Prevention with Positives

University of Connecticut's Center for Health, Intervention, and Prevention (CHIP) will develop two

programs for use with People Living with HIV/AIDS (PLWH) in the military: a Prevention-with-Positives

(PWP) program and an ARV adherence-support program. The current proposal describes the proposed

PWP program.

An estimated 0.9% to 3.5% of the population in Ethiopia is HIV-positive, with at least 7% of military

personnel believed to be HIV-positive. With an estimated 88% of all HIV transmissions acquired through

heterosexual contact, and military prevalence rates more than double that of the general population, there is

no doubt that many in the military are engaging in high-risk sexual behavior. Thus, effective HIV-prevention

programs for those in the military are greatly needed. In order to be effective, these programs must be

tailored to address the unique circumstances of the military environment, including high mobility, the

prevalence of commercial sex workers in areas where military live and socialize, and HIV/AIDS stigma.

Historically, HIV-prevention programs have focused on those who are HIV-negative and have done little to

support HIV-positive individuals in the practice of safer behavior. The goal of the proposed project is to

develop, implement, and evaluate a PWP program for HIV-positive military members and spouses who

attend military clinics in Ethiopia. This program will be implemented in two military healthcare sites in Addis

Ababa during Year One and then disseminated to multiple healthcare sites in subsequent years. CHIP will

work collaboratively with the National Defense Forces of Ethiopia (NDFE), UCSD, the US Embassy, the US

DOD HIV/AIDS Prevention Program (DHAPP), CDC, and USAID, as well as with local stakeholders (e.g.,

clinic staff and HIV-positive patients) to develop an HIV risk-reduction program that is acceptable to staff

and patients, feasible to implement in the clinical-care setting, can be delivered with fidelity, and effective at

reducing the HIV risk behavior of HIV-positive soldiers and spouses. By reducing the risky sexual and drug

use behaviors of PLWH, this program can help prevent the transmission of HIV and other pathogens to

uninfected individuals, as well as help protect PLWH from possible reinfection with drug-resistant strains of

HIV and other sexually transmitted infections (STI).

CHIP has an extensive history of developing effective health-promotion and disease-prevention programs

internationally, with particular expertise in HIV risk-reduction programs and ARV adherence-support

programs. The content of the proposed PWP program will be informed by the empirically-validated

Information-Motivation-Behavioral Skills (IMB) model of HIV prevention, which has been used effectively

with a variety of populations in Africa, the US, Europe, and Asia. The program will use Motivational

Interviewing (MI) techniques to identify individuals' informational, motivational, and behavioral skills barriers

to safer sex and drug-use practices and to convey critical HIV risk-reduction information, motivation, and

behavioral skills content to them in order to help motivate them to engage in safer behaviors. The proposed

PWP program will be based on a program developed by the CHIP team for South African PLWH in clinical

care called "Izindlela Zokuphila/Options for Health." A rigorous evaluation of "Options for Health" revealed

that it significantly reduced risky sexual behavior among the participants. A version of this PWP program is

currently being implemented at the Maputo Military Day Hospital in Mozambique. This is a one-on-one

program that is designed to be implemented at each routine clinical care with HIV-positive patients. It can

be delivered by anyone who provides ongoing care to PLWH, such as doctors, nurses, adherence

counselors, and health educators. In Mozambique, trained peer educators are delivering the program to HIV

-positive patients in care.

The program consists of a collaborative, patient-centered discussion between the provider and the patient in

which the provider uses MI techniques to: assess the patient's risk behaviors; identify his/her specific

barriers to the consistent practice of safer behaviors; elicit strategies from the patient for overcoming these

barriers; and negotiate an individually-tailored risk-reduction goal or plan of action that the patient will work

on between clinic visits. These discussions of HIV risk-reduction are individualized for each patient based

on the patient's risk assessment and current readiness to change his/her risk behavior, and they are

designed to be brief (about ten minutes) and to occur on an ongoing basis when the patient comes to the

clinic for regularly scheduled medical visits.

GOALS AND OBJECTIVES

(1) Conduct a needs assessment to identify the prevalence and dynamics of HIV risk behaviors among HIV-

positive soldiers and spouses, and to determine what types of HIV-prevention programs are feasible and

practical to do in military healthcare settings. The specific goals of the assessment are to: (a) explore the

dynamics of risky sex and drug-use behaviors among Ethiopian PLWH; (b) identify culturally appropriate

strategies that PLWH can use to reduce their risky behaviors; (c) determine whether a modified version of

the "Options for Health" program is feasible to implement in military healthcare settings; (d) determine which

individuals (e.g., doctors, nurses, psychologists, counselors, pharmacists, and/or peer educators) are most

appropriate for implementing a risk-reduction counseling program with PLWH and what their specific

training needs are; and (e) assess how to most effectively and efficiently integrate an HIV-prevention

program for PLWH into the clinic routine.

