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U.S. Department of Health and Human Services

Archival Content: 1999-2005

HIV Prevention Among Drug Users:
A Resource Book for Community Planners & Program Managers


Appendix A: Evaluation Study Summary Forms for Interventions Addressing Drug Users

Each summary in Appendix A describes a study conducted on a specific intervention with a particular target group. These summaries will help prevention planners and program managers consider interventions for particular target groups in the drug-using population. The contents of this appendix provide the following information:

  • Summaries of selected peer-reviewed journal articles of evaluation studies completed on HIV prevention interventions conducted with drug users.
  • Information on the: 1) authors of the article, 2) the journal where the article was published, 3) the target and study populations addressed, 4) the objective(s) of the intervention for risk behavior, 5) the objective(s) of the intervention for determinants of risk behavior, 6) the taxonomy category and intervention description, 7) the evaluation methods, and 8) the evaluation findings.
  • Comments on special implications or usefulness of the study or intervention.

Articles in the peer-reviewed literature are often written for academic audiences and contain much information that is useful for their purposes, but difficult for planners and program staff to interpret and apply. Based on suggestions from representatives of Community Planning Groups, we focused attention on three key aspects of the studies included in the appendix: the target population, the description of the intervention based on CDC's suggested taxonomy, and the findings on demonstrated effectiveness. To accomplish this, we created a standard Evaluation Study Summary Form to help capture consistent information as we reviewed each article. The box below lists the elements of the Summary Form, with a brief definition of each. CDC's taxonomy framework adapted from Holtgrave, Valdiserri, and West (1994), is shown in Exhibit L.


Exhibit L: A Suggested Taxonomy for Classifying HIV Prevention Interventions

Category I.

Counseling, Testing, Referral, and Partner Notification (CTRPN)

A. HIV Counseling and Testing

B. Referral

C. Voluntary Partner Notification

D. Other

Category II.

Health Education/Risk Reduction (HE/RR)

A. Individual-level Counseling

B. Group-level Counseling

C. Street and Community Outreach Programs

D. Institution-based Programs

E. Community-level Interventions/Mobilizations

Category III.

Health Communication/Public Information (HC/PI)

A. Mass Media

B. Other Media

C. Social Marketing

D. Endorsements/Testimonials by Opinion Leaders

E. Hotlines/Clearinghouses

We hope that these summaries will help prevention planners and program managers interpret and incorporate evaluations of effectiveness into their decision making. In addition, with the Evaluation Study Summary Form we hope to provide a useful framework for continued efforts to interpret emerging research on HIV prevention intervention effectiveness.

Evaluation Study Summary Form

Target and Study Populations: The target population is the population for whom the intervention was developed. The study population is that part of the population that participated in the evaluation and is typically more restricted than the target population.

Objective(s) of the Intervention for Risk Behavior: The intervention is described in terms of the specific HIV risk behavior(s) it was designed to influence.

Objective(s) of the Intervention for Determinants of Risk Behaviors: The intervention is described in terms of the determinants through which it is intended to have its desired effect.

Taxonomy Category and Intervention Description: The intervention is categorized in terms of the Suggested Taxonomy from the Overview of HIV/AIDS Prevention Interventions: An Approach to Examining Their Effectiveness. A description of the intervention is provided.

Evaluation Methods: The sample size, study design, measures, and analysis techniques are described.

Evaluation Findings: Three types of findings are reported - effectiveness at influencing risk behaviors, effectiveness at influencing the determinants of risk behaviors, and implementation issues.

Comments: This section includes comments on special implications or usefulness of the study or intervention.


Risk Reduction in Sexual Behavior: A Condom Giveaway Program in a Drug Abuse Treatment Clinic

Calsyn DA, Meinecke C, Saxon AJ, Stanton V
American Journal of Public Health 1992;82(11):1536-1538

Target and Study Populations
Target population. The intervention was designed for male injection drug users receiving outpatient drug abuse treatment.

Study population. The intervention was evaluated in a sample of men receiving outpatient drug abuse treatment at the Veterans Affairs Medical Center, Seattle, Washington, during December 1989 and remaining in treatment through May 1990. The men were primarily white (77 percent); 22 percent were African American. About half were employed.

Objective(s) of Intervention for Risk Behavior
To increase the use of condoms during vaginal intercourse.

Objective(s) of Intervention for Determinants of Risk Behavior
To increase accessibility of condoms.

Taxonomy Category and Intervention Description
Health education/risk reduction program that is institution based.

The intervention consisted of providing free access to a variety of styles of individually packaged condoms in an outpatient drug abuse treatment center. The condoms were made readily available throughout the clinic (e.g., staff offices, restrooms, therapy rooms). Most clients attended an AIDS education class in which the correct use of condoms was demonstrated and a free starter pack of condoms was distributed.

Evaluation Methods
The intervention was effective at improving behavior. A modest, but statistically significant increase occurred in condom use during vaginal intercourse. Specifically, use of condoms during vaginal intercourse increased from 20 percent at baseline to 34 percent at four months after the initiation of the condom giveaway program. There was also a statistically significant increase in the proportion of the sample possessing condoms from 59 percent before to 76 percent four months after.

Without a control group it is difficult to conclude that the increases are attributable to the giveaway program. However, this evaluation study suggests that increasing access to condoms may increase the possession and use of condoms among clients of a drug abuse treatment clinic.

Comments
This study illustrates the role that free access to a variety of styles of individually packaged condoms can play in influencing condom use. Although condoms are available in stores and pharmacies, free offerings of a variety of styles may eliminate barriers to purchase and increase the likelihood that individuals will be carrying condoms at times they may engage in sexual activity.


AIDS and the Transition to Illicit Drug Injection - Results of a Randomized Trial Prevention Program

Des Jarlais DC, Casriel C, Friedman SR, Rosenblum A
British Journal of Addiction 1992;87(3):493-498

Target and Study Populations
Target population. The intervention was designed for adult drug users who were using heroin intranasally.

Study population. The impact of the intervention was evaluated in a study conducted between 1986 and 1988 with 104 participants from New York City who were using heroin intranasally ("sniffing") as their primary route of heroin use and who had injected no more than 60 times in the previous two years. Participants were required to be HIV antibody or hepatitis B antibody negative in status. None of the subjects seroconverted for HIV during the follow-up period. The mean age of the sample was 27 years, and the mean level of education completed was nearly 13 years. The sample was predominantly male (70 percent), white (51 percent) or African American (26 percent), and heterosexual (78 percent).

