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The Healthy Living Project Team (2007) conducted a randomized, controlled trial involving 936 men and women living with HIV in four U.S. cities: Los Angeles, Milwaukee, New York, and San Francisco. Participants were assigned to either a 15-session, individually delivered, cognitive behavioral intervention designed to "help ... people to cope with the challenges of living with HIV, ... particularly not transmitting the virus" (p. 213),1 or to a control condition, in which no active psychosocial interventions were delivered until the trial had concluded. "Both groups completed follow-up assessments at 5, 10, 15, 20, and 25 months after randomization ... [and t]ransmission risk, as measured by the number of unprotected sexual risk acts with persons of HIV-negative or unknown status, was the main outcome measure" (p. 213). The investigators report that the intervention
was successful in helping [people living with HIV] reduce unprotected sexual intercourse with HIV-negative or unknown status partners. At the 20-month assessment, or 5 months after completion of the intervention, the intervention group had reduced transmission risk acts by an average of 36% compared with the control group. Although the early part of the intervention, which addressed general coping skills, did not establish a significant treatment effect at the 5-month point, a positive intervention effect was seen around the time of the [second] module[, which dealt with] applying coping effectiveness skills to specific sexual situations involving potential for HIV transmission[,] at 10 months. This intervention effect increased over time, as seen in the 15- and 20-month assessments.
Unfortunately, the treatment effect in terms of a reduction of HIV transmission risk acts was not maintained at 25 months. Nonetheless, significant reductions in transmission risk acts from baseline levels were observed for the intervention and control groups at 25 months.2 The attenuation of the intervention effect over time in this study is consistent with results from other randomized controlled trials of behavioral interventions. ... This finding highlights how HIV is now more like a chronic disease, requiring ongoing case management over time as HIV-positive persons enter new relationships or new life challenges. A "booster" model seems warranted. (p. 218)
The Healthy Living Project Team concludes that "[c]ognitive behavioral intervention programs can effectively reduce the potential of HIV transmission to others among [people living with HIV] who report significant transmission risk behavior" (p. 213). Importantly, "[a]lthough this intervention was delivered as 15 sessions for research purposes, the same content was adapted to 8 sessions when delivered to the lagged control participants. The intervention is intensive and would only be feasible for complex cases in which less intense provider-based or group interventions do not seem to be sufficient for reducing transmission risk" (p. 219).
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1 "The Healthy Living Project experimental intervention ... consisted of 15 90-minute individual counseling sessions grouped into 3 modules, each consisting of 5 sessions. Module 1 (stress, coping, and adjustment) addressed quality of life, psychologic coping, and achieving positive affect and supportive social relationships. Module 2 (safer behaviors) addressed self-regulatory issues, such as avoiding sexual and drug-related risk of HIV transmission or acquisition of additional sexually transmitted diseases, and disclosure of HIV status to potential partners. Module 3 (health behaviors) addressed accessing health services, adherence, and active participation in medical care decision making. Intervention sessions followed a standard structure and set of activities but were individually tailored to participants' specific life contexts, stressors, and goals" (p. 215).
2 "[E]ven through the control arm did not receive the specific theory-guided intervention, the effect of repeat assessments of sexual behavior (just asking about unprotected sex) may serve as a cue for risk reduction for subjects" (p. 218).
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Summer 2007 Newsletter / Volume 8, Issue 4
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