions continued to engage in other high-risk behaviors. The integrated treatment findings are promising and suggest that interventions which target both HIV risk behavior in addition to other life areas (substance use, mental health and housing) among homeless youth may be necessary in order to significantly impact high-risk behaviors among this unique group.     

Opportunities to diagnose, treat, and prevent HIV in the criminal justice system

Persons involved with the criminal justice system are at risk for HIV and other transmissible diseases due to substance use and related risk behaviors. Incarceration provides a public health opportunity to test for HIV, viral hepatitis, and other sexually transmitted infections, provide treatment such as highly active antiretroviral therapy, and link infected persons to longitudinal comprehensive HIV care upon their release for such comorbidities as addiction and mental illness. Delivering health interventions inside prisons and jails can be challenging, yet the challenges pale in comparison to the benefits of interventions for inmates and their communities. This article reviews the current state of delivering HIV testing, prevention, treatment, and transition services to incarcerated populations in the United States. It concludes with summary recommendations for research and practice to improve the health of inmates and their communities.     

Couple-based HIV prevention in the United States: advantages, gaps, and future directions

This article presents an overview of couple-based HIV prevention research to date, advantages of using and core components of couple-based interventions, gaps in the current understanding of couple-based HIV prevention, status of dissemination research and the transportability of effective couple-based HIV prevention and treatment to real-world settings, and recommendations for future directions in couple-based prevention and treatment. Couple-based studies conducted among several populations-heterosexuals, men who have sex with men, and drug users-reported in the research literature were reviewed. Commonalities and limitations were noted in customary focus areas of the couple-based approaches: sexual and drug risk reduction, HIV testing behaviors, adherence to HIV treatment, and prevention of mother-to-child transmission. Couple-based intervention strategies have been rigorously tested and are a valuable addition to the arsenal of HIV prevention strategies. Immediate needs and opportunities include couple-based intervention strategies for prevention of HIV and other sexually transmitted infections among serodiscordant couples, couples who do not know their HIV status, and couples in whom both partners are HIV negative but at risk of HIV infection. There is a particular need to develop couple-based intervention strategies for men who have sex with men and for drug-involved couples.     

Seroadaptation among Men Who Have Sex with Men: Emerging Research Themes

Seroadaptation describes a diverse set of potentially harm-reducing behaviors that use HIV status to inform sexual decision making. Men who have sex with men (MSM) in many settings adopt these practices, but their effectiveness at preventing HIV transmission is debated. Past modeling studies have demonstrated that serosorting is only effective at preventing HIV transmission when most men accurately know their HIV status, but additional modeling is needed to address the effectiveness of broader seroadaptive behaviors. The types of information with which MSM make seroadaptive decisions is expanding to include viral load, treatment status, and HIV status based on home-use tests, and recent research has begun to examine the entire seroadaptive process, from an individual's intentions to seroadapt to their behaviors to their risk of acquiring or transmitting HIV and other STIs. More research is needed to craft clear public health messages about the risks and benefits of seroadaptive practices.     

The evolving role of HIV counseling and testing in resource-limited settings: HIV prevention and linkage to expanding HIV care access

The role of voluntary counseling and testing (VCT)of HIV in resource-limited settings has recently broadened from primarily that of a prevention intervention to its identification as the key entry point into expanding access to life-saving antiretroviral therapy, additional HIV-specific medical care, and other support services. To fulfill this expanded mandate, calls for routine counseling and testing in diverse health care settings, in addition to other innovative approaches to traditional VCT, are emerging. The efficacy and cost-effectiveness of traditional facility-based VCT with respect to risk-behavior reduction of HIV have been demonstrated rigorously in resource-limited settings. Additional research is needed urgently to evaluate the feasibility, acceptability, and effectiveness of streamlined counseling and testing interventions that seek to reach as many individuals as possible to meet dual prevention and treatment goals.     

New Insights in the Prevention, Diagnosis, and Treatment of Cryptococcal Meningitis

Cryptococcal meningitis (CM) remains a major cause of morbidity and mortality among immunocompromised patients, especially in areas of high HIV prevalence, although it can also cause disease in the apparently immunocompetent. Improving the management of HIV-associated CM is important to ensure that patients can survive to benefit from increasing access to ART. In this review we focus on recent advances in prevention, diagnosis, and treatment of CM.     

Treating curable sexually transmitted infections to prevent HIV in Africa: still an effective control strategy?

BACKGROUND: Evidence regarding the effectiveness of sexually transmitted infection (STI) treatment for HIV prevention in Africa is equivocal, leading some policy makers to question whether it should continue to be promoted for HIV control. We explore whether treating curable STIs remains a cost-effective HIV control strategy in Africa. METHODS: The model STDSIM was fitted to the characteristics of 4 populations in East and West Africa. Over the simulated HIV epidemics, the population-attributable fractions (PAFs) of incident HIV attributable to STIs, the impact of syndromic STI management on HIV incidence, and the cost per HIV infection averted were evaluated and compared with an estimate of lifetime HIV treatment costs (US $3500). RESULTS: Throughout the HIV epidemics in all cities, the total PAF for. all STIs remained high, with > or = 50% of HIV transmission attributed to STIs. The PAF for herpes simplex virus type 2 increased during the epidemics, whereas the PAF for curable STIs and the relative impact of syndromic management decreased. The models showed that the absolute impact of syndromic management remains high in generalized epidemics, and it remained cost-saving in 3 of the 4 populations in which the cost per HIV infection averted ranged between US $321 and $1665. CONCLUSION: Curable STI interventions may remain cost-saving in populations with generalized HIV epidemics, particularly in populations with high-risk behaviors or low male circumcision rates.     

