Positive Prevention: Reducing HIV Transmission among People Living with HIV AIDS (Perspectives on Critical Care Infectious Diseases)

301 Pages·2005·1.36 MB·English

by  Seth C. Kalichman

Positive Prevention
Reducing HIV Transmission among
People Living with HIV/AIDS
Positive Prevention
Reducing HIV Transmission among
People Living with HIV/AIDS
Edited by
Seth C. Kalichman
University of Connecticut
Storrs, CT
Kluwer Academic/Plenum Publishers
New York, Boston, Dordrecht, London, Moscow
Library of Congress Cataloging-in-Publication Data
ISBN 0-306-48699-7
⃝C 2005 by Kluwer Academic/Plenum Publishers, New York
233 Spring Street, New York, New York 10013
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Printed in the United States of America
This book is dedicated to Sydney, Rita, Moira, and
Hannah Fay Kalichman, my sources of inspiration.
Contributors
Shalini Bharat, Tata Institute of Social Sciences, Mumbai
Heiner C. Bucher, University Hospital Basel, Switzerland
Nicole Crepaz, Centers for Disease Control and Prevention
Maria Ekstrand, University of California San Francisco
Jonathan Elford, City University, London
Amy Elkavich, Center for HIV Identification, Prevention, and Treatment
Services, Department of Psychiatry University of California, Los Angeles
Jeffrey D. Fisher, Center for Health/HIV Intervention and Prevention,
University of Connecticut
William A. Fisher, University of Western Ontario and Center for
Health/HIV Intervention and Prevention
Diane Flannery, Center for HIV Identification, Prevention, and
Treatment Services, Department of Psychiatry University of California,
Los Angeles
Andrea Fogarty, University of New South Wales, Australia
Rise Goldstein, Center for HIV Identification, Prevention, and Treatment
Services, Department of Psychiatry University of California, Los Angeles
Lauren K. Gooden, University of Miami School of Medicine
Christopher Gordon, National Institute of Mental Health
Robert S. Janssen, Centers for Disease Control and Prevention
Ida M. Onorato, Centers for Disease Control and Prevention
Patricia Jones, Center for HIV Identification, Prevention, and Treatment
Services, Department of Psychiatry University of California, Los Angeles
Susan M. Kiene, Center for Health/HIV Intervention and Prevention,
University of Connecticut
Susan Kippax, University of New South Wales, Australia
Lisa R. Metsch, University of Miami School of Medicine
David W. Pantalone, University of Washington
vii
viii CONTRIBUTORS
Jeffrey T. Parsons, Hunter College and the Graduate Center of the City
University of New York
Thomas L. Patterson, Department of Psychiatry, University of California,
San Diego
David W. Purcell, Centers for Disease Control and Prevention
Jayashree Ramakrishna, National Institute of Mental Health and
Neurosciences in Bangalore
Patrick Rawstorne, University of New South Wales, Australia
Mary Jane Rotheram-Borus, Center for HIV Identification, Prevention,
and Treatment Services, Department of Psychiatry University of
California, Los Angeles
Leckness C. Simbayi, Human Sciences Research Council, Cape Town
South Africa
Jane M. Simoni, University of Washington
Steffanie A. Strathdee, Division of International Health and Cross
Cultural Medicine, Department of Family and Preventive Medicine,
University of California, San Diego
Paul Van de Ven, University of New South Wales, Australia
Lance S. Weinhardt, Center for AIDS Intervention Research, Medical
College of Wisconsin
Richard J. Wolitski, Centers for Disease Control and Prevention
Foreword
Acknowledgments: This foreword was aided by a meeting sponsored by the
NIMHandCDC to overview state-of-the-science interventions, whichwas
held in conjunction with the 2003 National HIV Prevention Conference in
Atlanta.
Note: The views expressed in this foreword do not necessarily represent
those of the National Institute of Mental Health nor any other agency of
the federal government.
It is rare for edited scientific texts to be as timely as this one. Each sec-
tion addresses pivotal issues in HIV prevention with positive persons,
new data are presented, and innovative recommendations are offered. The
chapters cover the prevention priority areas outlined by the CDC (Janssen
et al., 2001; Wolitski et al. in this volume), which are supported by the
relevant divisions and centers of the National Institutes of Health (NIH)
and the Health Resources and Services Administration. In addition to de-
tailed interpretation of available data, the chapter authors are adept at
framing important research directions, which aids my task. I will identify
the most critical “positive prevention” issues. When possible, I offer my
comments with reference to the categories of the domestic prevention ini-
tiative; namely, reduction of barriers to early HIV diagnosis and increased
access to, utilization of, and adherence to quality medical care, HIV treat-
ment, and prevention services. Inmy position as a program officer for HIV
prevention and treatment adherence at the National Institute of Mental
Health, I am privileged to work with many careful thinkers, so I thank
them in advance for stimulating these ideas, both informally and formally.
The need for targeted interventions for persons living with HIV is be-
coming acute due both to our fiscal environment and to the shift in federal
prevention strategy described in the first Chapter. There is a finite pool of
resources for research and implementation that is competing with an ex-
panding set of recommendations for how thesemonies shouldbe allocated.
Ideally, all of the questions identified in this book could be answered. In re-
ality, research initiativesneed tobe triaged, andefforts toprioritizeareoften
inextricably linked with cost-effectiveness concerns. Funders, researchers
ix
x FOREWORD
and providers must grapple with the complexities of sexual behavior,
relationships, and HIV risk-reduction, and balance this understanding
