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Every 6-12 months over a period of 8 years (1994 through 2002), Aidala, Lee, Garbers, and Chiasson (2006) interviewed a representative sample of 968 men and women living with HIV in New York City. This cohort
reported considerable variability in sexual behaviors over time. Many persons were not sexually active at all for months at a time; some continued to have multiple partners. Over one third of the cohort had one or more periods when they had engaged in unprotected sex with a partner who was HIV-negative or status unknown ... and one in five reported exchanging sex [for money or drugs]. Periods of unsafe sex alternated with periods of safer sex. Predictors of sexual risk varied by gender, and among men who had sex with men [MSM], and men sexually active with women only. Contextual factors such as partner relations, housing status, and receipt of HIV services were as important as individual attributes as predictors of unsafe sex and sex exchange. (pp. 12-13)
The investigators submit that these findings
underline the importance of conducting risk screening – a cornerstone of evidence-based HIV prevention recommendations – on an ongoing basis, not just at entry into care. ... [This] study indicates that HIV sexual and drug-related risk behaviors, sexual partnering, [self-described] sexual orientation, and contextual factors like housing status and service utilization change over time. For prevention messages to be effective, at a minimum, they must be relevant to the patient's behaviors and circumstances at the time they are delivered ... . Given the fluidity of the factors that have been shown to be significant predictors of unsafe sex and sex exchange, regular and repeated risk screening is essential. (pp. 28-29)
With regard to sexual risk behavior among persons living with HIV, another contribution to the Tool Box on meta-analysis and HIV prevention interventions presented in the Spring 2006 issue of mental health AIDS comes from Johnson, Carey, Chaudoir, and Reid (2006). These investigators conducted a meta-analytic review of sexual risk reduction interventions implemented in studies involving men and women living with HIV. Both published and unpublished studies were considered for inclusion in the meta-analysis "if they examined a deliberate sexual risk-reduction strategy in a sample that included HIV+ participants, used a randomized controlled trial design, measured condom use or number of sexual partners after the intervention, and provided sufficient information to calculate effect size (ES) estimates" (p. 642). Ultimately, 15 published studies describing 21 interventions, involving 3,234 participants, and available as of November 30, 2004, qualified for review. "Across the studies, intervention participants exhibited lowered sexual risk relative to control participants on condom use ... but not for number of sexual partners ... . Interventions were more successful at increasing condom use if the sample included fewer ... MSM ... or younger participants and when interventions included motivational and skills components" (p. 642). Johnson and colleagues conclude that "[b]ehavioral interventions reduced sexual risk especially if they included motivational and skills components. Such interventions have been less effective for older samples, suggesting the need for further refinement to enhance their efficacy. Motivation- and skill-based interventions have not yet been tested with HIV+ MSM who, in general, seem to have benefited less from extant risk-reduction interventions" (p. 642).
On the topic of condom-related interventions, Durantini, Albarracín, Mitchell, Earl, and Gillette (2006) meta-analyzed 166 HIV prevention interventions "included in Albarracín et al.'s (2005) meta-analysis testing the effectiveness of different contents of interventions across different populations and contexts" (p. 217); these latter findings were the centerpiece of the Spring 2006 Tool Box referenced above. The focus for Durantini and colleagues was the relationship between source characteristics ("professional expertise1 and recipient-source similarity in demographics and behaviors" [p. 232]) and the effectiveness of HIV prevention interventions.
Durantini and colleagues report that, "[i]n general, expert interventionists produced greater behavior change than lay community members, and the demographic and behavioral similarity between the interventionist and the recipients facilitated behavioral change. Equally importantly, there were differences across groups in the efficacy of various sources, especially among populations of low status and/or power" (p. 212). More specifically,
experts are advisable in all cases, with the exception of groups of people under 21 years old. In addition, women and girls respond best to sources of the same gender, ethnicity, and behavior-risk group, whereas men and boys respond best to sources of either gender and of different ethnicity and behavior-risk group. Both Blacks and Whites change more when sources match their ethnicity and their risk group, although African Americans change more in response to experts than both European American and foreign samples of European and African ethnicities. People over 21 respond better to sources of their same gender, ethnicity, and behavior-risk group, and people under 21 respond better to sources of the same age in addition to the same gender, ethnicity, and behavior-risk group. Finally, all of the risk groups in all ... analyses changed more when sources included experts and individuals from the same risk groups. The only exception was [MSM], who showed greater change when the source included an expert but were unaffected by the inclusion of a behavior-risk-similar source. (pp. 235-236)
Drawing on these findings, Durantini and colleagues contend that
the decision of who intervenes to change the behavior of an audience is highly consequential. ... [Findings confirm] that demographic similarity generally has a health-promoting effect. Behavioral-risk group similarity between intervention sources and recipients is also beneficial, and generally increases compliance with the intervention's recommendation. ... [P]ast doubt in the use of experts as a catalyst for behavior change may be misguided because experts appear to be uniquely qualified to facilitate change. In particular, women and African Americans are the ones who most benefit from the use of physicians, nurses, or professional health educators, while also benefiting from exposure to intervention sources who are similar to them. Given this finding, comprehensive efforts to combat HIV must necessarily address the shortage of professionals who will effectively promote change in their own communities. (p. 241)
Shifting focus away from condom-related interventions, Longshore, Stein, and Chin (2006)
used the AIDS risk reduction model2 ... as a conceptual framework to guide a prospective analysis of sexual risk reduction in a sample of 600 heterosexually active, HIV-negative persons involved in illegal drug use (337 men and 263 women). The sexual risk reduction measure was a latent variable based on number of sex partners and risky sexual behavior such as engaging in sex while on drugs and having sex with high-risk partners. These indicators represent behavior by which women as well as men may be able to exert indirect control over their sexual risk. (p. 93)
The investigators found that, "[w]ith baseline sexual risk behavior controlled, stronger commitment to safer sex predicted less sexual risk behavior for both men and women. For men but not women, greater AIDS knowledge predicted safer sex commitment. For women but not men, higher self-efficacy predicted stronger commitment to safer sex, and peer norms favoring sexual risk reduction predicted higher self-efficacy" (p. 93).
