HIV: Interventions to Reduce Sexual Risk Behaviors or Increase Protective Behaviors to Prevent Acquisition of HIV in Men Who Have Sex with Men Community-Level Interventions

The CPSTF finding is based on evidence from a systematic review of 3 studies (search period 1988 – 2005).

The review was conducted on behalf of the CPSTF by a team of specialists in systematic review methods, and in research, practice, and policy related to HIV prevention.

Detailed results from the systematic review are available in the published evidence review.

The systematic review included three studies that reported on three interventions.

• Unprotected anal intercourse (UAI): 35% reduction in odds at follow-up intervals ranging from 4 months (two studies) to 1 year (one study)
• Condom use during anal intercourse: 59% increase in odds (two studies)

Detailed results from the systematic review are available in the published evidence review.

The economic review included three studies that found that potential savings in HIV-related medical costs exceeded the costs of implementing the intervention. Estimates are reported in 2003 U.S. dollars.

• In two of the studies, the average of costs per HIV infection averted was $45,418. Although the source of cost data and modeling assumptions were different in the two studies, both reported that costs per discounted quality-adjusted life years (QALY) saved were negative, implying the original program was cost saving.
• The third study reported a range of cost per HIV infection averted using different timeframes, epidemic scenarios, cost perspectives, and modeling inputs. From a societal perspective that included volunteer time, costs per HIV infection averted were estimated to range from $49,580 in 1 year to $7,373 in 20 years, depending on the particular assumption about the HIV prevalence rate.

Based on the evidence, this finding should be applicable across a range of settings and MSM populations in the United States, assuming interventions are appropriately adapted to the needs and characteristics of the population.

CPSTF identified several areas that have limited information. Additional research and evaluation could help answer the following questions and fill remaining gaps in the evidence base. (What are evidence gaps?)

• How effective are interventions among particular groups?
  • Nonwhite MSM, and in particular, African-American and Latino populations who are disproportionately affected by HIV
  • Non gay-identified MSM, who may have different HIV prevention needs than gay-identified men
  • MSM who are substance users
• Given the included studies were set in locations such as gay bars, community-based organizations, health clinics, and research study sites, how effective are they in other settings (e.g., “circuit parties”)?
• What are intervention effects on health outcomes (e.g., STDs and HIV)? What are the most effective ways to measure such biological outcomes?
• What are the minimal and optimal variables for intervention effectiveness (e.g., number of sessions, program duration, type of skills training)?
• How have advances in technology and medicine over the past decade altered the social and behavioral landscape of the MSM community? Has commitment to reducing sex risk behaviors declined since HIV became a more manageable condition?
• Has the Internet led to elevated levels of sex risk behavior among MSM seeking and meeting sex partners?

In the included studies, HIV behavioral interventions at the community level

• Aimed to motivate and reinforce behavior change in individuals who did not participate directly in the intervention by promoting norms that support safer sex through popular opinion leaders, community mobilization, or social networks
• May have had several components, requiring complex coordination and several years or longer to implement

Following are characteristics of studies included in the reviews of HIV behavioral interventions at individual, group, and community levels.

• Most of the included studies were conducted in the United States, though some were conducted in Brazil, the United Kingdom, New Zealand, or Canada.
• Of the 19 included studies, 13 were conducted before 1996, the year highly active antiretroviral treatment (HAART) was introduced.
• Participants were recruited in a variety of settings, including clinics, community-based organizations, and gay community venues such as bars and public cruising areas.
• Most studies evaluated interventions with follow-ups longer than 3 months, and only two studies failed to achieve at least 80% retention.
• The median age across all study samples was 33 years, and in the 15 studies reporting education, at least 50% of participants had some college.

Herbst JH, Beeker C, Mathew A, et al. The effectiveness of individual-, group-, and community-level HIV behavioral risk reduction interventions for adult men who have sex with men: a systematic review. American Journal of Preventive Medicine. 2007;32(4S):S38-67.

Task Force on Community Services. Recommendations for use of behavioral interventions to reduce the risk of sexual transmission of HIV among men who have sex with men. American Journal of Preventive Medicine. 2007;32(4S):S36-7.