with practical realities that call for feasible models for change—that is,
for interventions to be cheaper and briefer to implement. This challenge
can be dauntingwhenmultiple factors and levels of influencemay be asso-
ciated with risk behavior (e.g., drug use, poverty, stigma, racism, unstable
housing, disparate access to prevention and treatment systems).
In terms of early HIV diagnosis, Weinhardt in this book and others
(e.g., Crepaz and Marks, 2002) have underscored the importance of HIV
serostatus knowledge for risk reduction.We know that themajority of per-
sons who learn their HIV-positive serostatus take measures to reduce risk
for themselves and others. However, the field has yet to fully capitalize on
this process through theory and intervention development to understand
and sustain these changes.Data presented byWeinhardt preliminarily sug-
gests that initial risk-reduction may be followed by a subsequent rebound
to pre-testing risk levels for some individuals. Moreover, although there
have been numerous studies of factors associated with a decision to get
tested for HIV, there are relatively fewer studies of interventions to in-
crease HIV-testing rates. The paucity of studies in this area is particularly
troubling because the huge problem of ethnic health disparities for HIV
testing (and treatment access) remains poorly understood. It is imperative
that our research, policy and interventions begin to close the gaps that are
responsible for delay in testing and access to treatment among minority
populations, especially women of color. Individual, structural, and social
factors likely contribute to these disparities, and interventions to reduce
HIV stigma as a barrier toHIV-testing are rare. Parsons highlights the need
formore creative approaches to testingandprevention that target relatively
untapped risk venues for gay and bisexual HIV-positive andHIV-negative
men. The CDC has also recommended to routinize HIV testing in some
settings, and early model programs suggest that these programs can be
cost-effective and lead to follow-up HIV care (Walensky et al., in press).
These approaches may reduce some barriers to HIV testing, but we
also lack critical information about how individuals navigate through the
public and private health care system in order to get tested for HIV, ac-
cess medical care and HIV treatment (if necessary), access HIV preven-
tion services (regardless of test results), and connect to other services that
might accompany HIV treatment (e.g., mental health care, substance use
treatment, and other supportive services). In communities that lack in-
tegrated systems of care, successful outcomes often rely on “referrals”
that may require sophisticated knowledge and persistence on the part of
patients and providers. Yet, we only have the most rudimentary notions
about whether and how these linkages occur, what to do to increase their
FOREWORD xi
likelihood, and there is no overarching framework to guide HIV/AIDS
service integration.
Once people living with HIV/AIDS are connected to a prevention or
treatment setting, research can be enhanced throughout the intervention
continuum—from development to dissemination, adaptation, and com-
munity/clinic adoption.As echoed by several chapter authors in this book,
theoretical models tested for prevention interventions with HIV-positive
persons have been largely limited to variants of social-cognitive theory.
Although some trials incorporate contextual factors in conceptualizing
interventions, most completed trials have utilized cognitive-behavioral
skill-building interventions to target behavior change of individuals and
small groups. This pattern of intervention development mirrors early
generations of primary HIV prevention interventions for high-risk HIV-
negative persons, and it suggests areas to further expand future interven-
tions for HIV-positive persons—i.e., to focus more efforts on structural
factors, community-level interventions, media, and multiple systems si-
multaneously. Several ongoing studies to reduce HIV-infections through
other levels of influence have been launched, including modification of
social/structural influences to reduce risk behavior, family- and couples-
based prevention, coping, and adherence approaches, internet-based in-
terventions, and mass media campaign evaluation.
To be clear, behavior change interventions for individuals still have an
important place in the national HIV prevention plan. As Holtgrave (2004)
has pointed out, perhaps only a minority of HIV-positive men andwomen
actually may need more intensive services, but for these persons the in-
dividual level of attention may be critical. Individuals who are struggling
with such problems as substance use, severe and persistent mental illness,
relationship abuse, childhood sexual abuse, poverty, or transient housing
may need to be referred to prevention case management or one of the
efficacious interventions detailed in this volume. The efficacy and effec-
tiveness of such programs for individuals struggling with multiple health
and social problems continues to need careful study (Stall, et al., 2003).
Although only a few efficacious interventions are currently in the litera-
ture, methodological descriptions and outcome data for several trials are
pending publication (e.g., Wingood et al., in press; Purcell et al., in press;
Rotheram-Borus et al., in press; Fisher et al., in press).
However, future prevention outcomes still depend on a fuller appre-
ciation that HIV is transmitted in inherently relationship-driven contexts
(Auerbach, inpress). Very little researchhas investigated relational dynam-
ics, condomusedecision-making forbothHIV transmission andacquisition
when one partner is HIV-positive, intimacy, the ways that partnerships are
affected by culture and more proximal social contexts, and the translation