(2) Based on the findings from the needs assessment, develop a tailored Prevention-with-Positives program

that addresses the specific risk-reduction needs of HIV-positive soldiers and spouses in Ethiopia. Once the

focus groups are completed, the findings will be compiled and analyzed, and a risk-reduction counseling

program developed. Our collaborators will play a central role in the framing, conduct, and analysis of the

needs assessment and its integration into the final PWP program. The needs assessment and

multidisciplinary collaboration will allow us to tailor the PWP program to the clinic site and the particular

needs of its HIV-positive patients.

(3) Train Ethiopian military interveners in the PWP program. The content of the PWP program and the

training protocol will be based upon: (a) the findings from the needs assessment; (b) the US team's

experience developing PWP programs in South Africa, Mozambique, and the US, and training interveners

to deliver them; and (c) input and feedback from the multidisciplinary Ethiopian team. Interveners (e.g.,

doctors, nurses, psychologists, counselors, pharmacists, and/or peer educators) will be jointly trained by the

US team. One or more of the interveners will be selected and trained as a master trainer in the program

protocol (Obj 6). This individual(s) will continue to provide training at other military healthcare sites in

Ethiopia once the US-led portion of the project is completed. Training materials will be given to each

intervener. In addition, they will be given educational materials that they can give to the patients to

supplement their discussions with them.

(4) Implement the PWP program at two military healthcare sites in Addis Ababa, Ethiopia. At each site,

trained interveners will implement the PWP program on an ongoing basis when patients come in for their

routine clinical-care visits. Each session will consist of a one-on-one patient-centered discussion in which

the intervener works collaboratively with the patient to: (1) identify the patient's HIV risk behaviors; (2)

understand the dynamics of those behaviors; (3) determine the barriers to consistently practicing safer

behaviors; (4) provide critical HIV-prevention information, motivation, and behavioral skills to overcome

those barriers and reduce risky behavior; and (5) set a specific goal for the patient to accomplish between

Activity Narrative: clinical care visits as a means of reducing his/her risky behavior or maintaining his/her safer behavior.

Subsequent discussions between the HIV-positive patient and his/her intervener will occur at each

successive medical visit and will focus on monitoring the patient's progress toward his/her risk-reduction

goal; providing information, motivation, and behavioral skills training; and negotiating a new goal, when

appropriate.

(5) Evaluate the effectiveness of the PWP program by comparing the self-reported HIV transmission risk

behaviors of 150 to 200 HIV-positive patients prior to the inception of the program with their self-reported

behaviors after the program begins. An in-country project assistant will recruit a randomly selected sample

of 75-100 HIV-positive NDFE military personnel and 75-100 HIV-positive spouses of soldiers to complete

the program evaluation.

(6) Identify and train one or more Ethiopian healthcare providers to serve as a master trainer in the PWP

program. This will allow the PWP program to be disseminated to additional healthcare sites throughout

Ethiopia and to function independently of the US team. Initially, the Ethiopian master trainer(s) will work

collaboratively with the US team to refine and revise the program and training protocol. The goal will be to

use any and all "lessons learned" from the program evaluation to modify the program to maximize its

effectiveness and utility. Once the PWP program is finalized, the master trainer(s) will disseminate the

program to multiple military healthcare sites, with support from the US team as needed. The long-term goal

is to provide sufficient training to the master trainer(s) so that they can independently maintain the program.

Adherence Support for HIV Positives

The current proposal aims to develop, implement, and evaluate an ARV adherence-support program for HIV

-infected military members and spouses who attend military clinics in Ethiopia. The University of

Connecticut's Center for Health, Intervention, and Prevention (CHIP) will work collaboratively with

representatives from the National Defense Forces of Ethiopia (NDFE), the University of California, San

Diego (UCSD), and the US Department of Defense HIV/AIDS Prevention Program (DHAPP) to develop an

ARV adherence-support program that is acceptable to staff and patients. This program is feasible to

implement in the clinical care setting, can be delivered with fidelity, and is effective at increasing the ARV

adherence of HIV-positive soldiers and spouses. This theory-based, ARV adherence-support program will

be adapted and tailored to the socioeconomic, cultural, and healthcare context of Ethiopia and the Ethiopian

military, and will be implemented in multiple military healthcare sites.

There is no doubt that maintaining optimal ARV adherence is challenging for people living with HIV/AIDS

(PLWH), but it is likely even more challenging for PLWH in the NDFE. They face ARV adherence barriers

that are unique to military life, such as combat and other deployment situations that make it particularly

difficult to access, store, and take medications as prescribed. In addition, because soldiers live and work in

such close quarters, they may be more likely to skip doses of their medications because of fears that they

will be observed taking their medications and thus reveal their HIV status and be exposed to HIV-related

stigma. These additional barriers increase the probability that members of the NDFE will be unable to

achieve and maintain optimal levels of ARV adherence necessary for reaping the health benefits of

treatment. Military PLWH who are unable to maintain high rates of adherence over time may not only

exhaust their options for treatment through the development of ARV resistance, but may also pose a larger

public health threat if they fail to consistently practice safer sex behaviors and transmit their drug-resistant

strain of HIV to others. With over 3,500 troops and family members in Ethiopia receiving ARV treatment

(DHAPP Country Report, 2006), it is therefore critical that programs be developed that provide PLWH in the

NDFE with the tools that they need to properly adhere to their ARV medications.

