Posts classified under: Substance Use

Friends Care I

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.

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P-QUAD Study

PQUAD is a pilot project to evaluate the acceptability, safety, and feasibility of delivering community-based HIV post-exposure prophylaxis in diverse Los Angeles County communities. It is a joint venture of UCLA, the Los Angeles Office of AIDS Programs and Policy (OAPP), the Department of Public Health Sexually Transmitted Disease Program, AIDS Project Los Angeles (APLA), and pharmaceutical industry partners.

Originally conceived in December, 2007, P-QUAD is now operational at 2 sites in epicenters of the HIV epidemic in Los Angeles: The Los Angeles Gay and Lesbian Center (opened March 2, 2010 in the Hollywood/West Hollywood area of Los Angeles with a largely MSM catchment), and The OASIS Clinic (opened April 15, 2010 in the south central area of Los Angeles with a largely lower socioeconomic status, at risk African-American and Latino catchment). The study provides dual or triple-agent ART for 28 days as post-exposure prophylaxis for HIV infection to individuals exposed sexually or via injection-drug works sharing, when presenting within 72 hours of an appropriately high-risk exposure. Additionally, substance use, mental health, and behavioral risk reduction referrals/linkages are provided as appropriate. Efficacy, safety, adherence, tolerability and behavioral outcomes are being collected. In the event of seroconversions, longitudinal specimens are stored for virologic analyses.

The program currently is providing Truvada (tenofovir + emtricitabine), or Combivir (zidovudine + lamivudine) with or without Kaletra (ritonavir + lopinavir). An upcoming amendment will offer Isentress (raltegravir) as an alternative to Kaletra for intolerance. An IND has been filed with the FDA for the use of these agents in a non-FDA approved study context (IND # 104,989) and the study is overseen and all study documents approved by the UCLA Institutional Review Board. Since opening the program, the P-QUAD has enrolled 30 participants as of May 6, 2010 [29 at LAGLC and 1 at OASIS], with an initially planned enrollment of 100 participants (50 at each site).

Community Health Study

There have been few attempts to monitor the risk behaviors and HIV seroprevalence among the general population.

Understanding the HIV epidemic in Los Angeles requires establishing an integrated, multilevel surveillance system for HIV, sexually transmitted diseases (STDs), and the Hepatitis C virus (HCV). Information about sexual and substance use risk behaviors, HIV seroprevalence, and public knowledge, attitudes, and norms regarding HIV are needed for public health planning. A surveillance system will be required in order for Los Angeles to maintain funding for Ryan White and other federal and state funding sources. To begin to develop a method for mounting a comprehensive surveillance system, the City of Los Angeles is planning a study examining the acceptability of anonymous HIV testing and volunteering information about one’s risk behaviors in order to allow planning for HIV-related services.

Most studies of HIV seroprevalence and risk behaviors have been conducted with subgroups identified at high risk for HIV: young gay men, injecting drug users, homeless adolescents, or seriously mentally ill adults. There have been few attempts to monitor the risk behaviors and HIV seroprevalence among the general population (not necessarily from identified high-risk groups). Before any comprehensive surveillance system can be established, the ability to monitor HIV in community settings and among households in neighborhoods with high rates of AIDS cases must be established. To fill this gap, a two-phase project is being initiated by the city in order to assess the acceptability of HIV testing and reporting one’s risk behaviors when approached: 1) in a household survey; or 2) in a neighborhood setting such as a shopping mall, grocery center, theater, or church.

First, the acceptability of gathering HIV-related information from a household will be examined by conducting a supplement to the Los Angeles Health Survey that will be mounted this summer. An anonymous telephone interview will be conducted with random digit dialing of households within the City of Los Angeles. Randomly selected telephone numbers (n=100) will be surveyed on knowledge of transmission of HIV, attitudes and norms towards members of high-risk groups (e.g., gay men) and infected persons, and willingness to anonymously be tested for HIV. All responses will be recorded unlinked from telephone numbers selected by random digit dialing; therefore the identify of all respondents will be unknown and can never be traced. From gathering this information, the acceptability of a household approach as a method of gathering information about HIV-related information will be assessed.

Second, a community with a high rate of AIDS cases will be selected. In this neighborhood, local leaders will be consulted to identify a strategy for sampling community members anonymously and in settings accessible to all community members. In shopping malls in both communities, adults will be asked to anonymously volunteer to participate in a survey of attitudes and norms regarding HIV prevention activities, recent sexual and substance use risks acts, and consent to a saliva-based HIV test. The results of any individual test results will not be available; unmarked samples will be collected in order to indicate a community seroprevalence rate. Interested individuals will be offered an incentive for participating in the survey and test. The willingness of adult members of the community to participate in a study anonymously will be evaluated. Similar to the telephone household survey, no identity of any participant will be obtained. Overall, community rates will be obtained, but no individual information regarding risk or infection status.

