With presentations by six principal investigators (PIs) and more than 15 affiliates, UConn’s Center for Health, Intervention, and Prevention (CHIP) had a strong presence at the 19th biannual International AIDS Conference held in Washington, D.C. in late July.
Five of the presentations made there highlighted results from CHIP Director Jeffrey Fisher’s five-year, $6.4 million National Institute of Mental Health (NIMH) grant to translate his evidence-based Options intervention for HIV-positive individuals for use in South Africa and to test the effectiveness of the adapted version, Options for Health/ Izindlela Zokuphila, at reducing HIV risk behavior among people living with HIV/AIDS (PLWH) at 16 clinics in KwaZulu-Natal province.
Based on the Information-Motivation-Behavioral Skills (IMB) model for health behavior change that Dr. Jeff Fisher and his brother, William A. Fisher, developed two decades ago, Options enlists trusted healthcare providers to have theory-based conversations with HIV-positive patients during routine medical appointments about reducing their risky sexual and drug use behaviors. Clinicians work collaboratively with patients in assessing their risky behaviors and willingness to change. Together, clinicians and patients then develop strategies and set future goals that are written out in a “behavioral prescription” for safer sex or drug use behaviors.
Options is one of relatively few HIV risk reduction interventions for use with HIV-positive patients. It has been lauded by the Centers for Disease Control and Prevention (CDC) as a promising intervention and has been included in its Compendium of Evidence-Based HIV Prevention Interventions.
At the International AIDS Conference, Fisher’s research team reported results from the randomized, controlled trial of Options for Health/Izindlela Zokuphila, which involved 1,891 people living with HIV (PLWH) on antiretroviral therapy (ART) who received either the intervention or a standard of care control and who were followed for 18 months.
Fisher said his team’s findings support the efficacy of the Options for Health/Izindlela Zokuphila intervention for reducing HIV transmission risk behavior among PLWH on ART in South Africa. Intervention participants, compared to standard of care control group participants, experienced consistent, statistically significant, and meaningful reductions in unprotected sex on each of eight HIV transmission risk behavior endpoints. These included reductions in unprotected sex with partners perceived to be HIV-negative and status unknown, across intervals varying from four weeks to six months. The intervention was delivered during routine care by trained lay counselors, nearly all of whom were already employed at the clinical care sites.
“This approach provides efficient and continuing intervention exposure that links clinical care with prevention,” Fisher said. “The South African HIV epidemic has caused catastrophic human suffering. Fortunately, in recent years, a record number of South Africans are being tested for HIV, learning their antibody status, entering care, and receiving lifesaving antiretrovirals.
“For the first time, it has been possible to develop potentially widely disseminable, South African, prevention-with-positives interventions that can be implemented in tandem with routine HIV care to protect the health of people living with HIV and, importantly, to prevent HIV transmission to others.”
At present, high level discussions are occurring between Fisher’s team and South African government officials to disseminate Options for Health/ Izindlela Zokuphila widely throughout KwaZulu-Natal, and to make it the standard of care for PLWH in that province, he said.
Other Options-related results reported at the International AIDS Conference included the following:
- CHIP Associate Director Deborah Cornman reported that 48 lay counselors from the trial’s eight active intervention sites (vs. the eight standard of care sites) had been trained to deliver the intervention within the context of routine clinic care; the intervention was implemented in 75 percent of more than 6,100 lay counselor visits; Options was delivered with fidelity (mean = 7 out of 8 protocol steps), and did not reduce the frequency with which lay counselors provided ART adherence counseling; and exit interviews and focus groups confirmed Options was feasible to implement in busy South African public clinics and the intervention was acceptable to patients and counselors.
- CHIP Affiliate William Fisher reported results from an analysis of data collected prior to trial participants’ exposure to the adapted Options intervention, which applied the IMB model to identify factors associated with HIV transmission risk behavior in the trial population. His results from the first test of the IMB model in HIV-infected South Africans on ART demonstrated the roles, differing by gender, of HIV prevention information, HIV prevention motivation, and HIV prevention behavioral skills as correlates of HIV transmission risk behavior in this population. Gender differences in the findings suggest that motivated men may act to practice safer sex more or less unilaterally, with minimal involvement of their partners, and without reliance on complex behavioral skill performance. Women, in contrast, may require complex and sophisticated behavioral skills to negotiate safer sex with their partners and effectively ensure that safer sexual practices are initiated and maintained. Implications of these findings are that gender-targeted interventions for HIV-infected men on ART may emphasize strengthening their HIV prevention motivation and gender-targeted interventions for HIV-infected women on ART may emphasize strengthening HIV prevention behavioral skills.
- CHIP Affiliate Paul Shuper reported gender-specific risk factors associated with HIV transmission behavior, based on audio computer-assisted self-interviews (ACASI) in isiZulu or English that trial participants completed upon enrollment in the trial. He found HIV transmission risk behavior among female PLWH was indicative of challenging partnerships, in which the prospect of physical abuse, low perceived power, and a lack of disclosure may have hindered safer sex efforts. For male PLWH, three unique, modifiable risk factors were identified: depression, negative condom attitudes, and seeking help from Traditional Healers. Additionally, male PLWH who were relatively younger tended to be riskier. These findings have implications for “positive prevention” in South Africa. Efforts targeting female PLWH could focus on empowerment, skills training, and the provision of referrals for abuse. For male PLWH, prevention efforts could focus on identifying and treating depression, altering HIV risk perceptions associated with traditional medicine, and improving attitudes toward condoms.
- Laramie Smith, a CHIP affiliate and UConn doctoral student in Social Psychology, used an IMB-based measure as a rapid needs assessment to identify the most prevalent retention in pre-ART care barriers among four primary healthcare clinics in KwaZulu-Natal. Smith found that barriers to pre-ART care identified across two or more clinics included: misinformation about ART eligibility, HIV transmission, and health screening; motivational barriers such as low perceived social support for attending care, and confidentiality and anticipated stigma concerns; and lower perceived skills to manage clinic wait times and transportation costs. Smith also found that each clinic had unique barriers to retention in pre-ART care and that the IMB-based measure can serve an important role in identifying clinic-specific barriers to retention in care among ART-ineligible patients and informing intervention approaches to address these specific barriers.
CHIP PI Rivet Amico also was a part of Fisher’s Options research team and CHIP PIs Seth Kalichman, Leslie Snyder, and Lisa Eaton presented research results from separate projects at the International AIDS Conference.