GOALS and OBJECTIVES

(1) Conduct a needs assessment to identify the dynamics of non-adherent behavior among HIV-positive

soldiers and spouses, and to determine what is feasible and practical to do in military healthcare settings.

We will conduct a minimum of five focus groups (two female PLWH, two male PLWH, and one staff focus

group) at each military hospital site in Ethiopia that participates in this project. The specific goals of the

needs assessment work are to: (a) explore the dynamics of non-adherence among Ethiopian military

PLWH; (b) identify culturally appropriate strategies that Ethiopian military PLWH can use to increase their

adherence to ART; (c) determine whether the adherence-support program should be delivered in a group or

one-on-one format; (d) determine which individuals (e.g., doctors, nurses, counselors, pharmacists, and/or

peer educators) are most appropriate for implementing the adherence-support program and what their

specific training needs are; and (e) assess how to most effectively and efficiently integrate the adherence-

support program into the daily clinic routine. There will be 6-10 participants in each focus group.

(2) Based on the findings from the needs assessment, develop a tailored ARV adherence-support program

that addresses the specific adherence needs of HIV-positive military and spouses in Ethiopia. Once the

focus groups are completed, the findings will be compiled and analyzed, and an adherence-support

program developed. Our Ethiopian collaborators (representatives of the NDFE and DHAPP) will play a

central role in the framing, conduct, and analysis of the needs assessment and its integration into the final

adherence-support program. The needs assessment and multidisciplinary collaboration will allow us to tailor

the adherence-support program to the clinic site and the particular needs of its HIV-positive patients.

(3) Train Ethiopian military interveners in the ARV adherence-support program. The content of the

adherence-support program and the training protocol will be based upon: (1) the findings from the needs

assessment; (2) the US team's extensive experience developing adherence-support programs in Uganda

and the US, and training interveners to deliver them; and (3) extensive input and feedback from the

multidisciplinary Ethiopian team. Interveners (e.g., doctors, nurses, psychologists, counselors, pharmacists,

and/or peer educators) will be jointly trained by the US team and at least one medical provider (preferably

someone from the NDFE) with expertise in ARV medications and adherence issues. One of the interveners

will eventually be selected and trained as a master trainer in the program protocol. This individual will

continue to provide training once the US-led portion of the project is completed.

(4) Implement the ARV adherence-support program at multiple military healthcare sites within Ethiopia. At

all sites, trained interveners will implement the adherence-support program on an ongoing basis when

patients come in for their routine clinical care visits. Depending on the format of the adherence-support

program (which will be determined as a function of the needs assessment and in collaboration with the

Ethiopian-DHAPP team), patients will either participate in group adherence-support sessions or in one-on-

one discussions with an intervener. If the adherence-support program is offered in a group format, different

adherence-related topics will be presented each month (e.g., how ARV medications work in the body,

strategies for remembering to take one's medications, managing side effects, learning from a missed dose,

effective communication with one's healthcare providers, disclosing one's HIV status, dealing with HIV-

related stigma, and managing one's stress levels). Each group session will include an interactive

component to encourage active participation in the group.

If instead, the format of the program is one-on-one, patients will meet individually with an intervener at each

routine clinical care visit. Each session will consist of a patient-centered discussion in which the intervener

works collaboratively with the patient to identify and understand the dynamics of the patient's ARV non-

adherence and to develop strategies to help him/her consistently adhere to his/her ARV medication

regimen. Specifically, these discussions will: identify patients' informational, motivational, and behavioral

skills barriers to taking their ARV medications as prescribed; provide critical ARV adherence information,

motivation, and behavioral skills to overcome the barriers; and set specific adherence-related goals for

PLWH to accomplish between clinical care visits as a means of enhancing their adherence. Subsequent

discussions between HIV-positive patients and their interveners will focus on: monitoring progress toward

their goals; providing additional information, motivation, and behavioral skills training as needed; and

negotiating a new goal, when appropriate.

(5) Evaluate the effectiveness of the adherence-support program by comparing the pre-program ARV

adherence to the post-program adherence of 150 to 200 PLWH. An in-country project assistant will recruit a

randomly selected sample of 75-100 HIV-positive NDFE military personnel on ARVs, and 75-100 HIV-

positive military members' spouses on ARVs to complete the program-evaluation measures. The project

Activity Narrative: assistant will administer measures of ARV adherence to these patient participants prior to the first

adherence support session (at baseline) and then again at four-month and eight-month intervals following

the patients' first adherence support sessions. The project assistant will also review each enrolled patient's

medical chart to obtain any available CD4 and pill count data. Baseline levels of self-reported adherence

behavior, pill counts, and CD4 counts will be compared to follow-up levels taken at four and eight months,

respectively. This will allow us to evaluate the effectiveness of the program at improving ARV adherence

behavior using three different indicators. We will also evaluate whether the adherence-support program is

differentially effective with soldiers and soldiers' spouses.