Objective(s) of Intervention for Risk Behavior
To decrease HIV exposure due to needle-use practices by reducing injection.
To increase the use of bleach and condoms.

Objective(s) of Intervention for Determinants of Risk Behavior
To increase knowledge about HIV transmission and prevention.
To improve skills in cleaning needles and using condoms.

Taxonomy Category and Intervention Description
Health education/risk reduction intervention using group-level, peer-mediated counseling emphasizing risk reduction for injection drug users.

The intervention was theory based and consisted of four 60 to 90-minute group sessions that took place over a two-week period. The sessions included basic information about HIV/AIDS, drug use and drug injection, sexual behavior and HIV/AIDS, and seeking entry into drug abuse treatment programs. The sessions were led by two trainers and involved didactic materials, group discussion, and role playing of critical situations, such as refusing an offer of injection or seeking entry into drug abuse treatment program when one's non-injected drug use became too heavy.

Instructions on safer injection procedures, such as using bleach to decontaminate injection equipment, were provided.

Evaluation Methods
Eligible participants were randomly assigned to the four-session intervention program or to the control condition. Assessments were made at baseline, before the intervention, and at follow up, about nine months after the intervention. At baseline, all participants took part in a lengthy intake and data collection process. Participants were interviewed on drug use history, sexual behavior history, and knowledge of HIV/AIDS. They provided a urine sample for drug testing. They received basic information about AIDS, including HIV counseling, and were asked to give a blood sample for HIV testing. Nearly 90 percent decided to take the test. All participants, including those who decided against HIV testing, were also required to give a blood sample for hepatitis B testing. Follow-up data collection included an interview covering drug and sexual behavior since the intake period, attitudes toward HIV/AIDS, and a second blood sample for HIV and/or hepatitis B testing. Due to intensive follow-up efforts, 83 subjects (80 percent) were successfully followed up at a mean of 8.9 months. Univariate and multivariate analyses predicting drug injection at follow up were conducted to assess the impact of the intervention as well as to determine factors associated with injection.

Evaluation Findings
The intervention was effective in reducing injection drug use. In comparison to the control group, intervention participants had a significantly lower level of injection at follow up. However, it did not prevent all drug injection. In fact, 15 percent of the persons assigned to the intervention injected during the follow-up period, compared to 33 percent of those assigned to the control group.

There was no evidence that the intervention was effective at improving safer sexual practices. For example, reported condom use increased for both the intervention and the control group from about 26 percent at baseline to about 49 percent at follow up.

Comments
An intensive four-session AIDS/drug injection prevention program was effective in reducing the level of injection use of heroin and cocaine during the follow-up period. The high follow-up rate achieved in this study among drug users, who were not associated with treatment programs, indicates the feasibility of this approach.


Preventing HIV/AIDS in Drug-Abusing Incarcerated Women Through Skills Building and Social Support Enhancement: Preliminary Outcomes

El-Bassel N, Ivanoff A, Schilling RF, Gilbert L, Borne D, Chen DR
Social Work Research 1995;10(3):131-141

Target and Study Populations
Target population. The intervention was designed for adult women with a recent history of significant drug use, currently incarcerated but scheduled for release.

Study population. The impact of the intervention was evaluated in a study of 145 incarcerated women 18-55 years of age, convicted and serving a sentence between three months and one year at New York City's Rikers Island Jail and who were scheduled for release within 10 weeks. The women reported recent history of significant drug use (three or more times a week during the three months before the arrest); 16 percent self-reported to be HIV seropositive. The sample was primarily composed of African American, unemployed, single mothers who had not completed high school.

Objective(s) of Intervention for Risk Behavior
To increase the practice of safe sex (abstinence or always condom use during vaginal intercourse).

Objective(s) of Intervention for Determinants of Risk Behavior
To increase knowledge of HIV/AIDS transmission and prevention.
To improve problem solving, coping, and condom use skills.
To enhance social support.

Taxonomy Category and Intervention Description
Health education/risk reduction intervention using group-level, non-peer mediated counseling, emphasizing skills and social support and delivered in a prison setting.

The intervention consisted of 16 two-hour group sessions held twice a week in jail. The sessions included about 10 participants and were led by two group facilitators. The facilitators were selected for similarity to participants, had three days of training, and received weekly individual and group supervision. The content of the sessions was theory based and emphasized skill building and social support enhancement. Sessions to improve skills at solving problems, coping with high-risk situations, and using condoms included introducing and modeling skills by facilitators, practice by participants during the session, and homework assignments. Social support was enhanced by assisting participants in identifying informal and formal sources of support and services and in making contact with these sources.

Participants shared successes and problems in making these contacts. The comparison was a standard HIV/AIDS information intervention typical of most jails, with three two-hour educational group sessions about HIV prevention.

Evaluation Methods
At baseline, incarcerated women were randomly assigned to the intervention (skills and social support) or control (information) group. Participants were interviewed several times during the study period: at baseline; at the exit interview two to seven days before release; in the community within two days of release; and at one, three, six, and 12 months following release. The interviews assessed demographic characteristics, HIV/AIDS knowledge, coping skills, emotional support, perceived vulnerability, drug use, and sexual behavior during 30 days (30 days before arrest for baseline and past 30 days for follow ups). Safe sexual practice was defined as used condoms always or not having vaginal intercourse. This article reports on the results comparing baseline to one-month follow up from 49 intervention participants and 52 control participants. Logistic regression analyses using dichotomized versions of the six outcome variables were conducted.

Evaluation Findings
There was some evidence of the effectiveness of the skills and social support intervention on two key determinants of behavior: coping skills and social support. There was no evidence of the effectiveness of skills and social support intervention on perceived vulnerability to HIV, sexual self-efficacy, or HIV/AIDS knowledge.

Of approximately 200 women who were initially recruited, 159 met the eligibility criteria and completed the baseline assessment. Between baseline and the first session of the intervention, 14 participants were lost because of unplanned release or transfer to another facility, leaving a total of 145 participants. Among those who were assigned to the skills and social support intervention group, 19 percent attended three or fewer sessions, 28 percent attended four to 12 sessions, and 52 percent attended 13 or more sessions; among those in the information group, 86 percent attended the three sessions.

