Journal of the Association of Nurses in AIDS Care
Volume 22, Issue 1 , Pages 38-52, January 2011

Adapting Positive Prevention Interventions for International Settings: Applying U.S. Evidence to Epidemics in Developing Countries

published online 11 June 2010.

Article Outline

HIV prevention efforts with people living with HIV are critical, and Positive Prevention (PP) interventions have expanded globally to address this growing need. This article provides an overview of U.S. PP literature addressing evidence-based interventions. It continues by looking at the prevention needs and care issues of people living with HIV in Mozambique and the larger African context, and then discusses which U.S. PP models may be best suited for adaptation and use in Mozambique. The research suggests that the lessons learned from these U.S.-developed interventions can be modified to develop theoretically sound interventions. These interventions must be culturally specific and include a collaborative approach for best results.

Key words: adapting interventions cross-culturally, behavior change theory, HIV prevention, positive prevention

 

In the last several years, U.S. and international HIV prevention efforts have expanded to address people living with HIV (PLWH), in addition to their focus on risk reduction efforts aimed at HIV-uninfected individuals. In response to the prevention needs of PLWH, clinicians, activists, researchers, and policy and program implementers in the U.S. have worked to address prevention as an important concern for individuals who know their HIV status. Moreover, the Advancing HIV Prevention Initiative of the U.S. Centers for Disease Control and Prevention (CDC) highlighted the need to work with PLWH as a key strategy to decrease the steady rate of new HIV infections in the U.S. (CDC, 2003). These interventions, often known as Prevention with Positives or Positive Prevention (PP), and more recently as Positive Health, Dignity, and Prevention (Global Network for PLWH [GNP+], 2009), aim to provide prevention and care services for PLWH to address HIV prevention needs and to ultimately decrease HIV transmission risk behaviors. Given that one positive person is involved in each case of HIV transmission, infected individuals play a key role in the spread of HIV (International HIV/AIDS Alliance, 2003). Thus, a change in the risk behavior of a PLWH will have a greater effect on the spread of HIV than an equivalent change in the behavior of an uninfected person (King-Spooner, 1999). It is this principle that has guided PP programs, ensuring that the opportunity to address HIV prevention with infected individuals is not missed.

Globally, as HIV testing and antiretroviral therapy (ART) have become more available, there has been both an increased emphasis on HIV prevention with PLWH and a global scale-up of HIV testing and treatment (Bunnell, Mermin, & De Cock, 2006). This is critical given the scope of HIV prevalence in many international settings, specifically southern Africa. In response to a request from the Mozambique Ministry of Health and in-country U.S. partners to implement and adapt an evidence-based PP program, current literature was explored to identify lessons learned from U.S. PP research and programs. This review served as the starting point for addressing the prevention needs of PLWH beyond the U.S. context. This article provides an overview of U.S. PP literature addressing evidence-based interventions. It continues by looking at PLWH prevention needs and care issues in Mozambique and the larger African context, and then discusses which U.S. PP models may be best suited for adaptation and use in Mozambique. This endeavor resulted in adapting, piloting, and evaluating a PP intervention in Mozambique. A discussion of the intervention and results of the evaluation will be presented separately.

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Materials and Methods 

A systematic review of the published data was conducted to evaluate current PP program models from the U.S. with a focus on: (a) studies that reported interventions among heterosexual PLWH populations, (b) the type of professional delivering the intervention, (c) theoretical constructs used, and (d) intervention design (group vs. individual intervention). The review summarizes recent published data but focuses on theoretical constructs as well as two types of interventions, those that are incorporated into the medical care of the PLWH and are delivered by the patient's provider, and those that are peer led. These studies are discussed considering which would translate best in an international setting.

Eligible studies included research studies that (a) were published in peer-reviewed English language journals, (b) were published between 2000 and 2009, (c) used quantitative or qualitative study designs, (d) enrolled participants who were at least 18 years of age, HIV-infected, and living in the U.S., (e) were completed and had final results to report, (f) evaluated behavioral interventions designed to promote safer HIV transmission risk behaviors and HIV prevention among PLWH, and (g) showed a decrease in the number of risky sexual acts over time.

The primary method of study identification was electronic searches. Databases used included PubMed (National Library of Medicine)/MEDLINE, AIDSinfo, Web of Science, and CINAHL. A review of each article's reference list was also performed. The search terms (key words) used were HIV prevention, prevention with positives, positive prevention, U.S., behavioral theory, and behavioral interventions. Eleven studies met the inclusion criteria. Few U.S. studies were conducted with heterosexual populations; thus, the search was expanded to include studies among men who have sex with men (MSM).

After this review of U.S.-based prevention interventions, a review of published data were conducted to identify interventions that had taken place in Mozambique, using the aforementioned databases and following the same search criteria (with the exception that instead of participants being HIV-infected and living in the U.S., they needed to be HIV-infected and living in Mozambique). This search yielded no studies that met the inclusion criteria. This result was not unexpected given that prevention efforts with PLWH in Mozambique are in the nascent stage. Thus, we included a discussion of the few interventions that have been reported from Mozambique.

