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Compendium of Evidence-Based HIV Behavioral Interventions

Choosing Life: Empowerment, Actions, Results (CLEAR)

(In-person delivered intervention)

BEST-EVIDENCE

Intervention Description

Target Population
Young HIV-positive substance abusers

Goals of Intervention

  • Reduce sexual and substance use risk behaviors
  • Improve mental and physical health

 

Brief Description

CLEAR is a 3-module intervention that is delivered in one-on-one sessions to young people living with HIV. Each of the 3 modules is comprised of 6 sessions that focus on different target behaviors. Module 1 focuses on improving youths’ physical health, including the use of and adherence to antiretroviral medication, implementing new daily routines to stay healthy, and coping with their serostatus. Module 2 aims to reduce unprotected sex acts and substance use through the identification of situations that elicit risky behavior. In this module, participants build skills in condom use self-efficacy and negotiation of safer sex. Module 3 aims to reduce emotional distress and to increase quality of life of participants. Each participant is taught relaxation, self-instruction and meditation techniques in order to control negative emotional states. Participants also identify long-term life goals in this module.

Theoretic Basis

  • Cognitive Behavior Therapy
  • Social Action Theory

Intervention Duration
18 sessions total (6 sessions per module); each session lasts 1.5 hours

Intervention Settings
Coffee shops, community agencies, private rooms at collaborating sites, parks, or participants’ residences

Deliverer
Licensed therapist or clinical social worker

Delivery Methods

  • Demonstration
  • Exercise/games
  • Goal setting
  • Lectures
  • Role plays and practice

 

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Intervention Package Information

The intervention package and training modified for inclusion with Comprehensive Risk Counseling Services (CRCS), are available through CDC’s Diffusion of Effective Behavioral Interventions (DEBI) project.

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Evaluation Study and Results

The original evaluation study was conducted in Los Angeles and San Francisco, California, and New York City, New York, between 1999 and 2003. The study included a sample of 175 young people living with HIV.

Key Intervention Effects
Increased proportion of condom-protected sex acts with all partners and with HIV-seronegative partners

Study Sample

  • 42% Hispanic, 26% African American, 23% White, 8% other
  • 78% Male; 22% Female
  • 76% Homosexual, bisexual, or questioning
  • Median age of 23 years (range 16–29)

Recruitment Settings
Adolescent AIDS clinics, social service agencies, communitybased organizations, and media outlets including newspapers, conferences, and community events

Eligibility Criteria
Participants were considered eligible for the evaluation if they were HIVseropositive and used illicit drugs at least 5 times in the prior 3 months.

Assignment Method
Participants were randomly assigned to one of the three intervention arms: in-person intervention (n = 61), telephone-delivered intervention (n = 59), or wait-list control (n = 55).

Comparison Group
The waitlist control group received a delayed intervention.

Relevant Outcomes Measured and Follow-up Time

  • Sexual risk behaviors during the prior 3 months (including number of HIV-negative sex partners, percentage of protected acts with all partners, percentage of protected acts with HIV-negative partners, consistent condom use and abstinence) were assessed at 3, 6, 9 and 15 months post baseline.
  • Drug injection during the prior 3 months was assessed at 3, 6, 9 and 15 months post baseline.
  • Follow-up time points translate to during the intervention and 1.5, 4.5, and 10.5 post intervention.

Participant Retention

  • In-Person Intervention:
    89% retained at 3 months
    80% retained at 6 months
    79% retained at 9 months
    84% retained at 15 months
  • Telephone-Delivered Intervention:
    85% retained at 3 months
    71% retained at 6 months
    90% retained at 9 months
    80% retained at 15 months
  • Waitlist Control: 
    84% retained at 3 months
    80% retained at 6 months
    82% retained at 9 months
    78% retained at 15 months

Significant Findings
At 15 months post baseline, participants who received the inperson CLEAR intervention reported significantly greater increases in the proportion of protected sex acts with all sex partners (p < 0.01) and proportion of protected sex acts with HIV-seronegative partners (p < 0.05) than waitlist control participants. Participants receiving the inperson intervention also reported a significantly greater increase in the proportion of protected sex acts with HIV-negative partners at 15 months post baseline than participants in the telephone-delivered intervention (p < 0.01).

Considerations

  • The telephone-delivered intervention did not meet the best evidence criteria because the in-person intervention resulted in a significantly greater proportion of protected sex acts than the telephone-delivered intervention and the telephonedelivered intervention was not efficacious in reducing risk behaviors relative to the control group. Only the in-person CLEAR intervention is considered to meet the best-evidence criteria.
  • Other targeted outcomes – substance use, HIV medication adherence, health behaviors, and emotional distress-were not significantly improved by the intervention.

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References and Contact Information

  • Rotheram-Borus, M., Swendeman, D., Comulada, S., Weiss, R.E., Lee, M., & Lightfoot, M. (2004). Prevention for Substance-using HIV positive young people: telephone and in-person delivery. Journal of Acquired Immune Deficiency Syndromes, 37 (2) S68S77.

Researcher: Dr. Mary Jane Rotheram-Borus
10920 Wilshire Boulevard Suite 350
Los Angeles, CA 90024
e-mail: rotheram@ucla.edu

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