Comments
AIDS has become the leading cause of death among female inmates. This research demonstrates the feasibility of implementing a skill-building and social support intervention for drug-using women in a jail setting. The results indicate that a skills and social support intervention may be more effective than simply providing AIDS information.


The Long-Term Outcome of a Personal Network-Oriented HIV Prevention Intervention for Injection Drug Users: The SAFE Study

Latkin CA, Mandell W, Vlahov D, Oziemkowska M, Celentano DD
American Journal of Community Psychology 1996;24(3):341-364

Target and Study Populations
Target population. The intervention was developed for use with networks of injection drug users.

Study population. The intervention was evaluated with a sample of 117 predominantly unemployed, African American men with a median age of 40 living in Baltimore, MD. Most were recruited by word of mouth from a larger epidemiologic study on the natural history of HIV/AIDS infection among injection drug users. As participants in the larger study, they had received HIV/AIDS counseling and testing every 6 months; 24 percent were HIV seropositive. Individuals selected for the study were still actively engaging in HIV risk behaviors despite participation in the larger study. They injected cocaine and heroin, 80 percent shared needles in the previous 6 months and were part of a drug-sharing network. They were required to bring at least four members of their networks to the intervention.

Objective(s) of Intervention for Risk Behavior
To decrease HIV/AIDS-related needle sharing behavior.

Objective(s) of Intervention for Determinants of Risk Behavior
To increase awareness of the danger of needle-sharing among members of drug networks and increase awareness of where sterile syringes are available.

To increase the social norms of drug-sharing networks related to not sharing used needles and drug injection equipment.

To increase assertiveness skills in avoiding high-risk behaviors and settings, skills in cleaning injection equipment and identifying where sterile syringes are available.

Taxonomy Category and Intervention Description
Health education/risk reduction intervention using group-level, peer-mediated, risk-reduction training in a clinic setting.

The group intervention procedure used self-help, network-centered, and psychoeducational approaches to behavior change. The intervention program was highly scripted and was facilitated by former heroin users who maintained contact with and were respected by active drug users in Baltimore. The intervention included six interactive group sessions using the role play method.

Evaluation Methods
Before the intervention, all participants, network members, and control group members answered questions about their drug-sharing networks and completed a survey on demographic background, HIV/AIDS-related behavior, and drug use. They indicated how often they injected heroin, cocaine, or heroin and cocaine; how often they shared needles or cookers; and how often they injected drugs in shooting galleries. Participants were randomly assigned to intervention and control groups, and all were reinterviewed 18 months later. For the analysis, intervention participants, but not their network members, were compared with members of the control group.

Evaluation Findings
Of the 411 individuals told they were eligible for the study, 293 enrolled in and 117 completed the study. The intervention was effective in significantly reducing HIV/AIDS-risk behaviors among intervention participants who were HIV seronegative. At the 18-month follow up, intervention participants who were known to be seronegative reported significantly less needle sharing and injecting of heroin and cocaine and marginally less sharing of cookers than did participants in the control group. There was no significant difference between the groups when it came to attendance at shooting galleries. Seropositive individuals in the intervention group reported higher levels of injecting drugs and sharing needles and cookers than did those who did not receive the intervention.

The intervention was also effective in changing determinants of risk behavior. Some intervention participants reported that they no longer associated with individuals who continued to insist on sharing needles. This was verified by a significant reduction in the size of the networks of intervention participants, compared with control group members. Intervention participants were also slightly more likely than control group members to report that they and their network members cleaned their needles and discussed HIV/AIDS.

Comments
The greater associations between perception of network members' risk behaviors, greater reduction in size of drug networks, and a trend toward increased frequency of discussing HIV/AIDS in the intervention group, compared with the control group, suggest that the network approach for reducing risk behaviors is mediated by social influence processes. This study points out the potential importance of examining and intervening in personal network processes as a strategy for HIV/AIDS reduction among injection drug users.


Outcome of Psychoeducation for HIV Risk Reduction

Malow RM, West JA, Corrigan SA, Pena JM, Cunningham SC
AIDS Education and Prevention 1994;6(2):113-125.

Target and Study Populations
Target population. The intervention was designed for African American men receiving inpatient drug abuse treatment.

Study population. The intervention was evaluated with a sample of 152 African American male inpatients of the Veteran's Affairs Drug Dependence Treatment Program in New Orleans. Participants were chronic substance users with cocaine dependence but did not have psychiatric or cognitive impairments. Participants had an average age of 36 years, average schooling of 13 years, and a mean IQ of 105.

Objective(s) of Intervention for Risk Behavior
To reduce risk of HIV exposure due to sexual practices.
To reduce number of sex partners.

Objective(s) of Intervention for Determinants of Risk Behavior
To increase knowledge about HIV transmission and prevention.
To improve skills in cleaning needles, using condoms, and in negotiating safer sex.
To increase self-efficacy.
To increase perceived susceptibility to HIV.

Taxonomy Category and Intervention Description
Health education/risk reduction, group-level counseling, non-peer mediated, in treatment setting.

The theory-based intervention was delivered in groups of six to eight individuals. A clinical psychologist administered two-hour group sessions on three consecutive days. The first session developed rapport with patients, personalized the threat of HIV, provided information about HIV, discussed needle sharing, and demonstrated proper needle sterilization procedures. The second session focused on safer sexual practices, condom use, condom use negotiation, and skills-building exercises. The final session reviewed the knowledge and skills imparted in prior sessions and discussed in detail HIV serostatus testing. The delivery of the intervention was guided by a manual. The comparison group received the same information as did the intervention group but in the form of prerecorded audiovisual and printed material with minimal interaction.

Evaluation Methods
Adults who had agreed to participate were randomly assigned to either the skill-based intervention or the information-only comparison group. Baseline data were collected at least 10 days after hospital admission; follow-up data were collected immediately after the intervention and again after three months. Standardized instruments were used to assess HIV knowledge, perceived susceptibility to HIV, anxiety about health consequences, response-efficacy, self-efficacy, communication skills, and condom use skills. Demographic and background information was collected through personal interviews. Sexual behavior in the preceding three months was used to create a two-level overall measure of sexual risk behavior.

Participants who were abstinent, monogamous, or multipartnered but with 100 percent condom use were classified as "lower risk." Those who had multiple partners or did not always use condoms were classified as "higher risk." Analysis of variance and chi-square tests were used to assess impact.