The search criteria were then expanded beyond Mozambique to identify salient issues in HIV prevention for PLWH in the broader sub-Saharan Africa context. Ongoing projects by the Joint United Nations Programme on HIV/AIDS (UNAIDS), the World Health Organization (WHO), and the President's Emergency Plan for AIDS Relief (PEPFAR; n.d.) were also probed. This review of the published data was intended to provide a starting point for understanding current HIV prevention issues in Mozambique and a deeper understanding of issues that affect the region and might need to be considered when adapting U.S.-based intervention models for an international context.

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Research Summary: The U.S. Context 

Recent U.S. research provides convincing arguments for considering prevention activities and behavioral interventions with HIV-infected individuals. Furthermore, directing prevention efforts toward individuals who are aware of their HIV-infected status is a cornerstone of the CDC's Advancing HIV Prevention Initiative, which aims to reduce the barriers to early diagnosis of HIV infection and, if infected, increase access to quality medical care, treatment, and ongoing prevention services (CDC, 2003). This initiative has four core strategies: (a) make HIV testing a routine part of medical care whenever and wherever patients go for care, (b) use new models for diagnosing HIV infections outside of traditional medical settings, (c) prevent new infections by working with PLWH and their uninfected partners (discordant couples), and (d) continue to decrease mother-to-child transmission (MTCT) of HIV.

Providers play a crucial role in each of these strategies. Studies show that primary health care providers can help patients change health behaviors relating to such behaviors as smoking and sexually transmitted infection (STI) risk, among others (Law and Tang, 1995, Richardson et al., 2004). Since the introduction of ART, HIV can now be managed as a chronic disease. On ART, quality of life improves and the majority of people diagnosed with HIV remain sexually active (Erbelding, Stanton, Quinn, & Rompalo, 2000). Although many modify their behaviors to reduce unsafe practices after learning they are infected with HIV, constant behavior change messages from health care providers may be useful in reducing high-risk sexual and drug-use behaviors associated with HIV transmission (Richardson et al., 2004). The HIV primary care clinic offers an opportune setting to deliver HIV prevention counseling.

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Prevention Models and Projects in the U.S. 

In response to continuing HIV transmission risk behavior among PLWH, several behavioral prevention interventions have been developed and tested so as to understand the effect on risk behaviors. These range from individual or group interventions to peer-empowerment interventions to health care provider–initiated interventions.

Provider-Led Interventions 

Most PP interventions in the U.S. have focused on training health care providers to conduct short, risk-reduction interventions with HIV-infected patients during routine clinic visits. These interventions have been found to be effective (Fisher et al., 2004, Richardson et al., 2004) and are intended to increase the use of condoms, as well as to reduce the number of unprotected sex acts, the number of sexual partners, drug use and needle sharing, and STIs (Morin et al., 2007). One of the first evidence-based trials of such interventions in the U.S. (Richardson et al., 2004) reported on the efficacy of a provider-delivered intervention named Partnership for Health in reducing unprotected sexual intercourse among clinic patients. In the intervention clinics, all staff members were trained to integrate prevention messages into the clinic setting. Health care providers delivered brief risk-reduction counseling to their patients, using either a gain-frame approach (positive consequences of safer sex) or a loss-frame approach (negative consequences of unsafe sex). Among patients who had two or more sexual partners, self-reported rates of unprotected intercourse were reduced by 38% among those who received brief loss-frame counseling from their health care providers. The findings suggested that brief provider counseling emphasizing the risks or negative consequences of unsafe sex could reduce HIV transmission behaviors in HIV-infected patients presenting with risky behavior profiles. On the basis of these findings, training that uses this method to introduce prevention into the HIV clinic has been adopted by several U.S.-based HIV clinics.

The Options Project was a brief intervention designed to be initiated by HIV care clinicians with HIV-infected patients at each regularly scheduled medical visit. The protocol was based on the Information-Motivation-Behavioral (IMB) skills model (Fisher & Fisher, 1992), which asserted that HIV prevention information, motivation, and behavior skills are the fundamental determinants of HIV prevention behavior. The protocol was a framework that clinicians used to elicit the dynamics of HIV risk behavior for patients and then create tailored HIV risk-reduction interventions using motivational interviewing on a patient-by-patient basis. This intervention individualized the patient–clinician interaction to specific HIV risk and prevention needs of the patient and involved a patient and provider collaboration to address risk behaviors. The Options Project was found to be acceptable to both patients and providers. Outcome analyses for the Options Project showed that patients exposed to the protocol reduced HIV sexual risk behaviors significantly over time (Fisher et al., 2004).

