Economic Evaluations for HIV Prevention Programs for Adolescents

While the field of HIV prevention has demonstrated that adolescents do reduce their sexual and substance use risk acts in response to intervention programs, there have been no evaluations of the cost effectiveness of these program.

Effective HIV preventive interventions have been developed and evaluated with adolescents (Jemmott, in press). CHIPTS investigators designed, mounted, and evaluated HIV prevention programs with four adolescent samples at high risk for HIV: runaway youth (n=312), gay youth (n=154), youth living with HIV (n=351), and youth with parents with AIDS (n=423 adolescents from 280 different families). Each of these samples reflects a sub-population at high risk of contracting or transmitting HIV; each is composed predominantly of African-American and Latino youth aged 12-20 years. For each population, an intervention was designed based on social learning theory that focused primarily on skill building and aimed at reducing sexual and substance use risk acts; each intervention also was tailored for the specific population. Each intervention was delivered in a small group setting, used tokens to encourage social rewards, and monitored affect by the use of a feeling thermometer. Homework assignments were common across interventions and multiple sessions were implemented. Each sample has been followed for at least two years; the assessment points for follow-up were at least 3, 6, 12, 18, and 24 months. The same research team designed the measures and the domains of assessment were similar. Each sample was assessed for sex and drug use.

While the field of HIV prevention has demonstrated that adolescents do reduce their sexual and substance use risk acts in response to intervention programs, there have been no evaluations of the cost effectiveness of these programs. This project, funded by the National Institute of Mental Health (NIMH), will evaluate the cost-effectiveness of each of the four adolescent prevention programs already mounted and compare the consistency of the cost-effectiveness findings across studies. The project consists of three phases. First, building on a cost-effectiveness analysis of the HIV intervention on runaway youth, this project is using the existing data to perform the cost-effectiveness analysis of the other three HIV intervention programs which were delivered to adolescents (youth living with HIV, gay youth, and youth whose parents living with AIDS). Second, the results of these four cost-effectiveness analyses are being used to examine the similarity and the consistency of the cost-effectiveness of different HIV-related intervention programs. Third, because HIV sex risk acts among adolescents are usually part of a cluster of problem behaviors, this project will expand current strategies for examining cost-effectiveness to include social outcomes such as foster care, mental health institutionalization, jail, and temporary shelter.

HIV/STD Risk Behaviors in Methamphetamine User Networks

SATH-CAP stands for the Sexual Acquisition and Transmission of HIV Cooperative Agreement Program. The overall goal of SATH-CAP is to better understand how patterns of sexual and drug use behaviors along with other social and environmental factors, such as other sexually transmitted diseases, places where people gather for sex and drug activities, and types of partnerships, influence the spread of HIV/AIDS from people currently at high risk for HIV/AIDS, like drug users and men who have sex with men (MSM), to those at a lower risk.

Specifically, the study seeks to answer these primary questions:

  • To what extent do HIV infections among drug-using populations spread to uninfected drug users and non-drug users through drug-related and/or sexual transmission behaviors?
  • What individual (behavioral, biological), network, and structural characteristics influence the speed, extent and path of the spread?

The SATH-CAP includes five research centers, a scientific and logistical coordinating center at RAND, and the funder, the National Institute on Drug Abuse (NIDA). The research centers are:

  • Research Triangle Institute (RTI)
  • University of California, Los Angeles (UCLA)
  • University of Illinois, Chicago (UIC)
  • Yale University
  • The Biomedical Center (BMC), St. Petersburg, Russia, Andrei Kozlov

Long-Term Health Effects of Methamphetamine Use in the MACS

The overall goal of this study is to determine the long-term health effects of methamphetamine use within an existing cohort of men who have sex with men participating in the Multicenter AIDS Cohort Study. Specifically, this study focuses on stimulant abuse effects on health issues that occur at the intersection of mental health, drug abuse, and HIV infection.

The specific aims are:

  1. To identify the precursors of methamphetamine (“meth”) use and/or abuse among MSM,
  2. To identify the development of comorbidities and HIV risk among meth users,
  3. To identify development of comorbidities and HIV risk among minority men, and
  4. To test whether meth use hastens HIV disease progression in the era of highly active antiretroviral therapy.

