Studies Ready for Implementation

A number of interventions have been evaluated in current research and are ready to be implemented within communities. Indeed, some are already being implemented by health departments and community-based organizations. Interventions at the individual level include the following:

• Outreach, needle exchange activities, treatment programs, and face-to-face counseling programs for substance-abusing populations

• Cognitive-behavioral small group, face-to-face counseling, and skills-building (proper condom use, negotiation, refusal) programs for men who have sex with men

• Cognitive-behavioral small group, face-to-face counseling, and skills building (i.e., proper condom use, negotiation, refusal) programs for women that pay special attention to their concerns (e.g., child care, transportation, and relationships with significant others)

• Condom distribution and testing and treatment for sexually transmitted diseases for sex workers and other sexually active individuals at high risk for sexually transmitted diseases

• Cognitive-behavioral educational and skills-building groups for youth and adolescents in various settings.

At the family or dyad level, interventions include counseling for couples (including HIV- serodiscordant couples) in both the United States and other countries. Within the community, interventions include changing community norms through community outreach and opinion leaders for men who have sex with men as well as injection drug-using networks.

At the policy level there are a number of strategies:

• Lifting government restrictions on needle exchange programs

• Providing increased government funding for drug and alcohol treatment programs, including methadone maintenance

• Support for sex education interventions that focus beyond abstinence

• Lifting constraints on condom availability (e.g., in correctional facilities).

Implementation Considerations

Several factors may influence implementation of HIV risk behavior interventions within the United States.

First, compliance with interventions is improved when targeted individuals are involved at every phase of the process of conceptualization, development, and implementation of the programs. Input of these individuals is needed to help solve this health crisis.

Second, programs need to be culturally sensitive. This requires attention not only to ethnicity and language but also to other factors including social class, age, developmental stage, and sexual orientation.

Third, an appropriate intervention dosage must be selected for the population; this includes the number, length, and intensity of the intervention. Studies demonstrate that numerous intervention points over extended periods of time are more efficacious than once-only approaches for most populations. Almost all reported studies have short followup (3­18 months), which suggests that attention must be paid to maintenance efforts. It may be necessary to include additional, periodic intervention points for subsets of the population; longer-term followup would assist in determining this fact.

Fourth, when HIV risk behavior interventions are being introduced, it is important to address community myths. For example, scientifically derived results do not support assertions that needle exchange programs will lead to increased needle-injecting behavior among current users or an increase in the number of users. Nor do the data indicate that sex education programs result in earlier onset of sexual behavior or more sexual partners, or that condom distribution fosters more risky behavior. To the contrary, outcomes of these programs are quite consistent with the values of most communities. For example, behavioral interventions lead injecting drug users to inject less frequently, and the number of users in a community may decrease; after interventions, young people tend to delay initiation of intercourse or, if they are sexually active, have fewer partners; and adults, following intervention, engage in fewer incidents of risky sexual behavior. Armed with this knowledge, those who implement programs should confidently solicit the support and involvement of local government, educational, and religious leaders.

Despite notable gains relevant to implementation of prevention programs, very little cost analysis information has been available to guide community-based organizations, State and local health departments, and other practitioners. These analyses are important in determining the most cost-effective interventions for implementation. In addition, communities lack fiscal resources to support such interventions once they are proven successful. Finally, there are social and cultural barriers to implementation of programs; these include homophobia, gender inequality, and racism.

Sufficient training of personnel, monitoring of procedures to ensure fidelity to key components and established methods, and strong evaluation plans are essential components of any implementation strategy. When training and local capacity-building are necessary for implementation, training and technical assistance should be available to facilitate prevention programs at State and local levels. Evaluation results should be reported and widely disseminated so as to advance both science and practice. Newly implemented programs yielding results different from established findings should be carefully compared with original designs in order to explain the variance in outcomes.

The Next Step

Just as the Food and Drug Administration conditionally approves experimental drugs in emergency situations, so should policymakers support active dissemination of the most promising programs at this time based on the urgency of the AIDS epidemic. A critical issue that must be addressed involves the criteria for choosing interventions most ready for implementation in the community. The most obvious is evidence of strong program effects observed under rigorous, controlled research conditions. Among programs with strong effects, priority should be given to interventions that can be delivered with high reliability and fidelity to the original program model. Usually such programs do not require significant new demands or elaborate training at the delivery site.

At this next stage there will nevertheless be programs that show promise but still require additional research to ensure their effectiveness. At least two criteria should be considered in choosing promising programs for further evaluation. First, programs that show strong short-term effects but lack long-term results should be studied to estimate their long-term effectiveness. Second, programs that have shown promising effects for only a very narrowly defined range of settings or conditions of implementation should be studied to assess the generalizability of their effectiveness in other settings and contexts.

Numerous other interventions developed solely by community organizations were not described during the consensus development conference by the researchers, yet were brought to the attention of the panel by the public statements at the conference by community activists and practitioners. The efficacy of these approaches has not been demonstrated through careful evaluation. However, because community workers have developed a number of innovative and promising programs, there is a great need for them to work together with researchers to further HIV risk behavior intervention science and practice.

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