The Positive Steps program was a client-centered intervention model based on several behavioral theories: diffusion of innovations (Rogers, 1971), social cognitive theory (Bandura, 1986), the theory of reasoned action (Fishbein & Ajzen, 1975), the health belief model (Rosenstock, 1974), and the transtheoretical model (Prochaska & DiClemente, 1986). Positive Steps trained medical providers to deliver a standardized behavioral intervention to all patients during routine medical visits. Training focused on enhancing communication skills, practicing brief behavioral counseling, and delivering prevention messages. This study showed that the prevalence of unprotected anal or vaginal intercourse with any partner declined significantly from baseline to the follow-up. Positive Steps differed from Partnership for Health and the Options Project in that it revealed positive changes from baseline in providers' self-reported attitudes about prevention counseling. Positive Steps demonstrated that providers could learn to modify their own clinical practice behaviors in terms of comfort, willingness, and self-efficacy in discussing prevention issues, and increasing the frequency with which they delivered counseling to their patients (Thrun et al., 2009).

The Healthy Living Project was an intervention based on social action theory (Ewart, 1991), aimed at helping people cope with the challenges of living with HIV, especially stopping transmission of the virus. Sessions were tailored to individuals by trained facilitators within a structure that used problem-solving and goal-setting techniques. Three modules addressed stress and coping, sexual risk behaviors, and HIV-specific health behaviors (Healthy Living Project Team, 2007). In the study, the intervention group reduced transmission risk acts by an average of 36% as compared with the control group. The study effect, however, was not sustained up to the 25-month follow-up point, suggesting that ongoing case management and risk assessment over time was necessary to maintain risk reduction behaviors.

Patterson, Shaw, and Semple (2003) tested a brief counselor-administered behavioral intervention grounded in social cognitive theory that was designed to reduce the sexual risk behaviors of PLWH who reported unprotected sex with uninfected or unknown serostatus partners. Behavior change efforts in the study were focused on three domains: condom use, negotiation of safer sex practices, and disclosure of HIV status to sex partners. Participants in the intervention received either a comprehensive intervention that addressed all three behavior domains or a brief targeted intervention tailored to the individual, and addressing only those behaviors that were problematic for the participant (Patterson et al., 2003). The total number of unprotected sex acts reported by participants decreased over the 1-year follow-up period. The results suggested that a brief behavioral intervention designed to promote safer sex among PLWH could result in large reductions in HIV transmission risk.

Peer-Led Interventions 

Although receiving prevention messages from clinicians can hold considerable weight with clients, peer group interventions can bring people together to influence each other in ways that care providers, educators, and counselors cannot. The group experience can provide powerful opportunities for individual behavior change by allowing individuals to observe others, share experiences, practice new skills in a safe and supportive environment, and receive feedback from peers (Estrada, Trujillo, & Estrada, 2007). Support groups may also offer a venue to help PLWH maintain safer sexual practices and reinforce positive behavioral changes (Buck, 1991, Greenberg et al., 1996).

Healthy Relationships, a theory-based, randomized, controlled trial conducted by Kalichman, Rompa, and Cage (2005) showed that a behavioral skills-building intervention, grounded in social cognitive theory (Bandura, 1986), was effective in reducing sexual transmission risks for PLWH. The intervention was composed of five support-group sessions led by male and female co-facilitator pairs, in which one facilitator was always an HIV-infected peer and the other was an experienced mental health counselor. The intervention focused on enhancing motivation through self-reflection and developing coping efficacy skills in the areas of HIV decision-making for disclosure to family, friends, and sexual partners; HIV transmission risk reduction; and safer sex negotiation. Integrated skills practice sessions used role-plays based on scenes from popular films to address previous skills training, including problem solving, disclosure decision-making, and safer sex skills (Kalichman et al., 2005). Tailoring the intervention to the population being served was very important, as was patient involvement in terms of ongoing refinement of interventions for specific populations (Estrada et al., 2007).

The Interventions for Seropositive Injectors-Research and Evaluation (INSPIRE) Project was designed to test the efficacy of an integrated behavioral intervention intended to reduce sexual and injection transmission risk behaviors, and increase use of HIV primary care and adherence to ART among a sample of active injection drug users (IDUs). Participants were randomized to either receive a peer mentoring intervention (PMI, the intervention condition) or a video discussion intervention (the control arm). The PMI was developed on the basis of a combination of concepts and theories including empowerment (Zimmerman, 1995), peer leadership, and advocacy (Kelly et al., 1997); social learning theory (Bandura, 1986); social identity theory (Latkin, Sherman, & Knowlton, 2003); and the information, motivation, and behavior (IMB) skills model (Fisher & Fisher 1992). The PMI sessions focused on the power of peer mentoring, the use of HIV care and adherence, and sex- and drug-risk behaviors. The video discussion intervention group watched documentary or self-help videos that focused on issues relevant to HIV-infected IDUs. These were followed by facilitated discussions. Both groups decreased significantly from baseline for sex and injection risk behaviors (Purcell et al., 2007).