Evaluation Findings
The intervention was effective in decreasing one aspect of sexual risk behavior, proportion having more than one partner. More specifically, in the intervention group, 47.5 percent participants reported having more than one partner at three-month follow up, compared to 76 percent at the baseline. This decrease was statistically significant. In the comparison group, the change from 76 percent at baseline to 59 percent at the three-month follow up was not statistically significant.

Results suggest that the intervention might be effective at improving the overall measure of sexual risk behavior. Among participants in the skill-based intervention group, the proportion classified as higher risk reduced from 75 percent at baseline to 32 percent at the three-month follow up; among participants in the information-only comparison group, the proportion classified as higher risk reduced from 75 percent to 48 percent. Both these improvements were statistically significant. However, contrary to expectations, the improvement in the intervention group was not significantly greater statistically than the improvement in the comparison group.

The intervention was effective in improving two determinants of sexual risk behavior. Communication skills and condom use skills of participants immediately after the intervention were significantly higher in the intervention group than in the control group.

Out of 235 consecutive admissions to the inpatient drug abuse treatment facility, 75 percent met the eligibility criteria for this study, and 65 percent (152) actually consented to participate. Seventy percent of the participants attended all intervention sessions and completed all assessments.

Comments
This study demonstrated that communication skills, condom use skills, and sexual risk behavior of chronic substance users can be improved through group sessions provided in an inpatient treatment setting.


Evaluation of Two AIDS Education Programs for Impoverished Latina Women

Nyamathi AM, Flaskerus J, Bennett C, Leake B, Lewis C
AIDS Education and Prevention 1994;6(4)296-309

Target and Study Populations
Target population. The intervention was designed for adult Hispanic women who are homeless and/or drug-abusing.

Study population. The intervention was evaluated with a sample of 213 impoverished women in Los Angeles who had identified themselves within the past six months as being drug users (intravenous or non-intravenous), sexual partners of injection drug users, sex workers, having been diagnosed with an STD, having had unprotected sex with two or more partners, or as being homeless. The participants were recruited through homeless shelters and drug recovery programs. The majority of the participants were born in the United States or Mexico, were single, unemployed, and Catholic. Their mean age was 31 years and the mean years of education completed was 10. Only four of the women were HIV-positive at baseline.

Objective(s) of Intervention for Risk Behavior
To reduce risk of HIV exposure due to needle-use practices.
To reduce the number of sex partners.

Objective(s) of Intervention for Determinants of Risk Behavior
To increase knowledge about HIV transmission and prevention.
To improve skills in using condoms and cleaning needles.
To improve problem- and emotion-focused coping responses.
To decrease levels of distress and depression.

Taxonomy Category and Intervention Description
Health education/risk reduction intervention using group-level counseling by health educators.

Two culturally-sensitive HIV/AIDS education programs were administered by trained Hispanic nurse counselors and outreach workers using a detailed script. The one-hour, traditional program provided HIV/AIDS education and referral to community resources. The women watched a video, "Alicia," that emphasized cultural characteristics, including the stigma associated with HIV/AIDS among Hispanics, and received basic education on HIV/AIDS transmission and prevention. They received HIV counseling and had blood drawn for HIV testing. Condoms, bleach, and pamphlets were provided free. The second, more specialized two-hour program added three components: demonstration of risk-reducing strategies, including condom use and needle cleaning skills; discussion of problem-focused coping responses; and self-esteem and self-control enhancement.

Evaluation Methods
The convenience sample of women from 13 homeless shelters and/or eight drug recovery programs were randomized by site into the specialized (98) or traditional (135) intervention groups. Assessments of sociodemographic, cognitive, psychologic, and behavioral variables using nine instruments translated into Spanish and backtranslated to check semantic validity were made at baseline and at two weeks after the intervention. Variables included perception of current concerns about survival, hopelessness, drug addiction, and parenting; appraisal of threat to well-being; knowledge of and attitudes toward HIV/AIDS; problem- and emotion-focused coping behaviors; distress; and depression. Acculturation was assessed with a 12-item scale. Risk behavior was assessed with items on multiple partners, drug use, and intravenous drug use. Repeated measures analysis of variance and log-linear models were used with data from the 213 participants available for follow up.

Evaluation Findings
Both interventions were effective in improving potential cognitive, coping, and psychologic determinants of risk behavior. For example, perfect knowledge scores increased from 17 percent to 76 percent in the specialized group and from 19 percent to 76 percent in the traditional intervention group. Distress scores decreased from means of 49 to 31 for participants in the specialized group, and from 47 to 32 for those in the traditional group. Similar and statistically significant improvements for both groups were seen with measures of current concerns, depression, and use of coping strategies.

The results suggest the intervention may be effective at facilitating some short-term change in risk behavior. Longer-term follow-up assessments are needed. About 20 percent of eligible women who were approached declined to participate due to lack of time. Almost all (91 percent) of the original sample were located at the two-week follow up.

Comments
Women in both the specialized and traditional education programs improved their knowledge of and attitudes toward HIV/AIDS, benefited in terms of decreased levels of distress and depression, and developed improved coping responses. These findings, which replicate a larger study with a predominantly African American sample of homeless and drug-addicted women, suggest that even short-term interventions incorporating general risk-reduction content may be useful for a substantial number of impoverished women.


Increasing The Use of Bleach and Condoms Among Injecting Drug Users in Denver: Outcomes of a Targeted, Community-Level HIV Prevention Program

Rietmeijer CA, Kane MS, Simons PZ, Corby NH, Wolitski RJ, Higgins DL, Judson FN, Cohn DL
AIDS 1996;10(3):291-298

Target and Study Populations
Target population. The intervention was designed for injection drug users.

Study population. The intervention was evaluated with a sample of 890 street-recruited injection drug users in Denver, Colorado. The majority were male; 34 percent were African American, 33 percent white and 31 percent Hispanic. The average age was about 36 years; HIV seroprevalence was 5.1 percent. They were compared with 1,107 injection drug users recruited in Long Beach, California, the comparison city that did not receive the intervention.

Objective(s) of Intervention for Risk Behavior
To increase the use of bleach for needle cleaning among drug users who share injection equipment.
To increase the use of condoms for vaginal intercourse with occasional partners.
To increase the use of condoms for vaginal intercourse with steady partners.

