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Behavioural intervention

Where next for HIV prevention in New Zealand?

29 Jan, 16 | by Leslie Goode, Blogmaster

A recent issue of the New Zealand Medical Journal (NZMJ) (128: vol. 1426) gives pride of place to a series of papers that reconsider the way forward for HIV prevention in New Zealand (NZ) against the background of the past thirty years.  Recent contributions to STI journal by these authors analyse the behavioural surveillance data from NZ (Saxton & Hughes (STIs); Lachowsky & Summerlee (STIs); Lachowsky & Dewey (STIs)); the papers in NZMJ set these findings against a broader background (Saxton & Giola; Hughes & Saxton; Dickson & Saxton; Saxton & Ludlam).

Broadly speaking, the situation in NZ resembles, both in nature and scale, what we find in Western European countries: namely, persistent but relatively low-level epidemics concentrated in the MSM population (above all, in Auckland), and among heterosexual individuals of foreign extraction (Dickson & Saxton).

The distinctiveness of the NZ epidemics, as against those of Western Europe, lies primarily in geo-political factors: such as migration from sub-Saharan Africa, which reached a peak in 2006 before abruptly declining – or the changing demography of Auckland with its large populations of South Asians and people of Pacific origin (Dickson & Saxton: Lachowsky & Summerlee (STIs)).  The main emphasis of the NZMJ papers, however, is on issues that will have a familiar ring to West European readers – such as the importance of achieving a balance between public health and clinic-based approaches to HIV control.

Overall, their account suggests some considerable degree of success on the part of health interventions – but in the face of a public health challenge that is constantly evolving and may yet prove intractable.  As regards the success, some behavioural surveillance data indicate levels of condom use with casual partners of 85% (Hughes & Saxton; Saxton & Hughes (STIs));  The challenge is represented by the growing minority who do not perceive HIV as a threat on account of new treatments (Hughes & Saxton; Saxton & Ludlam). There also remain, as elsewhere, the problems of high levels of undiagnosed HIV (c. 20%) and relatively late presentation to health services (over a third of MSM at CD4=<350/mm3).  A things stand, the worst kind of scenarios seen amongst gay communities in Thailand or the US would appear to have been averted.  Nevertheless, the epidemics show every sign of persisting, and, given a level of diagnosis that it is marginally higher than seen hitherto, may still turn out to be on an upward trajectory.

A key focus of the NZMJ editorial (Saxton & Giola) is on the continued importance of behaviour-based interventions in a world where the momentum seems to have shifted to clinic based control involving pharmaceuticals.  They highlight the danger that the medicalization of HIV prevention could lead to a disinvestment in behaviour-based interventions, which, they imply, would not be conducive to controlling the epidemic.   In this regard, the authors cite Phillips & Cambiano who argue that a mere 10% reduction in condom use would, without improvements in testing levels and ART initiation, result in a doubling of HIV incidence over 15 years.

Pre-test HIV risk reduction counselling is not worth the money

2 Jan, 14 | by Leslie Goode, Blogmaster

A large US randomized control trial of the impact on STI risk of HIV risk reduction counselling in conjunction with the HIV test (Metsch & Colfax) challenges the view that pre-test counselling constitutes an efficient use of limited resources – at least in the US setting.

Counselling has long had an important place in the struggle against HIV/AIDS.  The established form of individual patient-centred counselling focussing on the discussion of the patient’s specific behaviours and the negotiation of achievable risk-reduction steps goes back to 1993.  Its effectiveness was apparently confirmed by the 1998 Project RESPECT study (STIs/Rietmeijer).  More recently (2008), however, a systematic review by the US Preventive Services Task Force (Lin & Bauer) could cite only one study – namely,  RESPECT – as showing an effect on subsequent STI acquisition.  A systematic review of 14 studies (of which 12 in the US), published 2007 in STIs, reached no very definitive conclusions (STIs/Ward & Radcliffe), though at about that time (2007) counselling was included in the UK National Institute of Clinical Excellence (NICE) guidelines (STIs/Ward).  Now, in the US, the resource implications of the National Strategy goal of increasing the percentage of HIV infected who know their status from 79% to 90% by 2015 has raised the question whether the resources expended on pre-test counselling could not be better spent.

The recently reported Project AWARE study (Metsch & Colfax) is comparable in scale to Project RESPECT (5,012 participants over nine clinics).  It revisits the same question of the effectiveness of pre-test counselling, though in the contemporary context of the existence of effective therapies.   It also includes among its participants, men who have sex with men, an important group who were not included in Project RESPECT.  Project AWARE divided participants between a “counselling” arm, who received c. 20’ of individual patient-centred counselling (as described above) along with their point-of-care HIV test, and a control arm, who were given information only.  Tests for STIs, plus a computer interview, were administered at base-line, and at six months follow-up.