The Seropositive Urban Men's Intervention Trial (SUMIT) tested the efficacy of a six-session peer-led behavioral intervention on the basis of behavioral theory for HIV-infected gay and bisexual men (Wolitski, Gómez, Parsons, & the SUMIT Study Group, 2005). Primary outcomes for the study were sexual behaviors, which posed at least some risk for HIV transmission to uninfected partners, and serostatus disclosure. The intervention consisted of either a one-session standard intervention that provided safer sex information, or an enhanced intervention that consisted of six sessions and included safer sex information, interactive learning activities, and discussion groups facilitated by HIV-infected peers. Fewer men in the enhanced intervention group reported unprotected sex with an uninfected or unknown serostatus partner at the 3-month assessment compared with men in the standard intervention. However, there were no significant differences in transmission risk or serostatus disclosure at 3 or 6 months after the intervention (Wolitski, Gómez, Parsons, & the SUMIT Study Group, 2005).

A number of peer interventions have also been aimed specifically at women, recognizing that the needs of HIV-infected women deserve special attention. Wyatt et al. (2004) looked at the need to address histories of childhood sexual assault (CSA) among women when attempting to reduce HIV risk behaviors. The randomized clinical trial tested the efficacy of a gender-specific, culturally-congruent Enhanced Sexual Health Intervention (ESHI) that was designed to reduce sexual risks and increase HIV medication adherence in HIV-infected women with histories of CSA. The ESHI was guided by cognitive-behavioral approaches to risk reduction along with cultural and gender-specific concepts, such as collectivism and interconnectedness. The intervention addressed HIV risk behaviors, interpersonal and health behaviors, and psychological symptoms. Group sessions were conducted by a trained group facilitator and a peer mentor who was an HIV-infected woman with a history of CSA. Women in the ESHI group were about 1.5 times more likely to report sexual risk reduction at post-test than women assigned to the control group (Wyatt et al., 2004).

Another women's peer intervention, the WiLLOW (women involved in life learning from other women) intervention, evaluated the efficacy of a sexual risk reduction and social network intervention designed to reduce sexual transmission risk behaviors and to enhance psychosocial mediators and structural factors associated with preventative behaviors among a sample of HIV-infected African American women. Social cognitive theory (Bandura, 1986) and the theory of gender and power (Wingood & DiClemente, 2002) were used as theoretical frameworks for the development and implementation of the WiLLOW project. The theory of gender and power addressed how societal expectations of women as caregivers constrain their ability to seek new networks and ask existing social networks for support (Wingood et al., 2004). The intervention consisted of interactive group sessions led by a trained female health educator and an HIV-infected female peer educator. The intervention was successful and participants reported fewer episodes of unprotected vaginal intercourse, were less likely to report never using condoms, had a lower incidence of bacterial infections, and had more social network members (Wingood et al., 2004). The researchers suggested that prevention interventions with PLWH should be tailored to their unique needs and that programs for women should be gender-tailored, easily accessible, and theoretically derived.

The HIV Intervention for Providers (HIP) study expanded on HIV PP research that focused on peer empowerment and emphasized a tailored approach to risk reduction oriented in a harm reduction framework (Springer, 1991). The HIP study trained HIV health care providers to conduct one-on-one prevention interventions with their HIV-infected patients during routine clinical visits. This study focused on empowering clinicians to address PP by working toward incremental changes in clinician and patient behavior, with a goal of integrating PP into clinic visits and eliminating behavior risk among patients (Dawson-Rose et al., in press). The training focused on building provider skills to assess behavioral and contextual risk among patients and to provide a harm-reduction–based prevention message tailored to a patient's transmission risk behavior and prevention needs (Dawson-Rose et al., in press). In the 6-month follow-up period, patients whose providers were assigned to the HIP intervention reported a relative increase in provider–patient discussions of safer sex, assessment of sexual activity, and significantly fewer HIV-uninfected or unknown partners with whom they had unprotected anal or vaginal intercourse (Dawson Rose et al., in press). The HIP approach was innovative because it focused on (a) changing clinicians' behaviors, (b) increasing provider skill to screen for transmission risk behavior and risk context (e.g., using drugs during sex), and (c) communicating brief prevention messages focused on incremental changes toward context of risk or specific risk behaviors.

With numerous intervention options and models, it can be difficult to decide which model would best fit the needs of PLWH. However, we can draw certain conclusions on the basis of U.S.-based studies. A meta-analysis of U.S.-based studies conducted in 2006 found that the most efficacious interventions for reducing HIV-risk behaviors had certain characteristics. These interventions were often (a) based on behavioral theory, (b) specifically designed to change HIV transmission risk behaviors, (c) delivered by health care providers or counselors, (d) delivered to individuals on a one-on-one basis, (e) delivered in an intensive manner, (f) delivered over a longer duration, (g) delivered in settings in which PLWH received routine services or medical care, (h) designed to provide skill-building opportunities, or (i) designed to address myriad issues related to coping with HIV infection (Crepaz et al., 2006).

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The Mozambique Context: Can a U.S.-Adapted Prevention Model Work? 