This is a multicenter, prospective substudy of the MACS study designed to test the theoretical model of the emergence of meth use and associated health problems among MSM by administering psychosocial/behavioral questionnaires at two consecutive MACS Visits, 49/50. Data collected included a battery of psychosocial measures, early lifetime stressors, ongoing stressors, current sexual behaviors, drug use patterns, and other health risks.

Methamphetamine Abuse Treatment in HIV Prevention

Gay and bisexual males who use methamphetamine are at extremely high risk for HIV infection. Methamphetamine use in this population is highly associated with risky sexual behavior, with users of the drug reporting an increased number of sexual partners, decreased use of condoms, and an increased likelihood of being HIV-infected or having a sexually transmitted disease.

This study (1) adopted, tailored and transferred an evidenced-based, gay-specific cognitive behavioral therapy (GCBT) intervention for methamphetamine-abusing gay and bisexual males from a research setting for use in a community-based HIV prevention setting; (2) optimized the GCBT intervention by coupling it with a contingency management (CM) intervention to create one behavioral intervention for producing sustained HIV sexual and drug risk reductions; and (3) developed a continuing care intervention to support and maintain longer-term behavior changes.

171 gay or bisexual males who meet criteria for methamphetamine abuse were enrolled into the 16-week behavioral intervention consisting of GCBT+CM during weeks 1 through 8, and Continuing Care+CM during weeks 9 through 16. Assessments were conducted at baseline, 8-week, 16-week, and 26-week post admission. Findings from this study will inform the field on best practices for providing HIV prevention interventions specifically designed for methamphetamine-abusing gay and bisexual males.

Optimizing Access to nPEP for HIV Using Contingency Management in Stimulant-Using MSM

The majority of new HIV infections across Los Angeles County continue to be found among men who have sex with other men (MSM). Within MSM, stimulant abuse, particularly methamphetamine abuse, is the major factor in driving new infections, primarily via behavioral disinhibition contributing MSM methamphetamine users to engage in extremely high-risk sexual transmission behaviors. Friends Care combines the biomedical intervention of Post-exposure Prophylaxis (PEP) for HIV prevention with the behavioral intervention Contingency Management (CM), which targets reduction of methamphetamine use as a way of reducing concomitant high-risk sexual behaviors for HIV-negative, methamphetamine-using MSM.

Friends Care will enroll 49 HIV-negative, methamphetamine-using MSM into the CM component of the dual intervention. Participants receive a baseline assessment including urine analysis for the presence of methamphetamine metabolites, a rapid oral HIV antibody test, a physical examination including a comprehensive metabolic panel and complete blood count, HIV/STI prevention information, and medication adherence information. Following baseline assessments, participants begin an 8-week, 3x/week, CM intervention and are given a 4-day starter pack of tenofivir with emtricitabine (i.e., Truvada). Participants earn vouchers for methamphetamine metabolite-free urine samples, which are redeemable for goods and services.

In the event of an unexpected high-risk sexual exposure to HIV, i.e., unprotected anal intercourse with an HIV-positive or status unknown partner, participants are instructed to immediately call the clinic and begin the 4-dose starter pack of Truvada. An appointment with the physician is scheduled within 96 hours of the participant’s first dose of Truvada; participants then receive a second rapid oral HIV antibody test and are given the additional 24-day pack of Truvada.

Participants return to the clinic at 3-months post baseline for a follow-up evaluation and a third rapid oral HIV antibody test. In combining these two interventions in this unique program, Friends Care aims to reduce methamphetamine use and concomitant high-risk sexual behaviors, while reducing potential seroconversions.

Healthy Living Project (HLP): Multi-Institutional Collaborative Research Project

The UCLA Healthy Living Project was funded by the National Institute of Mental Health (NIMH) and was designed to promote health-related behavior changes in adults living with HIV. This project aimed to reduce sexual and injection drug use risk behaviors among 1,200 HIV positive men and women in order to decrease the likelihood of secondary HIV transmission. The research study focused on four subgroups: women, heterosexual men, men who have sex with men, and injection drug users. The study was conducted at four sites: Los Angeles, Milwaukee, New York, and San Francisco.