Objective(s) of Intervention for Determinants of Risk Behavior
To increase knowledge about HIV transmission and prevention.
To improve access to bleach kits and condoms.

Taxonomy Category and Intervention Description
Health education/risk reduction, community-level intervention using peer and non-peer street and community outreach.

As part of a five-city, theory-based program known as the AIDS Community Demonstration Projects, volunteers discussed and distributed intervention kits with small-media behavior intervention materials (brochures, pamphlets, flyers, and newsletters containing role model stories), bleach kits, and condoms to individuals in high-risk populations in Denver on a monthly basis over a 2.5-year period. This intervention was provided to hard-to-reach injection drug users on a one-to-one basis by both peer and non-peer volunteers (persons known to and trusted by the target group). Volunteers were recruited by project outreach workers through referrals from other service organizations or referrals from current or former volunteers. The volunteers received training at regular intervals in basic HIV/AIDS education, role-playing interactions, methods of street approach and non-threatening conversation, and methods for dealing with individuals who refuse materials.

Evaluation Methods
Ten three-month data collection periods (waves) were completed using standardized instruments in high-risk areas of the intervention and comparison cities. Of these, three were completed before the intervention was implemented in June 1991; three more (July 1991 to May 1992) were used to measure the early effects of intervention; and four (June 1992 to December 1993) assessed full implementation. During each wave, every third person was approached by interview staff and a set of screening questions was used to determine the respondent's drug injection and sexual behavior. This was followed by a full questionnaire for those who had used injection drugs within the past 30 days, had shared injection equipment within the past 60 days or had vaginal intercourse during the past 30 days. A total of 13,145 individuals were approached for interview during the study period. Of these, 2,599 met the eligibility criteria and consented to the full interview. After removal of duplicates and sex traders, 890 interviews were available for analysis in Denver and 1,107 in Long Beach. Multivariate logistic regression models were constructed to analyze the effect of exposure to the intervention.

Evaluation Findings
The intervention was effective at increasing both needle cleaning and consistent condom use over the time of the study. The proportion of participants who reported consistent use of bleach to clean needles increased significantly from baseline (20 percent) to early implementation (16 percent) to full implementation (29 percent) in the intervention city; but decreased from 22 percent at baseline to 12 percent at early and full implementation in the comparison city. In addition, consistent condom use during vaginal intercourse with occasional partners increased significantly from 2 percent at baseline to 7 percent at early implementation and to 24 percent at full implementation in the intervention city, but decreased from 12 percent to 10 percent in the comparison city. Rates of consistent condom use with steady partners did not change significantly in the intervention city and remained stable (2 percent) in the comparison city. At full implementation, the measure of exposure to the intervention using unprompted recognition reached 32 percent in the intervention city.

Comments
This study demonstrates that a community-based HIV prevention program can have a significant positive effect on consistent needle cleaning and condom use with occasional partners among hard-to-reach injection drug users. Similar interventions may be useful in other communities at risk for HIV infection.


Comparison of Education Versus Behavioral Skills Training Interventions in Lowering Sexual HIV-Risk Behavior of Substance-Dependent Adolescents

St. Lawrence JS, Jefferson KW, Alleyne E, Brasfield TL
Journal of Consulting and Clinical Psychology 1995;53(1):154-157

Target and Study Populations
Target population. The intervention was developed for substance-dependent adolescents.

Study population. The intervention was evaluated with a sample of adolescents receiving drug-abuse treatment at a residential facility in Jackson, Mississippi. Thirty-four adolescents participated in the study. Most (73 percent) were male; 84 percent were white, and 16 percent were African American. The mean age was 15.6 years. Eighty percent of the participants were sexually active, and 15 percent had been treated for a sexually transmitted disease within the previous two months.

Objective(s) of Intervention for Risk Behavior
To decrease the incidence of high-risk sexual behavior.

Objective(s) of Intervention for Determinants of Risk Behavior
To increase knowledge about HIV/AIDS and risk behavior.
To produce more favorable attitudes toward HIV/AIDS prevention and condom use.
To increase internal health locus of control.
To increase interpersonal and technical skills necessary to decrease risk behavior.
To increase self-efficacy in the use of interpersonal and technical skills.

Taxonomy Category and Intervention Description
Health education/risk reduction intervention using group-level, non-peer mediated skills training.

This behavioral skills training intervention, based on cognitive-behavioral principles, consisted of six weekly, 90-minute group sessions. Separate sessions were conducted for males and females and were led by group leaders representative of the race and gender of the participants. The first two sessions focused on HIV/AIDS education and training and skill rehearsal in correct condom use. Three sessions provided training in assertive partner negotiation and communication skills related to engaging in sexual activities.

Evaluation Methods
The 34 participants were randomly assigned to behavioral skills training or to receive a standard educational intervention that provided risk-reduction information but no skills training. All participants were tested before and two months after the intervention on HIV/AIDS knowledge and attitudes toward prevention. The AIDS Knowledge Test, the Attitudes Toward HIV Prevention Measure, Health Locus of Control Scale, and the Condom Attitude Scale-Revised were among the tests used. Participants estimated their risk for infection on the basis of their behavior in the previous two months and role played high-risk sexual behavior scenarios. Univariate and chi-square tests were used to analyze differences between the groups following the intervention.

Evaluation Findings
The intervention was effective in decreasing the incidence of high-risk behavior. Compared with participants in the education condition, those who received behavioral skills training reported significantly lower rates of coercion into unwanted sexual activity (15.4 percent versus 5.3 percent), exchanging sex for money (15.4 percent versus 0 percent), exchanging sex for drugs (23.1 percent versus 10.5 percent), and engaging in casual sex (23.1 percent versus 10.5 percent). These self-reported changes were substantiated by the residential treatment program's records on the number of sexually transmitted diseases treated. During the two months following the intervention, six of those in the education-only group required treatment; only one in the behavioral training group required treatment.

The intervention was effective in changing the determinants of risk behavior. Compared with participants in the education condition, those who received behavioral skills training demonstrated significantly increased knowledge about HIV/AIDS, more favorable attitudes toward prevention and condom use, increased self-efficacy, and greater recognition of personal vulnerability. They attached higher value to sexual safety in relationships and were less inhibited about using condoms. Comparable changes were not evident in the adolescents who participated in the education-only groups.