In Mozambique, it is estimated that 1,500,000 people are infected with HIV and that 67,000 to 98,000 people die annually from the virus (WHO, 2008). Of the infected population, 60% are adult women (WHO, 2005). Of all new infections, 43% are 15 to 24 years of age, with the highest rate of infection (16%) being among girls between 15 and 19 years old (International HIV/AIDS Alliance in Mozambique, n.d.). In addition, 370,000 people in Mozambique are in need of ART. However, only 90,000 (24%) are currently accessing them (UNAIDS, 2008). Contraceptive rates are also low (only 16.5% in 2004), and an estimated 97,000 pregnant women living with HIV need access to ART to prevent MTCT (UNAIDS, 2008). The numbers are grim, but they do not begin to elucidate the myriad issues that allow the epidemic to thrive.

With many proven intervention models in the U.S. PP context, it might seem reasonable to take the best components and export them around the world. Although data from Mozambique have been historically scant, studies in Kenya, Uganda, and other African countries corroborate U.S. findings, which argue that prevention activities and behavioral interventions should be extended to the HIV-infected population (Bunnell et al., 2006, King-Spooner, 1999). Still, the HIV epidemics in other countries exhibit marked differences from that in the U.S. Health systems and infrastructure, gender inequality and dynamics, social systems, the predominant modes of HIV transmission, and the lack of availability of ART and other medications, significantly affect HIV services and prevention efforts internationally. Perhaps the most pervasive issue constraining prevention work in African countries is the presence of HIV-related stigma.

How Stigma Affects Prevention Interventions 

In the struggle against HIV, AIDS-related stigma has a staggering effect on quality of life for PLWH, undermining all aspects of HIV prevention, care, and treatment. In this context, stigma is defined as a trait or attribute that is viewed negatively by society and leads to less than full social acceptance or social rejection (Holzemer et al., 2009). In the published data, HIV and stigma have been linked to negative health and psychological outcomes including depression, posttraumatic stress disorder, increased high-risk sexual behavior, distrust of health care providers (Whetten, Reif, Whetten, & Murphy-McMillan, 2008), delays in seeking HIV testing including programs aimed at preventing MTCT (Nyblade et al., 2003), and poor adherence to ART regimens (Dlamini et al., 2009). Stigma also impedes HIV status disclosure (Medley et al., 2004, Wolfe et al., 2006).

Although stigma remains a serious issue in the U.S., its effect is far more severe in Africa, where it can result in social rejection and isolation. In African contexts, PLWH and their families, as well as HIV care providers, are subjected to prejudice, discrimination, abuse, and hostility related to HIV stigma (Holzemer & Uys, 2004). In particular, disclosure can be a very stigmatizing event that can lead to negative outcomes such as abandonment, rejection, verbal or physical abuse, violence, depression, loss of financial support, gossip and public shaming, accusations of promiscuity or immoral behavior, and even the denial of basic human rights (Greeff et al., 2008, Kohi et al., 2006, Maman et al., 2009, Medley et al., 2004, Turan et al., 2008).

One way to deal with stigma and to facilitate disclosure is to create peer support groups that provide psychological support for PLWH (DiClemente & Wingood, 1995). Various studies have shown that individuals with HIV experience lower levels of social support after diagnosis, and less support than people with other chronic illnesses and those who are uninfected (Klein et al., 2000, Turner-Cobb et al., 2002). Involvement in support groups with those who have the same conditions is an acknowledged way of coping with stigma (Nyblade et al., 2003). It has also been reported that participating in social networks reduces physical and social isolation because of HIV status (Majumdar, 2004). Peer support groups have been shown to be effective in supporting various groups of people (adolescents and women's groups) to initiate safer sex behaviors. These groups are generally inexpensive and highly sustainable (Norr, Norr, McElmurry, Tlou, & Moeti, 2004). Research has also shown that HIV-infected women who attend support groups are more likely to disclose their status and gain access to treatment (Kalichman, Sikkema, & Somlai, 1996). HIV support groups can be a valuable tool to help individuals adjust to the consequences of living with HIV in the absence of support from family and friends (Brashers, Haas, Klingle, & Neidig, 2000).

A study in South Africa found that HIV-infected women needed support to deal with their diagnosis, to disclose their status to significant others, and to deal with the stigma they perceived in their communities (Visser & Makin, 2004). Another study found that groups can provide individuals with a non-stigmatizing atmosphere in which to gain information, share experiences, and learn from one another (Visser & Mundell, 2008). Support groups can help to renew hope, contribute to social reintegration, and help people feel they are taking control of their lives (Visser & Mundell, 2008).

Serostatus Assumptions 

In addition to stigma, the assumptions about serostatus that people make when trying to assess the HIV status of others, and how this relates to sexual risk behaviors in the context of HIV, affects disclosure efforts and must be addressed in prevention programs. In the U.S., studies of MSM have shown that there is a tendency to assume the sero-concordance of sex partners of unknown HIV status (O'Leary, 2005). Although the research has not supported it, there is also a fear that, with the availability of ART, some may see HIV as a less threatening illness and may engage in risky sexual behaviors when their viral load is undetectable and infectivity is perceived to be low (Remien, Halkitis, O'Leary, Wolitski, & Gómez, 2005). Therefore, serostatus assumptions may play a part in sexual decision-making.

