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A theory-based behavioral intervention program has shown that HIV-positive men and women will reduce unprotected sexual activity over a six-month follow-up period. "In a nutshell, what we learned was that after six months we saw the HIV-positive risk reduction group was using condoms more and having less unprotected sex, particularly with partners who were not HIV-positive," says Seth C. Kalichman, PhD, psychologist and professor in the department of psychiatry at the Medical College of Wisconsin and the Center for AIDS Intervention Research in Milwaukee.
The study found that participants who were involved in the intervention program had lower rates of self-reported anal and vaginal intercourse across all sexual partners and reportedly exposed seronegative or unknown serostatus partners to HIV at a reduced rate when compared with the health maintenance comparison group of participants.1 "A colleague did a statistical modeling of the effects, and it suggested that if this kind of intervention was implemented in a community, it would likely prevent new HIV infection," adds Kalichman.
The study focused on both condom use and on reduction in unprotected acts, including a variety of different strategies for safer sex and how to reinforce these strategies. There were 230 HIV-positive men and 98 HIV-positive women participants who were recruited from AIDS services and infectious disease clinics in Atlanta. Eligibility criteria were to be living with HIV/AIDS and voluntary willingness to complete the study activities. The mean age was 40.1 years; 52% of the sample identified themselves as gay, and another 9% identified as bisexual. African-Americans accounted for 74% of the participants, while 22% were white and 4% were other ethnic backgrounds. Nearly half had completed at least 12 years of education.
Participants were randomly assigned to a transmission risk reduction intervention and a health maintenance control condition. In both groups, participants met in groups of six to 10 people for five 120-minute sessions, consisting of two sessions per week over 2.5 weeks. All participants received $10 for each group session attended and $35 for completing each assessment.
The control condition consisted of a social support group modeled after support groups offered in the community. These sessions included education and updates on HIV disease, management of health problems, medication adherence, health care and insurance concerns, and nutrition. These participants were expected to develop a personalized health maintenance plan at the end of the final group session. The intervention staff, which consisted of one female and one male facilitator, worked with the intervention group and the comparison group.
Here’s how the intervention program worked:
• Teaching ways to disclose HIV serostatus: Three sessions addressed how to disclose HIV serostatus to sexual partners and other people. The intervention program used role-playing and movie clips to stimulate discussion within the group, Kalichman says. "For the family and friends disclosure session, we focused on how to make an effective decision, and we clipped out popular film scenes lasting two or three minutes and providing a good situation for the group to assess and evaluate," Kalichman says.
For example, one movie scene that was very effective was from the movie Philadelphia, showing the character played by Tom Hanks disclosing to the lawyer portrayed by Denzel Washington that he has AIDS. "We showed the scene and then asked the group, What do you think about how he did it?’" Kalichman says. "How would you have done it?’" Other movie scenes used came from the films An Early Frost and Boys on the Side, starring Whoopi Goldberg. The role-playing typically involved having participants act out six different scenes depicting how to disclose their HIV status to family and friends. "This was an essential part of how we ran the groups, and people really liked it," Kalichman says.
• Explaining hazards of co-infection with other STDs: The session that dealt with risk behaviors emphasized the importance of maintaining safer sexual practices over the long term of infection. Facilitators explained how unsafe sex could place HIV-positive people at risk for sexually transmitted diseases (STDs), which might be more dangerous to a person with AIDS. "There are some researchers who have a philosophy that if people only have sex with an HIV-positive partner, then it’s a good risk reduction strategy," Kalichman says. "But we were very clear that all unprotected sex is risky."
STDs can be difficult to treat in people with HIV/AIDS, and herpes is an AIDS-defining diagnosis, Kalichman says. "We discussed this a lot, because it was our view that it was a significant health problem for people with HIV," he adds.
Besides providing discussions and education about unsafe sexual practices, facilitators gave participants a personalized feedback report about their own risk practices based on the baseline assessments. "We also used personalized feedback as an emotional strategy, giving people feedback on their behavior and their specific risky situations," Kalichman says. Then the groups discussed strategies for protecting oneself and one’s partner while maintaining satisfying relationships.
• Exploring negative attitudes about condoms: The intervention program had a big segment on condom desensitization and how to get over barriers to using condoms. For example, facilitators helped participants explore their negative attitudes toward condoms, and they conducted practice sessions using male and female condoms on anatomical models. "In a more therapeutic kind of approach, we tried to deal with the issue of using condoms 100% of the time, and we put condoms on wooden penis models as a desensitization test," Kalichman says. This session also featured movie clips that dealt with the anticipation of sexual activity, such as a scene from Eddie Murphy’s movie Coming to America and One Night Stand with Wesley Snipes.
• Identifying problem-solving strategies: The intervention program taught participants how to negotiate safer sex and how to make decisions. Participants were asked to think about how they set their own expectations for their own behavior with HIV-positive and negative partners. "We used role-playing a lot with those elements and used movie clips to drive the role-playing," Kalichman says.
Participants were asked to identify problem-solving strategies and to discuss barriers to practicing safer sexual behavior. The intervention concluded with participants filling out an individualized sexual health and relationship plan, including personal decision criteria for disclosing HIV serostatus and strategies for maintaining safer sexual behavior.
"Our study wasn’t just about condom use," Kalichman notes. "It was about reduction in unprotected acts, the broader picture." Although condoms are an important option, they’re not the answer for everyone, so the intervention sessions focused on a variety of strategies for making sexual behavior safer, he adds. "Not only did we get an increase in condom use, but we also saw a reduction in unprotected acts," Kalichman says.
(Editor’s note: Intervention manuals are available upon request. For more information, contact Seth C. Kalichman, PhD, Center for AIDS Intervention Research, Medical College of Wisconsin, 8701 Watertown Plank Road, Milwaukee, WI 53226. E-mail: email@example.com.)
1. Kalichman SC, Rompa D, Cage M, et al. Effectiveness of an intervention to reduce HIV transmission risks in HIV-positive people. Am J Prev Med 2001; 21:84-92.