Positive Health, Dignity, and Prevention Behavioral Interventions with PLHIV Rigorous Evidence – Usable Results Third in a series, this summary fact sheet presents existing evidence from rigorously evaluated interventions to pre- vent HIV transmission in developing countries. Results are presented here from the meta-analysis of positiveDecember health, 2010 dignity and prevention studies published in leading scientific journals. In contrast to the many anecdotal reports of best practices, this series provides readers with the strongest evidence available in a user-friendly format. The evi- dence provides program planners, policy makers, and other stakeholders with information about “what works.” Positive Health, Dignity, and Prevention (PHDP) PLHIV now know their serostatus and are living lon- is a term for HIV prevention interventions with ger, healthier lives, and concerns of stigmatization people living with HIV (PLHIV). PHDP has also have been counterbalanced by legal protection, in- been called positive prevention, prevention with creasing advocacy and involvement of PLHIV in HIV positives, prevention by positives, and prevention prevention efforts. Today, program planners and for positives. In general, PHDP activities focus on PLHIV advocacy groups recognize that continuing achieving four main goals: (1) keeping PLHIV physi- to focus on general HIV prevention messages may cally healthy; (2) keeping PLHIV mentally and psy- limit the effectiveness and efficiency of HIV preven- chologically healthy; (3) preventing transmission tion strategies. Adding a focus on HIV prevention of HIV; and (4) involving PLHIV in HIV prevention interventions with PLHIV may improve overall HIV activities, program design, implementation and prevention strategies. In addition, across much of monitoring, leadership, and advocacy. the world, a significant number of new cases of HIV PHDP is a relatively new area of focus for HIV prevention Effectiveness of PHDP Interventions: Condom Use programs. Historically, HIV Number of Confidence interval Outcome Odds ratio prevention efforts focused studies (95% confidence level) on reducing HIV risk among individuals assumed to be Interventions for both HIV-positive and HIV-negative individuals HIV-negative. Program plan- Reported condom use among HIV- ners were hesitant to target positive participants versus non- 4 3.61 2.61-4.99 PLHIV with HIV prevention participants interventions due to con- Reported condom use among HIV- cerns about victim-blaming negative participants versus non 4 1.32 0.77-2.26 and increasing stigma for participants PLHIV. In addition, the limit- Interventions for PLHIV ed availability of HIV testing services globally meant that All interventions for PLHIV 7 7.84 2.82-21.79 most PLHIV did not know their HIV status. Recently, Reported condom use following counseling and group education however, antiretroviral ther- 4 2.08 0.93-4.62 apy availability and associ- among heterosexual adult PLHIV compared to non-participants ated care has been scaled- up dramatically worldwide. Reported condom use following HIV In addition, efforts to main- counseling and testing among HIV 3 67.38 36.17-125.52 stream HIV care and com- serodiscordant couples compared to bat stigma have also been non-participants expanded. As a result of these efforts, many more infection occur in HIV serodiscordant couples, but • Among serodiscordant couples who received HIV rates of HIV serostatus disclosure and condom use counseling and testing, both in an individual and in such couples remain low. Focusing attention on couples- based setting, participants were many HIV serodiscordant couples may therefore be an ef- times more likely to use condoms than non-par- fective way of reducing HIV transmission. ticipants. The large odds ratio depicted in the table on page 1 (OR=67.38) results from the dra- PHDP is a broad term that can encompass biologi- matic increase in condom use reported among cal, behavioral, and structural interventions. Here, serodiscordant couples following HIV counseling we focus on behavioral interventions with PLHIV, and testing as compared to little or no increase re- such as counseling and testing or group education ported among non-participants. interventions. Three review articles have examined behavioral interventions with PLHIV predominantly How is the Effectiveness of a PHDP Intervention in the United States.1,2,3 To our knowledge, there has Determined? been just one systematic review of behavioral inter- The findings presented in this fact sheet come from a 4 ventions with PLHIV in developing country settings. recent review of 19 studies. Of the 19 studies, 15 were Effectiveness of PHDP Interventions conducted in sub-Saharan Africa,1 in Asia (China), 1 in Latin America (Brazil), and 2 