Millett GA, Peterson JL. The known hidden epidemic; HIV/AIDS among Black MSM in the U.S. American Journal of Preventive Medicine. 2007;32(4S):S31-S33.

Ramirez-Valles J. The quest for effective HIV-prevention interventions for Latino gay men. American Journal of Preventive Medicine. 2007;32(4S):S34-S35.

Stall R. Opportunities to improve AIDS prevention practice among MSM. American Journal of Preventive Medicine. 2007;32(4S):S29-S30.

Effectiveness Review

Analytic Framework – See Figure 1 on page S41

When starting an effectiveness review, the systematic review team develops an analytic framework. The analytic framework illustrates how the intervention approach is thought to affect public health. It guides the search for evidence and may be used to summarize the evidence collected. The analytic framework often includes intermediate outcomes, potential effect modifiers, potential harms, and potential additional benefits.

Effectiveness Review

Summary Evidence Table
Contains evidence from reviews of HIV behavioral interventions at individual, group, and community levels

Economic Review

Summary Evidence Table – Economic Review see Table 3 on page S49

The following list of included studies is for HIV behavioral interventions at individual, group, and community levels.

The number of studies and publications do not always correspond (e.g., a publication may include several studies or one study may be explained in several publications).

Effectiveness Review

Carballo-Di guez A, Dolezal C, Leu CS, Nieves L, D az F, D cena BI. A randomized controlled trial to test an HIV prevention intervention program for Latino gay and bisexual men: lessons learned. AIDS Care, 2004 GALLEY COPY

Choi KH, Lew S, Vittinghoff E, Catania J, Barrett DC, Coates TJ. The efficacy of brief group counseling in HIV risk reduction among homosexual Asian and Pacific Islander men. AIDS 1996;10(1):81-7.

Dilley JW, Woods WJ, Sabatino J et al. Changing sexual behavior among gay male repeat testers for HIV: a randomized, controlled trial of a single-session intervention. J Acq Immune Def Syndr 2002;30(2):177-86.

Imrie J, Stephenson JM, Cowan FM, et al. A cognitive behavioural intervention to reduce sexually transmitted infections among gay men: randomized trial. BMJ 2001; 322(7300):1451-6.

Kegeles SM, Hays RB, Coates TJ. The Mpowerment Project: a community-level HIV prevention intervention for young gay men. American Journal of Public Health 1996; 86:1129-36.

Kelly J, Lawrence JS, Hood HV, Brasfield TL. Behavioral intervention to reduce AIDS risk activities. Journal of Counseling and Clinical Psychology 1989;57(1):60-7.

Kelly JA, Murphy DA, Sikkema KJ, et al. Randomised, controlled, community-level HIV prevention intervention for sexual-risk behaviour among homosexual men in US cities. Lancet 1997; 350:1500-5.

Kelly JA, St. Lawrence JS, Diaz YE, et al. HIV risk behavior reduction following intervention with key opinion leaders of population: an experimental analysis. American Journal of Public Health 1991;81:168-71.

Koblin B, Chesney M, Coates T; EXPLORE Study Team. Effects of a behavioural intervention to reduce acquisition of HIV infection among men who have sex with men: the EXPLORE randomised controlled study. Lancet 2004;364(9428):41-50.

Peterson J, Coates TJ, Catania J et al. Evaluation of an HIV risk reduction intervention among African-American homosexual and bisexual men. AIDS 1996; 10(3):319-25.

Picciano J, Roffman R, Kalichman S, et al. A telephone based brief intervention using motivational enhancement to facilitate HIV risk reduction among MSM: a pilot study. AIDS Behav 2001;5:251-62.

Roffman RA, Picciano JE, Ryan R et al. HIV- prevention group counseling delivered by telephone: an efficacy trial with gay and bisexual men. AIDS & Behavior 1997;1(2):137-54.

Roffman RA, Stephen RS, Curtin L et al. Relapse prevention as an interventive model for HIV risk reduction in gay and bisexual men. AIDS Education & Prevention 1998; 10(1):1-18.

Rosser BRS. Evaluation of the efficacy of AIDS education interventions for homosexually active men. Health Educ Res 1990;5(3):299-308.