Targeted Risk Group:

Adults living with HIV

Interventions, Training Manuals, etc. : 

Intervention model:

Cognitive behavioral intervention comprised of 15 individually delivered counseling sessions covering three areas: “Stress, Coping, and Adjustment,” “Risk Behaviors,” and “Health Behavior.”

Research Methods: 

In a random assignment study, individuals assigned to take part in the intervention were compared with individuals assigned to a control group, i.e. delayed intervention, on HIV-transmission behaviors, including unprotected sex and substance use. Because participants were followed over two years, longitudinal random effect regression models were used to test the efficacy of the intervention.

Local Significance: 

The intervention was demonstrated to reduce risky sexual behavior and substance use.
At the end of the study, the goal was to train service provider staff to deliver the intervention to their clients. By collaborating with service providers early on in the intervention study, it was possible to learn how to tailor the intervention to the specific needs of the agencies involved and the people they serve.

International Significance: 

HLP provided a behavioral intervention that can be adapted for other countries and cultures to reduce HIV-transmission risk behaviors

Project Tech Support

Interventions, Training Manuals, etc: 

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Out-of-treatment, methamphetamine-using men who have sex with men (MSM) are at extreme risk of HIV acquisition and transmission, predominantly through high-risk sexual behaviors that are facilitated by use of the drug. Project Tech Support study enrolls 50 out-of-treatment, methamphetamine-using MSM into an information technology (IT) communication intervention. Field workers conduct outreach in identified venues in the natural settings where out-of-treatment, methamphetamine-using MSM congregate. Over the course of two weeks, participants engage in a text messaging intervention and receive real-time HIV prevention messages, social support and referrals for healthier, prosocial choices regarding drug- and sexual-risk behaviors.

The study aims to:

(1) conduct formative work to assist in the development of an IT communication intervention for reducing methamphetamine use and high-risk sexual behaviors among out-of-treatment MSM;

(2) assess the feasibility and utility of the behavioral intervention on the target population; and

(3) gather indicators of the mechanism of action for this intervention, a dose-response association will be evaluated between the extent of use of IT communication system and the degree of reduction in methamphetamine use and concomitant sexual risk behaviors.

Evaluations, including biological markers for drug use and HIV serostatus are collected at baseline and two months post-intervention.  Cognitive and behavioral outcomes are measured. Findings from this study will inform the field on the feasibility of adapting an IT communication intervention for reducing sexual risk behaviors and HIV acquisition and transmission among out-of-treatment, methamphetamine-using MSM.

 

Voucher-based Incentives in a Prevention Setting (VIPS)

Interventions, Training Manuals, etc. : 

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Homelessness is a significant problem plaguing American cities and homeless substance abusers face increased risks. Homeless, gay and bisexual male abusers suffer approximately 80% seroprevalence and often engage in exchange sex and resist treatment for substance abuse. Contingency management interventions, which provide positive incentives for behavior change, may be particularly well suited for this disenfranchised, high-risk cohort. Specifically, voucher-based incentive therapies may be effective since they have established potency for increasing prosocial behaviors that successfully compete with taking drugs and for reducing drug use.

A randomized, controlled trial assigns 131 non-treatment seeking gay, bisexual or MSM substance users to either voucher-based incentive therapy or control groups for 24 weeks, with follow-up evaluations at 7, 9 and 12 months post randomization. The voucher-based group earns vouchers in exchange for completing prosocial and healthy behaviors, and/or submitting drug-negative urine and alcohol-negative breath samples, and/or attendance in a standard HIV prevention program, OAPP-funded The G.U.Y.S. Program. The control group receives feedback regarding behaviors performed and urinalysis and breathe alcohol tests, but does not receive voucher points for these behaviors, but does receive vouchers for attendance in a standard HIV prevention program, The G.U.Y.S. Program. Vouchers are redeemable for goods located in an onsite voucher store or purchased for the participant.

