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