The results of these two activities will be used to inform the Los Angeles County Board of Supervisor’s decisions regarding the best method for establishing surveillance methods for HIV infection and predictions regarding the future routes and subgroups for HIV infection. Currently, the County is considering adopting a method of practitioners informing public health officials of all persons testing seropositive for HIV or for a system of unique identifiers for persons who test seropositive for HIV. Both of these systems rely on the identification of seropositive persons, an event that typically occurs about 10 years after a person has become infected. Alternative strategies for monitoring the epidemic, especially among communities with an emerging epidemic must be identified. These studies will inform the strategy selected by the County and may become a national model.

Hep-Safe Hollywood

Homeless, stimulant-using gay/bisexual men and transgender women are at high risk for hepatitis B virus (HBV), hepatitis C virus (HCV), and HIV infection due to high rates of injection drug use and high-risk sexual behaviors. Thus, use of stimulants threatens to intensify homeless persons’ risk of exposure to hepatitis B, C viruses and HIV; therefore, research focused on this group is critical. A contingency management (CM) intervention may be particularly well suited for this high-risk population. CM is an intervention that attempts to modify a targeted behavior by providing incentives for changing that behavior (in simple terms, positive reinforcement). CM interventions have been successfully implemented among stimulant-using gay and bisexual men to reduce drug use and concomitant sexual risk behaviors.

The Hep-Safe Hollywood study will implement a CM intervention to increase successful HAV/HBV vaccination completion programs among homeless, stimulant-using gay/bisexual men and transgender in Hollywood. This randomized, control trial will assign 500 homeless, stimulant-using gay and bisexual men to either an enhanced nurse case managed program, which includes specialized education and CM, or a standard program, which includes brief education and CM. This study is innovative in that it will allow us to look at the effect of an enhanced nurse case management and CM program versus a standard brief education and CM program. The study will evaluate the effectiveness of homeless, stimulant-using gay/bisexual men and transgender women on completion of the HAV/HBV vaccine and, secondarily, on reduction of risk for hepatitis and HIV. Additionally, the study will assess the relative cost of these programs in terms of completion of the vaccine series. The study combines best strategies to approach, engage and intervene with this hidden and high-risk population and to assess the feasibility and efficacy of interventions that may prove beneficial in preventing hepatitis A, B, C and HIV infections.

This study is a collaboration between UCLA School of Nursing and Friends Research Institute, with Dr. Adeline Nyamathi, as the principal investigator.

 

Teens and Adults Learning to Communicate (TALC: LA)

Project TALC was funded by the National Institute of Mental Health (NIMH) to evaluate the efficacy of a family-based intervention over time and to contrast the life adjustments of HIV-affected families and their non-HIV-affected neighbors in the current treatment era. Mothers living with HIV (MLH; n = 339) and their school-age children (n = 259) were randomly assigned to receive a behavioral intervention or standard care as the control condition. MLH and their children were compared to non-HIV-affected families recruited at neighborhood shopping markets.

Targeted Risk Group: 

HIV-positive mothers and their adolescent children

Published Journal Articles:

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Links to Interventions, Training Manuals, etc. : 

 Phase 1 – Taking Care Of Myself

Parents’ Curriculum

Phase 2 – Illness

Parents’ Curriculum

  1. TALC LA- Parents Phase 2, Sess 1: What Are My Children's Needs?
  2. TALC LA- Parents Phase 2, Sess 2: Who Will Take Care of My Children?
  3. TALC LA- Parents Phase 2, Sess 3: What Kind of Arrangements Can I Make?
  4. TALC LA- Parents Phase 2, Sess 4: How Do I Start My Plan?
  5. TALC LA- Parents Phase 2, Sess 5: How Can I Really Listen To My Children?
  6. TALC LA- Parents Phase 2, Sess 6: How Can I Tell My Children What I Feel?
  7. TALC LA- Parents Phase 2, Sess 7: How Should I Deal with Problem Behavior?
  8. TALC LA- Parents Phase 2, Sess 8: How Can We Create a Positive Atmosphere at Home?
  9. TALC LA- Parents Phase 2, Sess 9: How Can We Resolve Conflicts at Home? (Part 1)
  10. TALC LA- Parents Phase 2, Sess 10: How Can We Resolve Conflicts at Home? (Part 2)
  11. TALC LA- Parents Phase 2, Sess 11: How Can We Work Together on Selecting a Custodian?
  12. TALC LA- Parents Phase 2, Sess 12: How Can We Deal with Drugs and Alcohol?
  13. TALC LA- Parents Phase 2, Sess 13: How Do I Prevent Pregnancy and Fatherhood?
  14. TALC LA- Parents Phase 2, Sess 14: Where Am I in Making a Custody Plan?
  15. TALC LA- Parents Phase 2, Sess 15: How Can Mothers Encourage Safer Sex?
  16. TALC LA- Parents Phase 2, Sess 16: What is the Mother's Legacy and the Youth's Goals?