In Africa, where more than 85% of adult HIV infections are due to heterosexual transmission, serostatus assumptions are made frequently (Piot, Bartos, Ghys, Walker, & Schwartländer, 2001). People may be unwilling to believe that their friends or family members have HIV, and they may not believe people who disclose their status. This often occurs when PLWH do not appear sick or wasted (Greeff et al., 2008). Also, many individuals with HIV believe that their partners are already infected (Bunnell et al., 2005) and, thus, do not avoid high-risk practices. However, studies have reported that in couples in whom at least one partner was known to have HIV, 9% to 40% have an HIV uninfected spouse or partner (Bahizi et al., 2001, Bunnell et al., 2008, Kilewo et al., 2001, Lurie et al., 2003), further highlighting the need to address sero-discordance within couples.

Fertility Intentions and the Risk of MTCT 

In sub-Saharan Africa, contraceptive use is low and maternity is highly valued. Addressing the fertility intentions and desires of PLWH is becoming increasingly important as a prevention strategy because most HIV-infected women in Africa are in their reproductive years (Nakayiwa et al., 2006). Because ART continues to increase the lifespan and quality of life for PLWH, more individuals are in need of effective family planning methods to prevent unwanted pregnancies, space births, or stop childbearing. PLWH also require support and education should they consider having children. Although HIV-infection has been proven to have little effect on women's and men's childbearing and contraceptive decisions (Chen et al., 2001, Magalhaes et al., 2002), studies have shown that HIV-infected women often do not use contraception despite a desire to stop or delay childbearing (Anand et al., 2009, Homsy et al., 2009). Therefore, it is important to address the specific contraceptive needs of PLWH, recognizing that those needs may be different from the general population. PLWH must take into account the risk of unintended pregnancy, as well as vertical and horizontal transmission when making contraceptive choices. Overall, preventing unintended pregnancies among HIV-infected women is one of the most effective ways to prevent HIV infection in infants and to stop the spread of the epidemic to children. Therefore, family planning is a key component of HIV prevention.

The desire of PLWH to have children in the future has important implications for the vertical transmission of HIV to newborns. In developed countries, ART and infant feeding with breast milk substitutes have reduced MTCT to less than 1% to 2% (Dorenbaum et al., 2002), making MTCT almost completely preventable. However, in the absence of any intervention, the risk of MTCT is 15% to 25% when mothers are not breastfeeding and increases to 45% in children who are breastfed up to 24 months (WHO, 2008). In sub-Saharan Africa, where the majority of PLWH reside, the prevention of MTCT is an issue of grave importance. In Mozambique, it was estimated that nearly 100,000 pregnant women were in need of ART to prevent MTCT (UNAIDS, 2008).

Although reproductive rights, including the right of PLWH to have children, are widely accepted as basic human rights, pregnancy can be a stigmatizing time for PLWH (Yanda, Smith, & Rosenfield, 2003). Stigma during pregnancy can come from many sides including the community and health care providers. Community attitudes toward pregnancy in PLWH vary. A study in South Africa by Myer, Morroni, and Cooper (2006) found that 43% of community members thought that PLWH should remain sexually active if they chose. However, only 13% said that PLWH should have children if they wanted as compared with an overwhelming 77% who felt that they should not. Such community perceptions have a direct effect on the acceptance of prevention services and the stigma associated with HIV and childbirth. A study in Kisumu, Kenya, found that many women did not attend maternity care services because they feared HIV testing and the possibility of a positive result, the involuntary disclosure of HIV status to others (including spouses), and concern about HIV stigma (Turan et al., 2008).

Providers can also be an unfortunate source of stigma and discrimination during pregnancy. Many health workers fear contracting HIV infection at work (Turan et al., 2008), and discrimination against HIV-infected pregnant women has been reported in maternity services in various settings (Bain-Brickley et al., 2006, Kebaabetswe, 2007). Providers may also have negative responses when HIV-infected women arrive at clinics for antenatal care, clearly showing that they had engaged in unprotected sexual activity. Such negative responses may mean that HIV-infected women never return for prevention of MTCT services, resulting in a lost opportunity for prevention.

To date, most prevention interventions in Mozambique have targeted uninfected individuals, or infected individuals who do not yet know their HIV status. The goal of these interventions has been to prevent individuals from becoming infected and to encourage HIV testing. The content of primary prevention interventions has been generally informational (e.g., how HIV is transmitted, how to reduce transmission risks), motivational (e.g., why it is important to reduce HIV risk), and skills-based (e.g., how to negotiate risk reduction with a sexual partner). Ministry of Health program staff and non-governmental organization partners in Mozambique have gathered experience of HIV service implementation over years and expanded development of informational and some motivational interventions.