Comments
This intervention demonstrates the value of behavioral skills training in promoting risk-behavior changes in substance-dependent adolescents.


Building Skills of Recovering Women Drug Users to Reduce Heterosexual AIDS Transmission

Schilling RF, El-Bassel N, Schinke SP, Gordon K, Nichols S
Public Health Reports 1991;106(3)297-304


15-Month Follow Up of Women Methadone Patients Taught Skills to Reduce Heterosexual HIV Transmission

El-Bassel N, Schilling RF
Public Health Reports 1992;107(5)500-504

Target and Study Populations
Target population. The intervention was designed for women enrolled in methadone treatment.

Study population. The intervention was evaluated with a sample of 91 African American and Hispanic women enrolled for at least three months in one of five clinics in a large methadone maintenance program in the Bronx in New York City. The majority of the women were Hispanic (64 percent) or African American (36 percent), between the ages of 21 and 42 and had some high school education. Public assistance and food stamps were the major sources of income.

Objective(s) of Intervention for Risk Behavior
To increase use of condoms.

Objective(s) of Intervention for Determinants of Risk Behavior
To increase knowledge about HIV transmission and prevention.
To increase skills in condom use, communication, and negotiation.

Taxonomy Category and Intervention Description
Health education/risk reduction, group-level counseling led by non-peers.

The skills-building intervention consisted of five two-hour group sessions offered simultaneously to groups of 9 or 10 participants. The first two sessions provided information on HIV/AIDS transmission and prevention techniques through video, visual presentations, and didactic group exercises designed to help participants identify their own high-risk sexual behaviors and discuss barriers they encounter in adopting safer sex practices. During the third session, members discussed their negative associations with condoms, practiced condom use skills, and role played negotiation of condom use. During the final two sessions, participants practiced assertiveness, problem solving, and communication skills by participating in scenarios involving safer sex and by role playing scripted scenarios and scenarios reflecting their own lives. A single-session HIV/AIDS information-only control group received information routinely provided by the clinic. Sessions were led by experienced female drug counselors who had received 20 hours of training.

Evaluation Methods
Participants were tested and randomly assigned to one of two conditions: 48 to the five-session skills-building intervention and 43 to a single-session HIV/AIDS information-only comparison condition. Follow-up data were collected two weeks after completion of the intervention and again at 15 months. The initial and follow-up assessments involved sexual and drug-risk behavior and attitudes, HIV/AIDS knowledge, and locus of control. Several scenarios administered at follow up were designed to measure social skills and assertiveness in implementing safe sex in different high-risk situations. Analysis of variance was the primary statistical method employed.

Evaluation Findings
The intervention was effective at influencing condom use behavior. Those in the skill-building intervention group showed significantly greater levels of condom use than those in the control group at both the two-week and 15-month follow ups.

The intervention was effective at influencing potential determinants of behavior immediately after the intervention. Participants in the skills-building intervention showed significantly high levels of taking condoms from clinics, carrying condoms, feeling comfortable talking about sex, believing that AIDS can be prevented, and believing they could eliminate the risk of exposure to the AIDS virus than those in the comparison group at the two-week follow up. Most of these group differences had deteriorated by the 15-month follow up.

Of 100 eligible women first contacted, 85 agreed to participate. Fifteen were added to bring the initial study sample up to 100. Of these, only 91 completed the baseline, the intervention, and the two-week follow up assessment. At 15 months, 62 study participants remained. Skills-building participants had high rates of group attendance and program retention, especially at two weeks, suggesting that involvement in group interventions could enhance retention rates at methadone maintenance programs.

Comments
The study demonstrates that skill-building, preventive interventions composed of multiple sessions and conducted in treatment settings may have promise as useful HIV prevention strategies for drug-using women. Since many of the changes deteriorated over time, program planners should consider booster sessions or other methods of maintaining changes in risk behavior.


Reducing HIV Needle Risk Behaviors Among Injection-Drug Users in the Midwest: An Evaluation of the Efficacy of Standard and Enhanced Interventions

Siegal HA, Falck RS, Carlson RG, Wang J
AIDS Education and Prevention 1995;7(4):308-319

Target and Study Populations
Target population. The intervention was designed for adult HIV seronegative, injection drug users who are not currently in treatment.

Study population. The impact of the intervention was evaluated with a sample of injection drug users recruited from Dayton and Columbus, Ohio, a low HIV seroprevalence area. Seven indigenous outreach workers recruited the participants from March 1989 through September 1990 using opportunistic and chain-referral sampling techniques. All participants were over 18. The majority were African American (75 percent), male (74 percent), and high school graduates (65 percent). The participants reported injecting heroin (61 percent), cocaine (77 percent), and speed ball (43 percent) daily, weekly, or occasionally during the previous six months. Of the initial recruits who elected voluntary and confidential HIV counseling and testing, 1.5 percent were confirmed seropositive by Western blotting. Only HIV seronegatives participated in the intervention study.

Objective(s) of Intervention for Risk Behavior
To decrease HIV exposure due to needle-use practices.

Objective(s) of Intervention for Determinants of Risk Behavior
To increase knowledge about HIV transmission and prevention.
To improve skills in using condoms and in cleaning needles.

Taxonomy Category and Intervention Description
Two health education/risk reduction interventions on risk reduction for injection drug users, both using non-peer mediated counseling, one individual and one group counseling.

The standard intervention was delivered at a field office and consisted of a one-hour session, during which a counselor-educator reviewed the information in counseling and provided details on HIV disease and modes of transmission. The instructional session was followed by a videotape of role plays illustrating proper condom use and needle cleaning. A risk-reduction kit containing bleach, water, condoms, and brochures was distributed. The enhanced intervention added to the standard intervention three one-to two-hour sessions on the pathology of HIV disease, drug addiction, and safer sex. These were delivered over a one-month period in group sessions of three to five people. The interventions were theory based. All the participants received voluntary and confidential HIV counseling and testing as well as knowledge of results.