Importantly, "[t]he model explained only 9% of the variance in men's sexual risk behavior and 18% of the variance in women's" (p. 101). Clearly, then, additional factors not accounted for in this model influence sexual risk behavior among women and men. Nevertheless, these findings offer some guidance for framing interventions. Longshore and colleagues observe that
[g]ender differences in the pathways to sexual risk reduction imply that intervention to promote sexual risk reduction should be designed to address such differences. Commitment to safer sex was related to sexual risk reduction among drug-using men. Interventions with this population should therefore target safer sex commitment. Examples of commitment-building exercises include counterattitudinal advocacy, declarations or written statements of commitment, and behavior contracts ... . Interventions promoting cognitive accessibility of risk-reduction intentions are another potentially effective strategy .... . In addition, although drug users' knowledge regarding virus transmission routes is generally high ..., the path from AIDS knowledge to safer sex commitment – weaker for men than for women – suggests that men's intervention ought to target their AIDS knowledge. ... Interventions for men should ... provide definitive information regarding routes of transmission and seek to raise men's beliefs that this information is reliable. (pp. 101-102)
As with drug-using men,
[f]or drug-using women, safer sex commitment was related to sexual risk reduction. Women's interventions should seek to raise commitment to safer sex by strategies such as those described above for men. But they should also explicitly address self-efficacy. Self-efficacy for exerting direct control over sexual risk, i.e., for persuading men to use condoms, appears to be a pathway to risk reduction for women ... . However, the present study indicates that self-efficacy as a motivator for women's indirect control over sexual risk behavior is another such pathway. It is important to emphasize indirect as well as direct control in women's intervention ... [;] an overemphasis on use of condoms is unwise if it means devoting inadequate time to risk reduction strategies that women can control more readily, e.g., having sex with fewer partners, avoiding sex with men known or thought to be engaging in high-risk behavior such as drug injection, abstaining from drug or alcohol use during sex, and slowing the pace of sexual intimacy.
Self-efficacy was influenced by women's perceptions regarding peer norms for sexual risk reduction. This finding suggests that interventions with women should attempt to increase peer support for exerting control over sexual risk. Use of a small-group format ... is probably most appropriate in such interventions. The ... [facilitator] can raise various strategies for risk reduction, such as condom use and avoidance of sex. Participants as a group, on the basis of their experience, can identify the pros and cons of these strategies. The sharing of successful personal experience would serve to highlight the common concerns of participants and might provide a major boost to their sense of self-efficacy. (p. 102)
Longshore and colleague's analysis begs the following question: Do condom-related interventions increase the frequency of sexual behavior, inadvertently undermining sexual risk reduction efforts? To answer this question, Smoak, Scott-Sheldon, Johnson, Carey, and the SHARP Research Team (2006) conducted
[a] meta-analytic review of the influence of HIV risk reduction interventions on sexual occasions, number of partners, and abstinence ... . Included studies examined sexual risk reduction strategies and used a controlled design. Data from 174 studies (206 interventions, ...116,735 participants) were included. In general, HIV risk reduction interventions neither increased nor decreased sexual occasions or number of partners reported. Participants in intervention conditions were less likely to be sexually active than those in control conditions. When samples included more black participants, interventions reduced the number of sexual occasions; interventions were more successful at reducing the number of partners in samples that included more ... MSM ... or individuals engaged in sex trading. Samples that included more MSM were more likely to adopt abstinence as a risk reduction strategy. Interventions that included more information, motivational enhancement, and skills training also led to greater risk reduction. (p. 374)
Smoak and colleagues conclude that "HIV risk reduction interventions do not increase the overall frequency of sexual activity. To the contrary, for some subgroups, interventions that include components recommended by behavioral science theory reduce the frequency of sexual events and partners" (p. 374).
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Summer 2006 Newsletter / Volume 7, Issue 4 
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