Positive Prevention: Reducing HIV Transmission among People Living with HIV/AIDS

297 Pages·2005·2.53 MB·English

by  Richard J. Wolitski

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
UniversityofConnecticut
Storrs,CT
Kluwer Academic/Plenum Publishers
New York, Boston, Dordrecht, London, Moscow
LibraryofCongressCataloging-in-PublicationData
ISBN0-306-48699-7
(cid:1)C 2005byKluwerAcademic/PlenumPublishers,NewYork
233SpringStreet,NewYork,NewYork10013
http://www.kluweronline.com
10 9 8 7 6 5 4 3 2 1
AC.I.P.recordforthisbookisavailablefromtheLibraryofCongress.
Allrightsreserved
Nopartofthisworkmaybereproduced,storedinaretrievalsystem,ortransmittedin
anyformorbyanymeans,electronic,mechanical,photocopying,microfilming,
recording,orotherwise,withoutwrittenpermissionfromthePublisher,withthe
exceptionofanymaterialsuppliedspecificallyforthepurposeofbeingenteredand
executedonacomputersystem,forexclusiveusebythepurchaserofthework.
PermissionsforbookspublishedinEurope:[email protected]
PermissionsforbookspublishedintheUnitedStatesofAmerica:[email protected]
PrintedintheUnitedStatesofAmerica
ThisbookisdedicatedtoSydney,Rita,Moira,and
HannahFayKalichman,mysourcesofinspiration.
Contributors
ShaliniBharat,TataInstituteofSocialSciences,Mumbai
HeinerC.Bucher,UniversityHospitalBasel,Switzerland
NicoleCrepaz,CentersforDiseaseControlandPrevention
MariaEkstrand,UniversityofCaliforniaSanFrancisco
JonathanElford,CityUniversity,London
AmyElkavich,CenterforHIVIdentification,Prevention,andTreatment
Services,DepartmentofPsychiatryUniversityofCalifornia,LosAngeles
JeffreyD.Fisher,CenterforHealth/HIVInterventionandPrevention,
UniversityofConnecticut
WilliamA.Fisher,UniversityofWesternOntarioandCenterfor
Health/HIVInterventionandPrevention
DianeFlannery,CenterforHIVIdentification,Prevention,and
TreatmentServices,DepartmentofPsychiatryUniversityofCalifornia,
LosAngeles
AndreaFogarty,UniversityofNewSouthWales,Australia
RiseGoldstein,CenterforHIVIdentification,Prevention,andTreatment
Services,DepartmentofPsychiatryUniversityofCalifornia,LosAngeles
LaurenK.Gooden,UniversityofMiamiSchoolofMedicine
ChristopherGordon,NationalInstituteofMentalHealth
RobertS.Janssen,CentersforDiseaseControlandPrevention
IdaM.Onorato,CentersforDiseaseControlandPrevention
PatriciaJones,CenterforHIVIdentification,Prevention,andTreatment
Services,DepartmentofPsychiatryUniversityofCalifornia,LosAngeles
SusanM.Kiene,CenterforHealth/HIVInterventionandPrevention,
UniversityofConnecticut
SusanKippax,UniversityofNewSouthWales,Australia
LisaR.Metsch,UniversityofMiamiSchoolofMedicine
DavidW.Pantalone,UniversityofWashington
vii
viii CONTRIBUTORS
JeffreyT.Parsons,HunterCollegeandtheGraduateCenteroftheCity
UniversityofNewYork
ThomasL.Patterson,DepartmentofPsychiatry,UniversityofCalifornia,
SanDiego
DavidW.Purcell,CentersforDiseaseControlandPrevention
JayashreeRamakrishna,NationalInstituteofMentalHealthand
NeurosciencesinBangalore
PatrickRawstorne,UniversityofNewSouthWales,Australia
MaryJaneRotheram-Borus,CenterforHIVIdentification,Prevention,
andTreatmentServices,DepartmentofPsychiatryUniversityof
California,LosAngeles
LecknessC.Simbayi,HumanSciencesResearchCouncil,CapeTown
SouthAfrica
JaneM.Simoni,UniversityofWashington
SteffanieA.Strathdee,DivisionofInternationalHealthandCross
CulturalMedicine,DepartmentofFamilyandPreventiveMedicine,
UniversityofCalifornia,SanDiego
PaulVandeVen,UniversityofNewSouthWales,Australia
LanceS.Weinhardt,CenterforAIDSInterventionResearch,Medical
CollegeofWisconsin
RichardJ.Wolitski,CentersforDiseaseControlandPrevention
Foreword
Acknowledgments:Thisforewordwasaidedbyameetingsponsoredbythe
NIMHandCDCtooverviewstate-of-the-scienceinterventions,whichwas
heldinconjunctionwiththe2003NationalHIVPreventionConferencein
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
thefederalgovernment.
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,
newdataarepresented,andinnovativerecommendationsareoffered.The
chapterscoverthepreventionpriorityareasoutlinedbytheCDC(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)
andtheHealthResourcesandServicesAdministration.Inadditiontode-
tailed interpretation of available data, the chapter authors are adept at
framingimportantresearchdirections,whichaidsmytask.Iwillidentify
the most critical “positive prevention” issues. When possible, I offer my
commentswithreferencetothecategoriesofthedomesticpreventionini-
tiative;namely,reductionofbarrierstoearlyHIVdiagnosisandincreased
accessto,utilizationof,andadherencetoqualitymedicalcare,HIVtreat-
ment,andpreventionservices.InmypositionasaprogramofficerforHIV
prevention and treatment adherence at the National Institute of Mental
Health, I am privileged to work with many careful thinkers, so I thank
theminadvanceforstimulatingtheseideas,bothinformallyandformally.