Effects of health coaching on behavioral modification among adults with cardiovascular risk factors: Systematic review and meta-analysis

ObjectivesThis meta-analysis examined effects of health coaching on physical activities, dietary behaviors, health responsibility, stress management, and smoking behaviors among populations with cardiovascular risk factors.MethodsMultiple electronic databases were searched for randomized controlled trials utilizing health coaching for people with cardiovascular risk factors to lead behavioral changes. The included studies were pooled to estimate the effect size for health coaching interventions on each of the health behaviors.ResultsThis meta-analysis included 15 randomized trials. Motivational interviewing and education sessions were common coaching interventions with telephone calls or face-to-face contacts as the main contact methods. Health coaching for health behaviors showed small but significant effect sizes on physical activities, dietary behaviors, health responsibility, and stress management except for smoking behaviors.ConclusionThe study findings support that health coaching can induce positive behavioral changes among individuals with cardiovascular risk factors. Health coaching delivered by either expert or peer coaches would be easy to apply in clinical settings.Practical implicationsHealth care professionals should be aware that health coaching could provide effective motivation strategies to improve compliance of those who need to initiate and maintain their health behaviors. Health coaching could be easily delivered via telephone calls, text messages, or short-term face-to-face coaching.     

Low-cost contingency management for treating cocaine- and opioid-abusing methadone patients

This study evaluated the efficacy of a low-cost contingency management (CM) procedure in reducing concurrent cocaine and opioid use among methadone patients. Forty-two patients were randomly assigned to 12 weeks of standard treatment or standard treatment plus CM. CM patients eamed the opportunity to draw from a bowl and win prizes ranging from $1 to $ 100 in value for submitting samples negative for cocaine and opioids. Patients in the CM condition achieved longer durations of continuous abstinence than patients in the standard treatment condition, and these effects were maintained throughout a 6-month follow-up period. On average, patients in the CM condition earned $137 of prizes. These data suggest that this prize reinforcement procedure may be suitable for community-based settings.     

Contingency management treatments: Reinforcing abstinence versus adherence with goal-related activities

Contingency management (CM) interventions usually reinforce submission of drug-negative specimens, but they can also reinforce adherence with goal-related activities. This study compared the efficacy of the 2 approaches. Substance-abusing outpatients (N = 131) were randomly assigned to 1 of 3 12-week treatments: standard treatment (ST), ST with CM for submitting negative urine toxicology screens, or ST with CM for completing goal-related activities. CM patients remained in treatment longer and achieved more abstinence than ST patients, but the CM condition that reinforced submission of negative samples resulted in better outcomes than the CM condition that reinforced goal-related activities. Abstinence at 6- and 9-month follow-ups did not differ by group, but longest duration of abstinence achieved during treatment was associated with abstinence posttreatment.     

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

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 quasi-experimental 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.     

Vouchers versus prizes: contingency management treatment of substance abusers in community settings

Contingency management (CM) interventions usually use vouchers as reinforcers, but a new technique awards chances of winning prizes. This study compares these approaches. In community treatment centers, 142 cocaine- or heroin-dependent outpatients were randomly assigned to standard treatment (ST), ST with vouchers, or ST with prizes for 12 weeks. CM patients remained in treatment longer and achieved greater durations of objectively confirmed abstinence than did ST patients; CM conditions did not differ significantly. Although abstinence at 6- and 9-month follow-ups did not differ by group, the best predictor of abstinence was longest duration of abstinence achieved during treatment. Thus, prize and voucher CM systems are equally efficacious in promoting long durations of abstinence, which in turn are associated with benefits posttreatment.     

Mental health and HIV risk in men who have sex with men

Evidence-based HIV prevention interventions with men who have sex with men (MSM) in the United States have moderate effect sizes in reducing HIV sexual risk behavior. Mental health and psychosocial problems, which both disproportionately affect MSM populations and are implicated in HIV transmission risk behaviors, also likely interfere with the uptake of HIV behavioral interventions. Moreover, given that mental health and psychosocial problems such as depression, substance use, and violence frequently co-occur for many MSM (eg, as syndemic conditions), what is probably needed are combination prevention efforts, or prevention "cocktails," similar to treatment "cocktails," that address the psychological and behavioral mechanisms that interact to produce elevated risk for HIV. Such interventions should incorporate a holistic framework to address the sexual health and overall well being of MSM. Addressing co-occurring psychosocial risk factors is apt to improve effect sizes of current HIV prevention interventions and allow for more effective uptake by MSM.