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Compendium of Evidence-Based HIV Behavioral Interventions

Together Learning Choices (TLC)

GOOD-EVIDENCE

Intervention Description

Target Population
HIV-positive adolescent and young adult clinic patients

Goals of Intervention

  • Enhance health behaviors
  • Increase condom use
  • Eliminate or reduce unprotected sex or refuse to have unsafe sex
  • Eliminate or reduce drug and alcohol use

Brief Description

TLC (Together Learning Choices, previously referred to as Teens Linked to Care) is a small-group intervention designed for youth and young adults living with HIV. TLC consists of 2 modules: Stay Healthy and Act Safe. The Stay Healthy module consists of 12 sessions to promote positive health behaviors. Intervention sessions are focused on coping with learning one’s seropositive status, addressing issues of disclosure, and helping youth to implement new daily routines to stay healthy and actively participate in health care decisions.  The Act Safe module consists of 11 sessions to increase self-protection and other-protection motivation to change behavior and to reduce substance use and unprotected sex acts. HIV-positive youth identify their risk behavior triggers and modify their patterns of substance use as well as increase self-efficacy of condom use and negotiation skills. The modules are delivered in sequence by male and female facilitators to mixed gender groups of HIV-positive youth. A feeling thermometer is used in each session to assist youth in identifying and controlling negative emotional states.  Group discussions, role-play, video, exercises, and goal setting encourage the ability to effectively reach goals, solve problems, and effectively respond to stressful situations.

Theoretic Basis

  • Social Action Theory

Intervention Duration
Stay Healthy module: 12 sessions, 2 hours each, conducted weekly over 3 month period.
Act Safe module: 11 sessions, 2 hours each, conducted weekly over 3 month period.

Intervention Settings
Adolescent medical care sites

Deliverer
One male and one female trained facilitator

Delivery Methods

  • Exercises
  • Goal Setting
  • Group Discussion
  • Practice
  • Role play
  • Video

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Intervention Package Information

An intervention package was developed with funding from CDC’s Replicating Effective Programs (REP) Project. The intervention package and training are available through CDC’s Diffusion of Effective Behavioral Interventions (DEBI) project.

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Evaluation Study and Results

The original evaluation of the first two modules of TLC was conducted in Los Angeles and San Francisco, California; New York City, New York; and Miami, Florida between 1994 and 1996.

Key Intervention Effects

  • Increased abstinence or consistent condom use
  • Reduced unprotected sex with HIV-negative partners

Study Sample
The baseline study sample of 310 HIV-positive adolescents is characterized by the following:

  • 37% Hispanic, 27% African American, 19% White, and 17% Other
  • 72% Male, 28% Female
  • 63% homosexual or bisexual
  • Mean age of 21 years, range: 13-24 years
  • 55% completed high school education, 31% did not complete high school

Recruitment Settings
Hospital-based adolescent medical clinics or community-based agencies serving youth

Eligibility Criteria
HIV-positive youth were eligible if they were between 13 and 24 years old and received care at the participating clinical care sites. Parental consent was obtained for youth under age 18.

Assignment Method
Cohorts of about 15 HIV-positive youths (N = 27 cohorts, 310 youth) were assigned sequentially to 1 of 2 groups: TLC (n = 16 cohorts, 208 youth) or wait list control (n = 9 cohorts, 102 youth).

Comparison Group
Youth in the control group received standard care at the adolescent clinical care sites and were provided the intervention at the study’s conclusion.

Relevant Outcomes Measured and Follow-up Time
Sex behaviors during past 3 months (including overall number of partners, not having sex, condom use, unprotected sex, and substance use during sex) were measured at 15 months after baseline, which translate to 3 months after completion of the Act Safe module.

Participant Retention

  • TLC Intervention:
    69% retained at 3 months after Act Safe module (among those eligible)
  • Comparison:
    61% retained at 3 months after Act Safe module (among those eligible)

Significant Findings

  • TLC participants were significantly more likely to report no sexual risk pattern (no sex or 100% condom use) than control participants (p < .05) at 3 months after Act Safe module.
  • The TLC participants reported significantly lower percentages of unprotected vaginal and anal sex acts with HIV-negative partners than the control group (p < .05) at 3 months after Act Safe module.

Considerations

  • This intervention fails to meet the best-evidence criteria due to small analytical sample sizes and low retention rates.
  • TLC was developed as a 3-module intervention. Module 3 (Being Together) consists of 8 sessions (2 hours each over a 3 month period) focusing on improving quality of life. No published report has evaluated the intervention effects of all three modules on HIV risk behaviors. Therefore, module 3 is not presented here.
  • A substantial number of participants were not eligible for participation in the Act Safe module because the funding period was ending before their follow-up would have been completed. It does not appear that this logistical issue would affect the interpretation of the findings, however the analyses are based on small sample sizes.
  • The original research targeted teens and youth (ages 13 to 24), however, the intervention package has been expanded to target young people (up to 29 years old).

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References and Contact Information

  • Rotheram-Borus, M. J., Lee, M. B., Murphy, D. A., Futterman, D., Duan, N., Birnbaum, J. M., et al. (2001). Efficacy of a preventive intervention for youths living with HIV. American Journal of Public Health, 91, 400-405.
  • Rotheram-Borus, M., Murphy, D.A., Coleman, C., & Swendeman, D. (2002) Counseling adolescents: Designing interventions to target routines, relationships, roles, and stages of adaptation. In Chesney, M.A., Antoni, M.H. (Eds.), Innovative approaches to health psychology: Prevention and treatment lessons from AIDS (pp. 15-44). Washington, DC: American Psychology Association.
  • Rotheram-Borus, M., Murphy, D.A., Wight, R.G., Lee, M.B., Lightfoot, M., Swendeman, D., et al. (2001). Improving the quality of life among young people living with HIV. Evaluation and Program Planning, 24, 227-237.

    Researcher: Dr. Mary Jane Rotheram-Borus
    Department of Psychiatry, University of California Los Angeles
    10920 Wilshire Blvd., Suite 350
    Los Angeles, CA, 90024-6521
    email: rotheram@ucla.edu 

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