TheneedfortargetedinterventionsforpersonslivingwithHIVisbe-
comingacuteduebothtoourfiscalenvironmentandtotheshiftinfederal
preventionstrategydescribedinthefirstChapter.Thereisafinitepoolof
resourcesforresearchandimplementationthatiscompetingwithanex-
pandingsetofrecommendationsforhowthesemoniesshouldbeallocated.
Ideally,allofthequestionsidentifiedinthisbookcouldbeanswered.Inre-
ality,researchinitiativesneedtobetriaged,andeffortstoprioritizeareoften
inextricablylinkedwithcost-effectivenessconcerns.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
canbedauntingwhenmultiplefactorsandlevelsofinfluencemaybeasso-
ciatedwithriskbehavior(e.g.,druguse,poverty,stigma,racism,unstable
housing,disparateaccesstopreventionandtreatmentsystems).
In terms of early HIV diagnosis, Weinhardt in this book and others
(e.g., Crepaz and Marks, 2002) have underscored the importance of HIV
serostatusknowledgeforriskreduction.Weknowthatthemajorityofper-
sonswholearntheirHIV-positiveserostatustakemeasurestoreducerisk
forthemselvesandothers.However,thefieldhasyettofullycapitalizeon
thisprocessthroughtheoryandinterventiondevelopmenttounderstand
andsustainthesechanges.DatapresentedbyWeinhardtpreliminarilysug-
geststhatinitialrisk-reductionmaybefollowedbyasubsequentrebound
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-
creaseHIV-testingrates.Thepaucityofstudiesinthisareaisparticularly
troubling because the huge problem of ethnic health disparities for HIV
testing(andtreatmentaccess)remainspoorlyunderstood.Itisimperative
thatourresearch,policyandinterventionsbegintoclosethegapsthatare
responsible for delay in testing and access to treatment among minority
populations,especiallywomenofcolor.Individual,structural,andsocial
factors likely contribute to these disparities, and interventions to reduce
HIVstigmaasabarriertoHIV-testingarerare.Parsonshighlightstheneed
formorecreativeapproachestotestingandpreventionthattargetrelatively
untappedriskvenuesforgayandbisexualHIV-positiveandHIV-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-effectiveandleadtofollow-upHIVcare(Walenskyetal.,inpress).
These approaches may reduce some barriers to HIV testing, but we
alsolackcriticalinformationabouthowindividualsnavigatethroughthe
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-
tionservices(regardlessoftestresults),andconnecttootherservicesthat
mightaccompanyHIVtreatment(e.g.,mentalhealthcare,substanceuse
treatment, and other supportive services). In communities that lack in-
tegrated systems of care, successful outcomes often rely on “referrals”
thatmayrequiresophisticatedknowledgeandpersistenceonthepartof
patients and providers. Yet, we only have the most rudimentary notions
aboutwhetherandhowtheselinkagesoccur,whattodotoincreasetheir
FOREWORD xi
likelihood, and there is no overarching framework to guide HIV/AIDS
serviceintegration.
OncepeoplelivingwithHIV/AIDSareconnectedtoapreventionor
treatment setting, research can be enhanced throughout the intervention
continuum—from development to dissemination, adaptation, and com-
munity/clinicadoption.Asechoedbyseveralchapterauthorsinthisbook,
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-
negativepersons,anditsuggestsareastofurtherexpandfutureinterven-
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/structuralinfluencestoreduceriskbehavior,family-andcouples-
based prevention, coping, and adherence approaches, internet-based in-
terventions,andmassmediacampaignevaluation.
Tobeclear,behaviorchangeinterventionsforindividualsstillhavean
importantplaceinthenationalHIVpreventionplan.AsHoltgrave(2004)
haspointedout,perhapsonlyaminorityofHIV-positivemenandwomen
actually may need more intensive services, but for these persons the in-
dividuallevelofattentionmaybecritical.Individualswhoarestruggling
withsuchproblemsassubstanceuse,severeandpersistentmentalillness,
relationshipabuse,childhoodsexualabuse,poverty,ortransienthousing
may need to be referred to prevention case management or one of the
efficacious interventions detailed in this volume. The efficacy and effec-
tivenessofsuchprogramsforindividualsstrugglingwithmultiplehealth
and social problems continues to need careful study (Stall, et al., 2003).
Although only a few efficacious interventions are currently in the litera-
ture,methodologicaldescriptionsandoutcomedataforseveraltrialsare
pendingpublication(e.g.,Wingoodetal.,inpress;Purcelletal.,inpress;
Rotheram-Borusetal.,inpress;Fisheretal.,inpress).
However,futurepreventionoutcomesstilldependonafullerappre-
ciationthatHIVistransmittedininherentlyrelationship-drivencontexts
(Auerbach,inpress).Verylittleresearchhasinvestigatedrelationaldynam-
ics,condomusedecision-makingforbothHIVtransmissionandacquisition
whenonepartnerisHIV-positive,intimacy,thewaysthatpartnershipsare
affectedbycultureandmoreproximalsocialcontexts,andthetranslation