studies came from A recent meta-analysis by Kennedy et al.4 examined multiple sites (Kenya, Tanzania, and Trinidad; 2 stud- two approaches for implementing PHDP interven- ies from 1 article). Participants in these studies were tions: strategies that target both HIV-positive and mostly heterosexual adults (12 studies) and HIV se- HIV-negative individuals and ones that focus spe- rodiscordant couples (5 studies), although one study cifically on PLHIV. Therefore, the meta-analysis ex- was conducted among pregnant women (1 study) amined two separate questions: (1) Do behavioral and one was conducted among sex workers (1 study). interventions targeting both HIV-positive and HIV- negative individuals affect these two groups dif- Selection Criteria and Rigor Criteria of Studies In- ferently? (2) Do interventions that target PLHIV ef- cluded in the Kennedy et al.4 Meta-analysis fectively reduce HIV risk behaviors? Results of the A study had to meet three criteria to be included in meta-analysis showed that PHDP interventions in the analysis: developing countries had the following effects on participants compared to those not exposed to the 1. present behavioral, psychological, or biological intervention: outcomes related to HIV prevention in develop- ing countries Question 1: Interventions for both HIV-positive and HIV-negative individuals 2. use either a pre-/post- or multi-arm design (4 studies, 6 subgroup results) 3. appear in a peer-reviewed journal between These studies looked at the effect of counseling January 1990 and January 2006 and testing behavioral interventions on partici- Studies that did not meet these criteria were ex- pants who learned their HIV status as part of the cluded. intervention. Length of follow-up ranged from 2 The studies in the meta-analysis either report effect weeks to 14 months after testing. sizes for each outcome or provide sufficient infor- • Among PLHIV, participants were more than 3 mation in tables or text to calculate an effect size. times as likely to use condoms as non-partici- For the categorical outcomes typically presented pants. in the studies, these data include sample size infor- • Among HIV-negative individuals, participation in mation for each outcome, and either percentages the interventions did not affect condom use. or frequencies for each response category. Question 2: Interventions specifically for PLHIV What’s New? (7 studies, 7 subgroup results) Since the Kennedy et al.4 meta-analysis was com- • Among heterosexual HIV positive adults, there pleted, there have been several additional studies was no difference in condom use following coun- reporting the efficacy of positive prevention in de- seling and group education. veloping countries. Conceptual Framework showing goals, selected interventions and outcomes of positive prevention Positive Prevention Goals Keep people living Keep people living Prevent HIV Increase the agency with HIV with HIV transmission to of people living physically healthy mentally healthy other people with HIV Interventions • Provision of ART • Support groups • Prevention counselling • Training of PLHIV in • Prevention of opportu- • Substance abuse treat- • Partner/family HIV test- advocacy methods nistic infections ment programmes ing programmes • Encouragement and • Adherence counselling • Opioid substitution • Family planning educa- support for formation and support therapy tion/counselling of advocacy groups by • STI diagnosis/treat- • Medical management • Programmes for pre- people living with HIV ment of depression vention of mother-to- • Participation of PLHIV • Distribution of bednets • Psychosocial coun- child transmission on country-level techni- • Clean water pro- selling and support • Needle/syringe ex- cal working groups and grammes programmes change programmes other policy develop- • Nutritional education • Condom distribution ment groups and support • Mass media pro- grammes Outcomes Improve coping, pre- Reduce risk Increase visibility/ Prevent illness and vent depression, and behaviour /unintended participation of people infection reduce risk behaviour pregnancies living with HIV Reduced morbidity and mortality related to HIV/AIDS Reduced HIV incidence Reduced stigma Adpated from the Bulletin of the World Health Organization4 • One study in Thailand, India, and Uganda aimed to ventions on PLHIV are associated with positive behav- increase condom use among HIV serodiscordant ioral outcomes, including increased condom use. couples through a group-based intervention. One month following the intervention, the percentage What More Do We Need to Know about PHDP of participants reporting “ever” use of condoms in- Effectiveness? creased to 100%, and after 3 months, 90% of the The available evidence indicates that HIV counseling participants