Recent programmes for people with HIV

A session on Positive Prevention at the 2008 International AIDS Conference in Mexico heard that structured, theory-based prevention programmes for people with HIV could be very effective.

One study, conducted by the University of California at San Francisco,¹ randomised 44 primary care physicians to train or not to train in the delivery of tailored risk-reduction messages to patients. The training aimed to help doctors ask patients about sexual behaviour, assess risk behaviour and deliver risk-reduction advice. Data were then collected from 386 of their patients over the following six months to see if the training had had any effect.

Patients of doctors who underwent the training had, at six months, 57% fewer partners in general (though they had more sex), and 56% fewer partners who were potentially serodiscordant than patients of doctors who had not received the training.

In contrast with this provider-delivered advice, the second intervention, from the Fenway HIV clinic in Boston, devised a peer-taught modular series of training for HIV-positive gay men in which social workers and psychologists collaborated with patient focus groups, and then trained HIV-positive peer trainers to deliver it.²

The ENHANCE Project consisted of four hour-long modules. All 195 patients received the first one (‘Having Sex’), and could then choose three other modules from a list of six. These other modules were ‘Getting the Relationships You Want’, ‘Disclosure’, ‘Cultures, Communities and You’ ‘Managing Stress’, ‘Triggers for Risky Sex’ and ‘Party Drugs’ – in that order of popularity.

Thirty per cent of patients reported any sexual risk at baseline and were followed up for 12 months, with a 12-month retention rate of 78%. The patient group was a largely white (79%), well-educated group with a mean age of 43 and ten years’ diagnosis with HIV. However, psychological assessment also revealed a lot of vulnerability: 43% said they had been sexually abused as a child; 27% had major depression; and 10% had experienced panic attacks.

In contrast with what has been seen in some other interventions, patients with high levels of risk behaviour at baseline responded to the intervention particularly well, while those who did not have high levels of risk to start with did not change their behaviour. The estimated number of sexual-risk episodes in the 30% of high-risk patients declined from 15 in the previous six months at baseline, to five six months after the start of training, and was still 6.4 at 12 months, representing a 57% reduction in risk behaviour. The overall reduction in risk over three measures (any risky sex, number of different risky behaviours and the proportion of anal sex that was unprotected) was 33%.

In a study reported in December 2008,³ a programme of structured counselling sessions reduced reported rates of risky sex in a population of HIV-positive MSM. All the participants had reported unprotected sex in the previous three months with a partner who was HIV-negative or of unknown HIV status, or an HIV-positive partner other than their primary partner.

The Healthy Living Project provided 15 one-to-one counselling sessions, divided into three modules. The first module focused on stress, coping and adjustment, the second on safer behaviours and the third on health behaviours.

A total of 616 men who have sex with men were recruited to the study and randomised to either receive the counselling sessions immediately, or for these to be provided at a later date.

There was a significant reduction in the number of risky sex acts during the course of the study both for those who received the counselling and those who were in the control arm. However, from months 5 to 20, individuals who received the counselling reported significantly fewer episodes of unprotected sex that could have involved a risk of HIV transmission than those in the control arm (p = 0.02). There was no difference at month 25.

On entry to the study, approximately 40% of individuals reported having sex partners who were also HIV-positive. This figure remained unchanged amongst the men who received the counselling, but fell amongst men in the control arms, the difference being significant at month five (p < 0.04) and month ten (p < 0.05). The investigators interpret this as a success of the programme in encouraging maintenance of serosorting (see Serosorting, sexual harm reduction and disclosure:  this is definition ‘C’ of serosorting, i.e. HIV-positive people restricting sex to other people with HIV.)

The investigators noted that there were significant reductions in reported risk behaviour amongst men in both the counselling and control arms. They speculated that “having participants reflect on the numbers and HIV serostatus of their partners may, in itself, constitute a prevention intervention” and account for the results seen in the control arm.