The results showed no significant difference in six months STI incidence between the intervention and the control arm: for the 2,039 participants in the counselling arm, there were 250 (12.3%) incident cases; for the 2,032 in the information only arm there were 226 (11.1% incident) cases.  Furthermore, there was no significant difference in sexual behaviour at six months between the two groups in respect to number of sex acts, number of unprotected sex acts, and number of unprotected partners: though there was a small difference in the reported number of partners (2.7 in “counselling” as against 3 in “information only”).  The authors conclude that if pre-test counselling resulted in changes in sexual behaviour, such changes were not sufficient to affect cumulative STI incidence.

An important limitation, as stated by the authors, is that the results are not “generalizable to international settings”.  STI journal has featured a number of studies indicating the effectiveness of voluntary testing and counselling (VCT) in limited resource settings, whether changes of behaviour are the result of the counselling itself, or a change of attitude prior to the decision to attend VCT: see (Kenya) STIs/Arthur & Gilks; (South Africa) STIs/Nshiniyimana & Bruyn; (Zambia) STIs/Sikasote & Murray.  Another clearly stated limitation is that the study applies only to the established type of 20’ individual patient-centred intervention they describe – not to other types, such as, for example, the couple-based intervention very positively evaluated by LaCroix & Johnson (STIs/LaCroix & Johnson).

Are bisexuals well served by HIV interventions that assume gay identity?

30 Oct, 13 | by Leslie Goode, Blogmaster

Studies published in STI journal have examined the impact of bisexual concurrency on HIV epidemiology in South Africa (Behrer & Baral) (B&B) and China (Yun & Shang) (Y&S), where it is reckoned at 53.7% and 31.2% of the MSM population, respectively.  However, a recent randomized control study of an educational intervention in Los Angeles (Harawa & Cunningham) claims to be among the first studies addressing bisexual concurrency among black MSM in the US.

US black MSM who have sex with women (MSMW) are less likely than white MSM to identify gay, and more concerned to fulfil traditional gender expectations.  Consequently, say the authors, they may be less well served by interventions based on contemporary conceptualizations of sexual behaviour in terms of fixed sexual identities.  This raises a number of interesting questions, among them, how far the situation of US black MSM resembles that of MSM in traditional societies (e.g. South Africa or China), and how far influential contemporary conceptualizations about sexual identity, based on the cultural experience of white MSM, constitute an appropriate model for interventions outside that specific social context.   The authors see potential benefits for MSMW of interventions based on more fluid and context-dependent models of sexual behaviour.

The intervention that is the object of this study – Men of African American Legacy Empowering Self (MAALES) – is an HIV education and risk-reduction course addressed specifically to the needs of this group (Williams & Harawa).  It consists in six two-hour sessions delivered over a three week period (with booster sessions at six and 18 weeks), and aims, above all, to be “culturally congruent”.  It is conducted by black MSM facilitators, and its content is theoretically grounded in a teaching model developed in African American communities (the critical thinking model), as well as in reasoned action theory and empowerment theory.

The study itself compares sexual behaviours, at base-line and three and six months after the intervention, of 437 black MSMW randomly assigned to either the MAALES intervention or a twenty-minute HIV education and risk-reduction session based on a standard HIV test counselling approach. Adjusted results indicate the achievement of significantly less unprotected sex acts with male or female over prior ninety days at six months in the intervention arm as against the control arm (RR 0.61), significantly less unprotected sex acts with females (RR 0.5), and a near-significant reduction in sex acts with males (RR 0.63).  Given the time and resources dedicated to the MAALES as compared to the control intervention, one wonders how much of this behavioural modification is owed to the greater investment in the patients in the intervention arm of the study, and how much to the superiority of its culturally congruent methodology over the conventional alternative.

In their conclusions Harawa and Cunningham tend to corroborate the emphasis of Behrer and Baral, Yun and Shang and others on the influence of societal and cultural factors.  There have even been attempts to quantify the impact of psychosocial constructs on MSM sexual behaviour (Konda & Kegeles).  Yet, Harawa and Cunningham differ somewhat from these other studies in the greater stress they place on the role of participants as responsible agents.  They also recommend on the basis of the more frequent reporting of unprotected sex with females in their study, and the relatively low levels of sex with males, that interventions aiming to “responsibilise” MSMW should prioritize the reduction of risky behaviour which involves females, rather than males.

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