The study will assess the efficacy of the voucher-based intervention for increasing prosocial and healthy behavior and reducing substance abuse among these non-treatment seeking gay, bisexual and MSM substance users receiving standard HIV prevention services. The study will also assess the impact of the voucher-based incentive therapy on other measures of therapeutic change consistent with a harm reduction approach, including reduction of psychiatric symptoms, decreased injection drug use and high-risk sexual behavior, increased participation in The G.U.Y.S. Program, and improvement in different domains of overall functioning (medical/social/vocational).  Additionally, the study will examine whether baseline participant characteristics predict voucher-based outcomes.

Applying voucher-based incentive therapy to non-treatment seeking gay, bisexual and MSM substance users as well as integrating the intervention into a county-funded HIV prevention program with a harm reduction philosophy are both highly innovative. The VIPS study has the potential to have a significant impact on the public health of the Los Angeles homeless, gay and bisexual substance-using community. If voucher-based incentive therapy is efficacious for motivating non-treatment seeking gay, bisexual and MSM substance users in a community-based HIV prevention program to increase prosocial and healthy behaviors and decrease drug/alcohol use, established prevention programs may modify their approaches to include contingency management, and use it to address the staggering public health problems non-treatment seeking homeless substance users face on a daily basis.

 

Guys Understanding Your Situation (G.U.Y.S. Program)

Interventions, Training Manuals, etc. : 

The G.U.Y.S. Program offers a multi-tier health education/risk reduction (HE/RR) intervention – utilizing both individual and group-level interventions – designed to reduce high-risk sexual and drug behaviors among homeless, substance-using gay men and non-gay identified men who have sex with other men, and with women, and with transgender women. Most specifically the intervention targets sexual risk behaviors that are most likely to occur while using methamphetamine, particularly unprotected anal intercourse, as well as exchange sex risks and injection drug risks.

The program consists of a comprehensive, culturally appropriate, continuum of services that includes outreach, individual-level interventions (ILI), skills building group-level interventions (GLI) and art support GLIs. Follow-up ILI assessments are conducted at 30, 60 and 90 days. Face-to-face street outreach is conducted in identified high-risk areas of Hollywood and West Hollywood and in the natural settings where homeless, substance-using men congregate. The program has successfully worked with these populations in highly charged sexual arenas and developed non-invasive outreach and intervention strategies for these venues, which vary based on the safety and atmosphere of each public or commercial sex environment. The skills building GLI component of the intervention serves to increase knowledge and awareness of HIV risk behaviors and develop skills to decrease HIV risk behaviors. Concurrently, the art support GLI component of the intervention serves to increase social support and self-esteem. Art is used as a harm reduction strategy by offering an opportunity for participants to closely identify their feelings and work towards understanding many of their high-risk behaviors. The art support GLI provides a space to cultivate their voice and express their experiences through art. Both the skills building GLI and art support GLI – working concomitantly with the outreach encounters and ILI – motivate ongoing and maintained HIV risk reductions and gear participants’ towards HIV testing to identify their HIV status and, finally, develop skills for disclosing HIV status.

 

HIV Counseling & Texting Program

The HIV Counseling and Texting (HCT) program utilizes social networks testing methodology, specifically designed to work with HIV infected and high-risk gay and bisexual men of color and transgender women. HIV infected or high-risk negative participants who either come to the Friends Community Center site for services or are contacted through street outreach and meet eligibility are invited to serve as recruiters. The engagement of new recruiters will be an active and ongoing part of the program. Potential recruiters attend a group orientation, which explains the social network methodology and informs potential recruiters that they will be requested to recruit individuals from their social, sexual or drug-using networks whom they believe to be at high-risk of HIV infection. Following the training period (brief identification, group orientation, individual interview), the recruiter begins to locate network associates to be referred to our testing site. Confirmatory HIV tests and STI testing (syphilis, Chlamydia, gonorrhea) are also available at the Friends Community Center site. Participants (both those who test HIV negative and positive) are then linked to appropriate medical, social, psychological, CRCS and other needed services. Network associates who wish to become recruiters are be assessed for eligibility and appropriateness.

This program is funded by the Los Angeles County, Department of Health Services, Office of AIDS Programs and Policy (OAPP).