HIV This Week

Gilliam PP, Straub DM. Prevention with positives: a review of published research, 1998-2008. J Assoc Nurses AIDS Care. 2009 Mar-Apr;20(2):92-109.

HIV prevention education and counselling efforts have historically been directed toward those individuals considered at risk for exposure to HIV and assumed to be uninfected with HIV. In the late 1990s, prevention efforts began to include individuals who were HIV-infected. In 2003, the United States Centers for Disease Control and Prevention recommended that HIV prevention be incorporated into the medical care of persons living with HIV. This domain of HIV prevention work is known as prevention with positives or positive prevention, and research within this domain has been ongoing for a decade. This article provides a review of the scientific evidence within the prevention with positives domain from 1998 to 2008 . A discussion is provided regarding early descriptive and formative studies as well as more recent and ongoing intervention trials specifically designed for persons living with HIV. A summary of current knowledge, a description of ongoing research, and gaps in knowledge are identified. Topics for future research are suggested.

Editors’ note: This is a relatively new area of endeavour and therefore there are only preliminary results available for 11 of the 17 intervention trials conducted in the United States. The trials are grouped into two distinct categories: interventions delivered in the community in multiple sessions facilitated by professionals other than medical care providers and interventions incorporated into the medical care of people living with HIV using brief counselling techniques, delivered within the clinic setting, and including the patient’s care provider in the delivery of the prevention message. All use a theory grounded in behavioural change with the premise that HIV transmission is a behavioural phenomenon (e.g. Bandura, Prochasaka and DiClemente, Fisher and Fisher, etc) with only one theoretical foundation focused on a subpopulation, based on a theory of gender and power (Wingood and DiClemente). As results become available, cost analyses will help in deciding whether the brief intervention delivered in the context of a routine medical visit wins out.

Copenhaver M, Chowdhury S, Altice FL. Adaptation of an Evidence-Based Intervention Targeting HIV-Infected Prisoners Transitioning to the Community: The Process and Outcome of Formative Research for the Positive Living Using Safety (PLUS) Intervention. AIDS Patient Care STDS. 2009 Mar 4. [Epub ahead of print]

No evidence-based interventions have been designed for implementation during the critical period when HIV-infected prisoners are being transitioned from prison to the community. Copenhaver and colleagues therefore conducted formative research aimed at systematically selecting and adapting an evidence-based intervention that integrates HIV risk reduction and adherence to antiretroviral therapy to implement among HIV-infected prisoners transitioning back to the community. Their formative research involved a critical examination of established evidence-based interventions and associated published reports complemented by data elicited through structured interviews with key stakeholders in community and correctional settings and members of the target population. Between September 2006 and February 2007, structured one-on-one interviews were conducted with key stakeholders in the target organizations (n = 19) and with members of the target population (n = 26) in Hartford and New Haven, Connecticut. Based on the formative research, the authors abbreviated and adapted the Holistic Health Recovery Program targeting people living with HIV (HHRP+), an evidence-based intervention, to consist of four 45-minute sessions that cover a range of prespecified topics so that participants may individually apply intervention content as needed to their own HIV risk profile and antiretroviral adherence issues. The evidence-based intervention was adapted so that it could be provided in an individual or group format and delivered in either consecutive or weekly sessions and so that it could be provided within the prison system and delivered just prior to release, or in a community-based setting where it could be delivered immediately after release. This study provides a comprehensive exemplar of the process of selecting and adapting an evidence-based intervention taking into account both empirical evidence and input from target organization stakeholders and target population members in real-world settings where high-risk populations are concentrated.

Editors’ note: With as many as 25% of HIV-infected people in the United States passing through the correctional system each year, primarily due to policies incarcerating drug users, opportunities for improving the health of this ‘captive’ audience are real. Given evidence of a strong positive association between the length of incarceration of HIV-positive people and their health and well-being, the challenge is how to maintain these HIV-related health benefits when people leave the highly structured prison environment. This formative study began with an extensive literature review of interventions for people living with HIV with a history of drug use. Then prisoners with this profile and treatment providers in correctional and community-based treatment settings were enlisted to determine what intervention content would be most relevant, what design characteristics (modality and duration) would be most feasible, and what mechanisms of referral to the programme would be most appropriate. The results take into account the real world needs of the intended participants as well as the constraints of the prison and community settings where they are found. Now we await the outcome of the programme itself.