 Adolescents’ Curriculum

Phase 3 – Adjustment

New Caregivers and Teens’ Curriculum

  1. TALC LA- New Caregivers and Teens Phase 3, Sess 1: What Do Adolescents and Caregivers/Parents Need from Each Other?
  2. TALC LA- New Caregivers and Teens Phase 3, Sess 3: Dealing with Loss and Grief - Part I
  3. TALC LA- New Caregivers and Teens Phase 3, Sess 4 (Caregivers): Raising an Adolescent
  4. TALC LA- New Caregivers and Teens Phase 3, Sess 4 (Youths): Planning for My Future - Part I
  5. TALC LA- New Caregivers and Teens Phase 3, Sess 5: Dealing with Loss and Grief - Part II
  6. TALC LA- New Caregivers and Teens Phase 3, Sess 6: How Can We Improve Communication - Part I (Effective Expressing)
  7. TALC LA- New Caregivers and Teens Phase 3, Sess 7: Ways of Helping Someone Cope with Loss and Grief
  8. TALC LA- New Caregivers and Teens Phase 3, Sess 8: How Can We Improve Communication - Part II (Active Listening and Responding)
  9. TALC LA- New Caregivers and Teens Phase 3, Sess 9 (Caregivers): Caregiver Support
  10. TALC LA- New Caregivers and Teens Phase 3, Sess 9 (Youths): How Do I Achieve My Goals?
  11. TALC LA- New Caregivers and Teens Phase 3, Sess 10: (Joint) How Can We Deal With Anger in the Relationship?
  12. TALC LA- New Caregivers and Teens Phase 3, Sess 11: How Can I Cope with Sadness?
  13. TALC LA- New Caregivers and Teens Phase 3, Sess 12 (Caregivers): How Should I Deal with Problem Behavior?
  14. TALC LA- New Caregivers and Teens Phase 3, Sess 12 (Youths): How Do I Deal with Fear?
  15. TALC LA- New Caregivers and Teens Phase 3, Sess 13: How Do We Practice Safer Sex, Prevent Pregnancy, and Reduce Alcohol and Drug Use?
  16. TALC LA- New Caregivers and Teens Phase 3, Sess 14: How Can We Resolve Conflicts at Home?
  17. TALC LA- New Caregivers and Teens Phase 3, Sess 15: How Can We Create a Positive Atmosphere at Home?
  18. TALC LA- New Caregivers and Teens Phase 3, Sess 16: Looking to the Future Together, What Can We Do?

Young Adults’ Curriculum

  1. TALC LA- Young Adults Phase 3, Sess 1: How Are Things Going?
  2. TALC LA- Young Adults Phase 3, Sess 2: Planning for My Future - Part I
  3. TALC LA- Young Adults Phase 3, Sess 3: Dealing with Loss and Grief - Part I
  4. TALC- Young Adults Phase 3, Sess 4: Where and How Can Young People Get Support?
  5. TALC LA- Young Adults Phase 3, Sess 5: Dealing with Loss and Grief - Part II
  6. TALC LA- Young Adults Phase 3, Sess 6: Ways of Coping with Loss and Grief
  7. TALC LA- Young Adults Phase 3, Sess 7: Planning for My Future (Part II) - How Do I Achieve My Goals?
  8. TALC LA- Young Adults Phase 3, Sess 8: Hearing and Getting Heard
  9. TALC LA- Young Adults Phase 3, Sess 9: How Can We Deal with Anger?
  10. TALC LA- Young Adults Phase 3, Sess 10: Relationships and Sex (Part 1)
  11. TALC LA- Young Adults Phase 3, Sess 11: Relationships and Sex (Part 2)
  12. TALC LA- Young Adults Phase 3, Sess 12: How Can I Cope with Sadness?
  13. TALC LA- Young Adults Phase 3, Sess 13: Pregnancy and Parenthood
  14. TALC LA- Young Adults Phase 3, Sess 14: How Do I Deal with Fear?
  15. TALC LA- Young Adults Phase 3, Sess 15: How Can I Reduce Substance Use?
  16. TALC LA- Young Adults Phase 3, Sess 16: Looking to the Future