Evaluation Methods
Eligible participants (drug injection in past six months, at least 18 years of age, and not in drug-treatment program in previous 30 days) completed the baseline assessment and were offered voluntary and confidential HIV counseling and testing. Of eligible participants, 98 percent agreed to receive screening, and 95 percent of those screened returned seven to 10 days later to receive results. Before receiving results, all seronegative participants took part in the standard intervention. Participants were assigned in alternation to receive the standard or enhanced intervention. Standard participants were asked to return in six months for follow-up assessment; enhanced intervention participants were asked to return for three additional sessions in the following month and then asked to return for six-month follow-up assessment. For the purposes of this study, risk level for exposure to HIV with respect to needle use was defined as 'safe' if the participant reported always using a new needle, always cleaning needles and syringes with bleach before each use, or not injecting drugs. National standardized instruments were used. The article reports on analyses of the 232 standard participants who completed the six-month follow up and the 149 enhanced participants who completed all three enhanced sessions and the six-month follow up.

Evaluation Findings
Both standard and enhanced interventions appeared to be effective at improving needle practices. The enhanced intervention showed more effectiveness than the standard in helping those using unsafe practices become more safe, but did not appear to be more effective than the standard at helping those using safer needle practices maintain those practices. At the baseline assessment, 28 percent of both standard and enhanced intervention participants reported safe needle practice. At follow up, the proportion engaging in safe practices increased to 66 percent among standard and 73 percent among enhanced intervention participants. Contrary to expectations, there was no statistically significant difference between the two interventions in the degree of improvement overall. When the analysis was limited to the participants who reported unsafe needle practices at baseline, the proportion engaging in safe practices at follow up was 58 percent among the standard and 71 percent among the enhanced. This difference in improvement was statistically significant. The article reports results on the determinants of transition from unsafe to safe needle practices and indicates that daily injectors were less likely to make this transition than non-daily injectors.

It is important to note that 171 of the participants (49 percent) assigned to the enhanced condition returned and completed all three enhanced sessions.

Comments
The high return rate for all three sessions as well as its effectiveness at improving needle practices with at least some segments of the population illustrates the potential of this enhanced intervention. Further, the findings show the need to consider differences among injection drug users (daily versus non-daily, reduction versus maintenance) in designing effective interventions to reduce unsafe needle practices.


Psychoeducational Group Approach: HIV Risk Reduction in Drug Users

Sorensen JL, London J, Heizmann C, Gibson DR, Morales ES, Dumontet R, Acree M
AIDS Education and Prevention 1994;6(2):95-112

Target and Study Populations
Target population. The intervention was designed for adult injection drug users in outpatient treatment programs.

Study population. The impact of the intervention was evaluated in two outpatient treatment populations: 50 injection drug users participating in a methadone maintenance program and 98 active heroin users participating in 21-day outpatient methadone detoxification. All participants had extensive previous experience in drug treatment programs and were reached through clinics of the Substance Abuse Services at San Francisco General Hospital. The participants were primarily 30 to 49 years of age, mostly unemployed, and almost all heterosexual. The majority were male (65 percent). About half were white, 20 percent were African American, and 20 percent were Hispanic.

Objective(s) of Intervention for Risk Behavior
To decrease shared unsterilized needle use and to increase condom use.

Objective(s) of Intervention for Determinants of Risk Behavior
To increase knowledge of HIV transmission and prevention.
To improve syringe sterilization and condom use skills.

Taxonomy Category and Intervention Description
Health education/risk reduction, group-level, non-peer mediated counseling in a clinic setting.

The two to three sessions, for a total of six hours, included didactic presentation of facts about HIV transmission, group discussions to personalize risk, structured exercises and homework to build skills, and social interactions to increase cohesion and build trust between leaders and participants. The intervention was theory based, and its protocol was standardized in a training manual. The sessions with cohorts of five to eight participants occurred at the clinic during clinic dispensing hours and were held within a one-week period. The sessions were led by a two-to three-person team of two psychologists and one paraprofessional. All participants also received written materials on the connections among alcohol, drugs, sex, and HIV/AIDS; safer sexual practices; perinatal transmission; syringe sterilization; and condom use. Participants assigned to the comparison group received only the written information.

Evaluation Methods
The intervention was evaluated with two controlled studies; both used random assignment and compared the intervention to information-only comparison participants. Knowledge and attitudes about HIV/AIDS, syringe sterilization and condom use skills, and needle use and sexual practices were assessed at baseline, and at immediate and three-month follow up. Actual skills were assessed with interviewer ratings while participants demonstrated the correct way to clean the syringe with containers of bleach and water and the correct way to use a condom.

Evaluation Findings
Overall, the study provides evidence of the feasibility of conducting group-level counseling interventions with injection drug users in outpatient settings. In addition, the evaluation demonstrates the effectiveness of the intervention in terms of improvements in the determinants of risk behaviors. However, there was no evidence of effectiveness in changing either needle use or sexual risk practices.

With respect to the outpatient methadone maintenance clients, the level of participation was high. That is, most (80 percent) of those who agreed to participate completed at least three hours of the intervention. The article reports on the 47 (94 percent) participants who provided immediate and three-month follow-up interviews. Using repeated measures analyses of variance that compared intervention to comparison participants, the intervention demonstrated a statistically significant impact on factual knowledge about HIV/AIDS, knowledge about sexual risk-reduction practices, drug-related self-efficacy, sex-related self-efficacy, and condom use skills at the immediate follow up. The differences for syringe sterilization skills were in the expected direction but were not statistically significant. Significant impact at the three-month follow up was seen only for the two knowledge items. There was no evidence of impact on behavior; shared needle use and unprotected sexual activity started low at the baseline and remained low.

With respect to the outpatient detoxification clients, the level of participation was moderate. That is, most (65 percent) of those who agreed to participate completed at least three hours of the intervention. The article reports on the 60 (61 percent) participants who provided immediate and three-month follow-up interviews. The intervention demonstrated a statistically significant impact on factual knowledge about HIV/AIDS, knowledge about sexual risk-reduction practices, and actual condom skills at the immediate follow up. Two of these impacts (impact on knowledge about sexual risk-reduction practices and actual condom skills) were also statistically significant at the three-month follow up. Although the main analyses revealed no statistically significant impact on needle-use practices, subanalyses that removed distortion due to outliers suggested improvement in needle use.

Comments
Effectiveness at influencing behavior was not demonstrated in these studies. However, the level of participation and the effectiveness on determinants suggest that group-level counseling in outpatient settings is an intervention worthy of further exploration.