Very few studies of behavior change interventions have been conducted in Mozambique. The few that have been described were not specifically conducted among PLWH. A study in Mozambique by Mola et al. (2006) reported that both men and women who attended voluntary counseling and testing services increased their condom use over time, presumably as a result of counseling. A radio education campaign aimed at promoting behavior change for the prevention of STIs and HIV conducted by the non-governmental organization Population Services International found that among those who recalled hearing radio campaign messages, 97.2% intended to change their sexual behaviors compared with 62.8% of people who had not been exposed to the campaign (Karlyn, 2001). Other studies by Pearson et al. (2007) and San Lio et al. (2009) have described risky sexual practices in Mozambique but have not reported on interventions to decrease HIV transmission risk behavior.

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Discussion 

PLWH with access to ART are living longer, feeling better, and enjoying a renewed interest in life (Lima et al., 2007). However, improvements in the health and well-being of PLWH bring new challenges. The U.S. and African research has shown that HIV prevention programs aimed at PLWH are a critical component of HIV prevention efforts. The question is, how do we adapt U.S. prevention models for vastly different international contexts?

Findings have indicated that it is not advisable to export HIV interventions globally without considering the specific needs and desires of PLWH and their care providers. Intervention efforts should always be culturally specific and sensitive, and they should include a collaborative approach wherever possible. The U.S.-based Healthy Relationships and WiLLOW Projects both recommended tailoring interventions to the unique needs of the population being served. Local adaptation is a necessary component of any HIV prevention intervention. Tailoring prevention messages is especially important when adapting materials from the U.S. for a country such as Mozambique, where the issues that fuel the HIV epidemic differ from those affecting U.S. populations. Such an approach ensures that interventions are appropriate and address local concerns, issues, and gaps. It is possible to adapt U.S. PP interventions for an international setting, but these interventions always need to be tailored to the realities of those living with HIV in a given country context so that culturally and contextually specific interventions are developed. The process of adapting interventions and obtaining local input also promotes stakeholder buy-in for the finished product (McKleroy et al., 2006).

The HIV primary care clinic offers an opportune setting to deliver HIV prevention counseling and many studies have shown positive results with such a format. Models used in Partnership for Health, Options, Positive Steps, Healthy Living, and HIP have all shown that provider-delivered prevention messages can effectively reduce transmission risk behaviors. However, each intervention varied slightly, with interesting twists on the one-on-one provider approach. In the Partnership for Health model, all clinic staff was trained to integrate prevention messages. Although Positive Steps promoted a standardized prevention message for all clients, the Options, Healthy Living, and HIP projects all promoted tailored prevention messages (Dawson Rose et al., in press; Fisher et al., 2004, Healthy Living Project Team, 2007). Interventions focused on provider-delivered messages would seem to be most effective in Mozambique because interactions with health care providers outside of regular clinic visits are rare, and health care providers are well respected as a source of information and guidance.

Although patient and clinician interactions can be a place to transmit prevention messages, peer empowerment programs can also be an important medium for support and a place to safely discuss reducing transmission risks. In the U.S., peer support programs such as the Healthy Relationships, ESHI, and WiLLOW Projects have all found peer empowerment programs to be successful at reducing transmission risks. Such approaches may be effective in Mozambique considering that peer support emerges in the published data as an important intervention component because of the issue of stigma and the potential for a loss of partner and community support after disclosure (Derlega et al., 2002, Greeff et al., 2008). However, certain formats for this type of intervention, such as the Healthy Relationships intervention, which used role-plays based on films, would not be feasible in most African contexts because of a lack of equipment and community access to film media.

The studies discussed here also offer a multitude of theoretical approaches to prevention. As discussed earlier, it is critical to HIV prevention efforts, including PP, to have a theoretically-based and tested intervention model or program. Many of the clinician-delivered interventions as well as the peer support and empowerment models use the IMB model as well as social cognitive theory and coping adaptation models. Each of these theoretical foundations can effectively elicit behavior change in HIV prevention studies with HIV-uninfected and infected individuals (Fisher et al., 2004, Healthy Living Project Team, 2007).

In Mozambique, any of these theoretical models could appropriately address behavior change. However, in this setting, there are few nurses and other health care providers and the sheer number of HIV-infected patients in any clinic often prohibits the delivery of HIV care as it is conceptualized and delivered in the U.S.. For this reason, it is suggested that the focus be placed on assessing risk and giving risk reduction messages that would allow for a more rapid response and a less time-intensive interaction. Data from the HIP study also suggested that clinicians were satisfied with this approach because they felt that, although they might not be able to administer an in-depth risk assessment, they could still provide tailored messages that could affect behavior change while not giving an unattainable message to their patients (Dawson-Rose et al., in press).

Aspects of the interventions that seem most suited to the Mozambique context are short, tailored, clinician-delivered messages with a peer empowerment component. Clinician time with clients in Mozambique is limited, and yet clinicians also come to risk-reduction counseling with many biases about HIV. A model that stresses clinician comfort and a change in their behavior as well as tailoring short prevention messages for clients seems most appropriate. Models that stress a modular format for risk reduction change (such as the Healthy Living intervention) or approaches that take a great deal of time (such as the motivational interviewing used by the Options Project) may not be feasible in the Mozambique setting.