Intervention Model: 

Mothers and their adolescents attended a 16-session cognitive behavioral intervention over eight weeks. For MLH, intervention goals aimed to: 1) improve parenting while ill (i.e., reduce family conflict, improve communication, clarify family roles); 2) reduce mental health symptoms; 3) reduce sexual and drug transmission acts; and 4) increase medical adherence and assertiveness with medical providers. For adolescents, the intervention goals were to: 1) improve family relationships; 2) reduce mental health symptoms; 3) reduce multiple problem behaviors (e.g., drug use, criminal justice acts, school problems, teenage pregnancy); and 4) school retention.

Research Methods:

In a random assignment study, families assigned to take part in Project TALC were compared with families assigned to a control group on mental health and health behaviors, including sexual behavior and substance use. Both intervention and control families were compared to a neighborhood cohort, matched on sociodemographics. Because study participants were followed over two years, longitudinal random effect regression models were used to test the efficacy of the intervention.

Surveys and Scales Used:

  1. Living Situation, Including Neighborhood Problems - Scale
  2. Religion: Attendance and Experience
  3. Financial, Labor, and Educational Experience - Scale
  4. Loss and Grief - Scale
  5. Treatment History - Survey
  6. Social Support - Survey
  7. Romantic Relationships - Survey
  8. Needle Use and Sharing - Survey
  9. Reproductive Health - Survey
  10. Parentification - Survey
  11. Goals Scale
  12. Natural Mentors
  13. Dealing with Mother's Illness - Survey
  14. Acculturation, Habits, and Interests Multicultural Scale for Adolescents (AHIMSA)
  15. Sexually Transmitted Disease - Survey
  16. Medication Adherence - Survey
  17. Educational (Academic) Experience Assessment
  18. Family Functioning - Scale
  19. Family Composition - Scale
  20. Employment and Labor Experience Assessment - Survey
  21. World Health Organization Quality of Life (WHOQOL) - Survey
  22. Self Harm: Suicide History - Survey
  23. CDC Sexual Behavior Questions (CSBQ)
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  25. Detention and Jail History Assessment - Survey
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  27. Alcohol and Other Drug Abuse (AOD) - Scale
  28. Adolescent Substance Use - Survey
  29. PTSD Index for DSM IV (Adolescent version) - UCLA
  30. Parker Parental Bonding Instrument
  31. Positive and Negative Affect Scale (PANAS)
  32. Network Assessment
  33. Janis Self-Esteem - Scale
  34. Medical Outcomes Study (MOS) Social Support - Survey
  35. Living Situation for Adolescents - Survey
  36. Life Outcome Expectancies Assessment - Survey
  37. Life Goals Assessment - Survey
  38. Life Events Assessment - Survey
  39. House Rules - Scale
  40. HIV Related Incidents - Survey
  41. Healthcare Utilization, Providers, and General Health Assessment: Including STD and Pregnancy - Survey
  42. HIV Testing Assessment - Survey
  43. General Medical History Assessment
  44. Multiple Problem Behavior - DSM Conduct Problems (DSMC) - Conduct Disorder
  45. Conflict Resolution - Conflict Tactics Scale (CTS)
  46. Adult Adolescent Parenting Inventory (AAPI) - Survey
  47. Nutrition and Exercise - Survey
  48. Rosenberg Self-Esteem (RSE) - Scale
  49. Dealing with Illness - Scale

Local Significance: 

There was a lack of significant findings for an intervention effect on HIV-transmission behaviors and mental health. HIV-transmission behaviors were low to begin with and participants had little room for improvement. The populations affected by the HIV epidemic in the U.S. have shifted over the past number of years since a similarly mounted intervention in New York City led to improvements. HIV interventions in the U.S. need to shift their focus to persons living with HIV who are experiencing substantial problems.

International Significance:

While the focus of U.S.-based HIV interventions need to shift, interventions for the general HIV population may be effective outside the U.S.

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

Los Angeles County Methamphetamine Prevention Initiative

There is a significant unmet need in Los Angeles County for methamphetamine-specific training, and community service agencies and outreach workers need education and training on effective approaches to engage and serve persons in the community at risk. Training and technical assistance is also needed for service providers on the latest evidence-based methamphetamine treatment approaches.