Effects of an Intervention Program on AIDS-Related Drug and Needle Behavior Among Intravenous Drug Users

Stephens RC, Feucht TE, Roman SW
American Journal of Public Health 1991;81(5):568-571

Target and Study Populations
Target population. The intervention was designed for injection drug users currently not in treatment.

Study population. The intervention was evaluated with a sample of injection drug users who were recruited from February 1988 through August 1989 in Cleveland, Ohio, a low HIV seroprevalence area. The sample was predominately male and African American with a median age of 36. Very few (10 percent) were currently in outpatient treatment. Users who were in some institutional setting or in another intervention program were excluded.

Objective(s) of Intervention for Risk Behavior
To decrease HIV exposure due to needle-use practices.

Objective(s) of Intervention for Determinants of Risk Behavior
To improve skills in using condoms and in cleaning needles.

Taxonomy Category and Intervention Description
Health education/risk reduction intervention, using individual-level counseling with non-peer counselors.

The intervention was delivered one-on-one by a professionally trained health educator and lasted from 45 to 60 minutes. The session provided basic information about HIV transmission using a segment from a film; discussed sexual risk reduction and condom use; covered ways to reduce risk due to injection drug use (cleaning with bleach, not using drugs, not using drugs intravenously, not sharing needles or works); and ended with information on HIV testing. All participants received a kit of materials including bleach, condoms, and brochures about HIV/AIDS.

Evaluation Methods
Interviews were conducted immediately before the intervention session and from three to five months after the intervention. Results on change over time for the 322 (80 percent) participants who provided both baseline and follow-up information are reported in this article. Needle-risk behavior in the two months preceding the interview was assessed two ways: five dichotomous measures of sharing works, sharing cookers, using drugs intravenously, using others' works and cleaning works with bleach and two measures of the frequency of sharing others' works and cleaning with bleach.

Evaluation Findings
Results comparing baseline to follow-up interviews indicated statistically significant decreases in needle risk behaviors over time. Although these results suggest the potential effectiveness of the intervention, the data reported in this article make it difficult to determine the extent to which these differences are due to the intervention. The article comments on other analyses available by request.

Comments
The favorable findings are worthy of further exploration, given the special needs of this population.


Syringe and Needle Exchange as HIV Prevention for Injection Drug Users

Watters JK, Estillo MJ, Clark GL, Lorvick J
JAMA 1994;271(2):115-120

Target and Study Populations
Target population. The intervention was designed for injection drug users (IDUs) who are at risk for HIV infection from sharing contaminated needles and syringes.

Study population. The study was conducted with 752 IDUs from San Francisco from Fall 1991 through Spring 1992. Clients were most often between the ages of 31-40 (49 percent), male (69 percent), African American (56 percent) or Caucasian (30 percent), and been through some kind of drug treatment in the last five years (53 percent).

Objective(s) of Intervention for Risk Behavior
To decrease syringe sharing among IDUs.

Objective(s) of Intervention for Determinants of Risk Behavior
To increase IDUs access to sterile injection equipment.

Taxonomy Category and Intervention Description
Health education/risk reduction using street and community outreach to active IDUs.

This volunteer-based syringe exchange program operated in the evenings (6 to 8 p.m.) and had mobile teams assigned to street corners in neighborhoods with high drug use and homelessness. Although illegal, the intervention operated without major disruption from police and with tacit approval of two successive mayoral administrations. Program volunteers provided a one-for-one exchange in which a sterile, single-use insulin syringe was exchanged for each syringe deposited in a biohazardous waste container by the client. Limits on the number of syringes program clients were permitted to exchange changed during the course of the study. By the end of the study there were no limits on numbers of syringes exchanged. Volunteers also distributed 1-oz (80-mL) bottles of bleach, condoms, cotton and alcohol wipes and provided referrals to drug treatment, HIV testing and counseling, and other social and medical services on request.

Evaluation Methods
Data for the study came from two sources. Program records on client contacts and exchange of syringes were maintained during the study (1991-1992) and from when the program was first implemented (1988). In addition, data were derived from the Urban Health Study, a semiannual survey of IDUs recruited in natural settings in three inner-city communities in San Francisco where the intervention was located.

After obtaining informed consent, Urban Health Study participants were interviewed with a standard questionnaire dealing with AIDS knowledge, medical, drug use, and sexual histories, and knowledge of HIV/AIDS risk behaviors. Respondents were paid for their participation and given pre- and post-test counseling, and given referrals to medical and social services by trained staff. The intervention study used data from 11 semiannual cross-sectional surveys collected as part of the Urban Health Study between December 1986 and June 1992 (n=6216). Specific items used from the survey included demographic data as well as respondents reported visits to syringe exchange and their source of syringes. Items on the negative impacts of syringe exchange included changes in self-reported frequency of injection over time, changes in the age distribution of the cross sections, and proportion of respondents reporting first injection during the previous year. Syringe exchange was examined by assessing the relationship between reported syringe exchange use in the past year and reported needle sharing based on self-reported number of needle-sharing partners in the 30 days prior to interview.

One-way analysis of variance (ANOVA) with Scheffe's test for multiple comparisons was used to identify differences in the mean number of syringes exchanged and the reported frequency of injection over successive cross sections. Differences in the proportion of IDUs who used the syringe exchange more than 25 times in the past year and proportion of new injectors over time were assessed using the Mantel-Haenszel x2 test for trend.

Evaluation Findings
At the end of the study, 45 percent of the participants reported "usually" obtaining injection equipment from the syringe exchange, and 61 percent reported using the program within the past year. During the six years before the study ended, the median reported frequency of injection declined from 1.9 injections per day to 0.7, the mean age increased from 36 to 42 years, and the percentage of new initiates into injection drug use decreased from 3 percent to 1 percent. Six independent factors were found to be associated with syringe sharing. Protection from syringe sharing was associated with the use of syringe exchange, having received HIV testing and counseling, condom use, older age, and African American race. Injection of cocaine was a predictor for syringe sharing. The strength of association between use of the syringe exchange program and not sharing syringes was greatest in injection drug users younger than the median age of 40 years.

Comments
The results of the evaluation suggested that, when available, syringe exchange programs are used by IDUs. In addition, reduction in syringe sharing among IDUs was associated with use of syringe exchange programs and voluntary HIV testing and counseling. Results do not support the belief that syringe exchange programs stimulate increased drug abuse in terms of frequency of injection or recruitment of new and/or younger users.

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