PEPFAR is a major funder of HIV services in Mozambique. Through PEPFAR, significant resources have been directed toward ART roll out. Thus, it is feasible to incorporate PP activities into settings, such as ART, antenatal, or tuberculosis services, where care is already being delivered to PLWH, including those who do not know their status or are just learning their status (Bunnell et al., 2006).

In addition to clinician-focused PP efforts, peer empowerment and support will be important because of the need for peer support surrounding stigma and disclosure. The role of civil society in Mozambique is also different when compared to that in the U.S.. Although patients as advocates for their care and for the care of other PLWH is a relatively new concept, the need for support and addressing stigma surrounding HIV infection cannot be overstated.

United States and African studies have indicated that the prevention needs of PLWH do not differ greatly by geography. The larger social context differs immensely in various countries in terms of war, poverty, gender-based violence, health care systems, and access to care. However, on an individual level, the prevention needs of PLWH are strikingly similar. Some of the issues raised in the sub-Saharan African literature are similar to those that face PLWH and providers in the U.S., whereas others are quite different. The major commonality is the need for prevention of HIV risk behaviors, the availability of counseling and support, the need for support in disclosing HIV status, the fear of stigma and discrimination, and a desire to keep partners safe from HIV infection.

Some striking differences deserve special attention. Many of the issues highlighted here were also referenced in the State of the Program Area document for Prevention with People Living with HIV/AIDS developed by the PEPFAR Technical Working Group (n.d.).

First and foremost, the HIV epidemic in Mozambique is heterosexually driven through sexual contact, as opposed to the U.S., where the epidemic has historically been driven by most at-risk populations (MARP), such as MSM, IDUs, women (mostly African American and Latin American), and various minorities. This shift in focus requires that issues around sex and sexuality (an often taboo topic in African settings) be addressed and strengthened. In this context, preventing unwanted births, safely supporting PLWH who want children, and addressing MTCT and all its accompanying topics, such as ART recommendations and safe feeding options, become central issues for prevention. A supportive environment where health care providers use a risk reduction approach to work with women to reduce the chance of HIV transmission during pregnancy, delivery, and the postnatal period should be a key component of prevention.

Discordance is also not well understood and is difficult to explain. Discordant couples face a multitude of issues, not least of which is how to address safer sex, fertility intentions, and the desire for children. Although U.S. interventions did not address this specific issue, it is a critical component of PP efforts in Mozambique and in other southern African countries. Because HIV-related stigma is rampant in Africa, skills for positive living may need to be stressed as a way to approach life with a positive outlook that involves health promotion, disease prevention, healthy relationships, and community support.

Another major area of consideration when adopting interventions is the capacity of the health care system, which may be very different from the U.S., where these interventions were originally developed. Limited access to medical care in general is endemic in many southern African countries including Mozambique. The effort of building and strengthening inadequate health care delivery systems is a pressing issue.

By adapting U.S. models for international settings, we can take the lessons of U.S.-developed interventions and use them abroad to develop theoretically sound interventions that are tailored to specific contexts. Not all aspects of U.S. interventions are relevant or translate well to other settings, but with this sound background such interventions can be updated to reflect local concerns and issues.

Clinical Considerations


•Theoretically sound prevention efforts show greatest effect.

•Prevention happens over time. Behavior change does not occur with one education session or message.

•U.S.-based interventions are a possible starting point for adapting programs for international contexts, and it is critical to incorporate the context of local PLWH and clinical care into program planning.

•Integrating the prevention needs of PLWH into clinical care will allow providers to address these needs and minimize transmission problems for clinicians and patients.

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Disclosures 

This project was funded in part by the HIV/AIDS Twinning Center (TC), a program of the American International Health Alliance (AIHA), which is supported through funds from the President's Emergency Plan for AIDS Relief (PEPFAR) and the Health Resources and Services Administration (HRSA) through the U.S. Department of Health and Human Services. Carol Dawson Rose, Sarah A Gutin, and Michael Reyes report no financial interests or potential conflicts of interest.

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Acknowledgments 

The authors thank their colleagues at the Ministry of Health and the Centers for Disease Control and Prevention, Mozambique office, whose work on the prevention team was instrumental in all aspects of this project and its implementation; specifically Prafulta Jaintilal, Dr. Irene Benech, Monica Dea, and Dr. Francisco Mbofana.

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Carol Dawson Rose PhD, RN, is an associate professor and principal investigator of the Mozambique Positive Prevention Program, School of Nursing, University of California, San Francisco, San Francisco, California.

Sarah A. Gutin, MPH, is a program assistant, Mozambique Positive Prevention Program, Department of Family and Community Medicine, University of California, San Francisco, San Francisco.

Michael Reyes, MD, MPH, is a professor of Family & Community Medicine and Co-Director of the International Training and Education Center on HIV (ITECH), University of California, San Francisco, San Francisco.

PII: S1055-3290(10)00063-4

doi:10.1016/j.jana.2010.04.001

Journal of the Association of Nurses in AIDS Care
Volume 22, Issue 1 , Pages 38-52, January 2011

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