More specifically, trainings are needed that cover methamphetamine-specific issues crucial for the development of skills by medical providers, clinicians and outreach workers serving clients who use methamphetamine and address specific concerns around providing culturally appropriate care for specific populations. These trainings address issues such as: mental health considerations, psychological complications, sexual and cybersex addiction and current evidence based treatments.

This training project included the following activities:

  • Providing consultation and technical assistance to the Los Angeles County Alcohol and Drug Program Administration (ADPA) and the Office of AIDS Programs and Policy (OAPP)
  • Developing training curricula and module for ADPA or OAPP-funded substance abuse or HIV/AIDS treatment providers
  • Developing and disseminating web-based training module
  • Providing in-service trainings for Los Angeles County Methamphetamine Task Forces
  • Providing in-service trainings for ADPA and OAPP-funded Drug Abuse and HIV prevention agencies serving young women
  • Providing tailored technical assistance

Recruiting and Engaging Adolescents in Creating Hope (Project REACH)

Project REACH aims to create an effective recruitment and retention method for family interventions for substance abuse and adapt culturally-appropriate substance abuse programs targeting African American adolescents who are enrolled in Los Angeles County Office of Education (LACOE) schools and their parents (parents includes an adult guardian).
Targeted Risk Group: 
Probation youth and their families in Los Angeles
Research Methods: 
The project has two phases. The first phase is to develop an effective way to recruit families into a family intervention for substance abuse and determine how to make the intervention culturally appropriate. The family intervention that will be adapted for this project is Families that Care: Guiding Good Choices ((aka “Preparing for the Drug Free Years”) (GGC). GGC has been proven to reduce substance abuse, address family conflict through problem solving and communication techniques, and finally increase family connectedness. These activities will be done in collaboration with school administrators, probation officials, teachers, students and parents through key informant interviews and focus groups. The second phase will pilot test the adaptation of GGC in a sample of 60 African American from LACOE schools and their parents.
Local Significance: 
Expect to improve recruitment and retention in GGC, and GGC will improve family functioning and mental health, and decrease problem behaviors (HIV risk behaviors, school performance and recidivism).

Safety Counts

Drug users have a high risk of HIV infection. Because certain neighborhoods have higher levels of substance abuse, HIV risk becomes related to geography as well. Thus, there is need for local street outreach programs such as Safety Counts.

Research Methods:

In a quasi experimental, cross-over design, two Los Angeles neighborhoods were randomly assigned to receive either (1) Voluntary HIV Counseling and Testing (VCT) or (2) Safety Counts. In Phase 1, injection drug users and crack users in these neighborhoods attended the respective intervention. In Phase 2, each neighborhood and therefore its participants received the alternative intervention. Participants were reassessed at 5–9 months. Data collected included demographics, sexual risk behavior, and substance abuse.The Safety Counts intervention differed from the VCT intervention in that Safety Counts offered skill-building and goal-setting workshops, one-on-one counseling sessions to implement goals, street contacts to support other participants, and social events.

Local Significance: 

Drug users in the Safety Counts program reported significantly greater reductions in risky sex, crack and hard drug use, and risky drug injection. The more sessions of Safety Counts attended, the greater were the reductions in risky acts. Different analytic decisions result in very different findings for the same intervention. Safety Counts is an effective intervention for injection drug users and crack users.

Nsindikanjake Vocational Training Project

Socio-economic status plays an important role in HIV risk and prevention. Specifically, poverty can lead to survival sex and unprotected sex. The Nsindikanjake Vocational Training Project, a collaboration between UCLA and the Uganda Youth Development League (UYDEL), aims to reduce HIV risk among urban Ugandan youth through vocational education and training.

From February 2005 to January 2006, 100 13- to 23-year-old participants were recruited from two different youth centers in the slums of Kampala, Uganda. Youth were randomized by site to an immediate vocational training intervention (N=50 youth) or a 4-month delayed vocational training (N=50 youth). Participants were assessed at baseline, 4, and 24 months later. Youth were asked about employment, sexual risk behaviors, delinquent behavior, quality of life, mental health symptoms, and drug use.Vocational education consisted of apprenticeships with local artisans for 4 to 8 hours, 5 days a week. Artisans received training in having conversations with youth about HIV and how to cope with unprofessional behavior (e.g., tardiness, hygiene problems). Youth in the delayed training condition received vocational training after a 4-month follow-up assessment was completed. The final assessment was administered 24 months after enrollment, by which time all youth had received training.
Vocational training may be highly useful in supporting the impact of HIV prevention. The participants receiving vocational training showed reduced delinquent behaviors and greater improvements in employment, life satisfaction, and social support compared to control participants. Both conditions demonstrated such improvements at two years, especially ongoing employment which remained strong.
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