Sampaio M, Brites C, Stall R, Hudes ES, Hearst N. Reducing AIDS risk among men who have sex with men in Salvador Brazil. AIDS & Behavior 2002;6(2):173-81.

Shoptaw S, Reback CJ, Peck JA, Yang X, Rotheram-Fuller E, Larkins S, Veniegas RC, Freese TE, Hucks-Ortiz C. Behavioral treatment approaches for methamphetamine dependence and HIV-related sexual risk behaviors among urban gay and bisexual men. Drug Alcohol Depend 2005;78:125-34.

Stall R, Paul J, Barrett DC, Crosby GM, Bein E. An outcome evaluation to measure changes in sexual risk-taking among gay men undergoing substance use disorder treatment. Journal of Studies on Alcohol 1999;60(6):837-45.

Tudiver F, Myers T, Kurtz RG, Orr K. The talking sex project. Evaluation & the Health Professions 1992;15(1):26-42.

Valdiserri RO, Lyter DW, Leviton LC, Callahan CM, Kingsley LA, Rinaldo CR. AIDS prevention in homosexual and bisexual men: Results of a randomized trial evaluating two risk reduction interventions. AIDS 1989;3:21-6.

Economic Review

Kahn JG, Kegeles SM, Hays R, Beltzer N. Cost-effectiveness of the Mpowerment Project, a community-level intervention for young gay men. J Acquir Immune Defic Syndr 2001;27:482 91.

Kahn JG, Haynes-Sanstad KC. The role of cost-effectiveness analysis in assessing HIV-prevention interventions. AIDS Public Policy J 1997; 12:21 30.

Pinkerton SD, Holtgrave DR, DiFranceisco WJ, Stevenson LY, Kelly JA. Cost-effectiveness of a community-level HIV risk reduction intervention. Am J Public Health 1998;88:1239 42.

The search strategy for this systematic review was published separately:

DeLuca JB, Mullins MM, Lyles CM, Crepaz N, Kay L, Thadiparthi S. Developing a comprehensive search strategy for evidence based systematic reviews. Evidence Based Library and Information Practice 2008;3(1). Available at URL: https://journals.library.ualberta.ca/eblip/index.php/EBLIP/article/view/855

The following considerations are drawn from studies included in the evidence review, the broader literature, and expert opinion.

• The barriers most frequently reported in the included studies and broader literature involved the challenges of recruitment, enrollment, and retention of MSM in HIV behavioral interventions.
  • Some MSM subgroups were particularly hard to reach because of geographic isolation, social isolation, fear of being exposed as an MSM, and failure of the intervention to address the cultural values and practices of the community.
  • Several studies linked difficulties in retaining MSM in HIV behavioral interventions to the frequent perception that interventions are not motivating and captivating, or are irrelevant.
  • Time constraints, competing interests, and substance use have been identified as influences on participation in prevention programs.
  • Barriers to recruitment and enrollment are especially important in low-income minority communities with high HIV seroprevalence, where MSM may not want to acknowledge their homosexual behaviors. MSM may restrict their sexual activity to private clubs, people met through the Internet, or other venues not associated with the gay community.
• Included studies used the following strategies to address some of these barriers.
  • Interventions were delivered entirely over the telephone to overcome geographic boundaries
  • Peer opinion leaders diffused safe sex messages through social networks to reach isolated MSM
  • A variety of training elements were used to increase salience and appeal.
  • Culturally relevant content was incorporated for subgroups, particularly minority or substance-using MSM
• Multicomponent community-level interventions require extensive community mobilization and coordination that enables supportive relationships with key stakeholders.
• Where gay communities lack the resources or community support to mobilize community-level approaches, small-group or network-based interventions may work.
• The internet can be a useful tool to recruit and enroll MSM into behavioral interventions. Other strategies include the “foot in the door” approach and respondent-driven sampling.

Healthy People 2030

Healthy People 2030 includes the following objectives related to this CPSTF recommendation.

• Reduce the number of new HIV infections — HIV‑01
• Reduce the number of new HIV diagnoses — HIV‑03