The UConn Prevention with Positives and Adherence Support for HIV Positives project is developing, implementing, and evaluating a 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) is working with the (NDFE), UCSD, the US Embassy, DHAPP, CDC, and USAID, other PEPFAR partners, and clinic staff and HIV-positive patients developing a 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 HIV prevention and ARV adherence of HIV-positive soldiers and spouses.

This theory-based program is being adapted to the socioeconomic, cultural, and healthcare context of the Ethiopian military, and will be implemented in multiple military healthcare sites. The NDFE face 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 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.

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 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 program which has been used effectively with a variety of populations in Africa, the US, Europe, and Asia, uses 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 PWP program is 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 participants. It can be delivered by anyone who provides ongoing care to PLWH, such as doctors, nurses, adherence counselors, and health educators. 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 and to occur on an ongoing basis when the patient comes to the clinic.

The program will utilize educational materials already developed by the PEPFAR PwP taskforce and adapted for the PEPFAR Ethiopia program.

GOALS and OBJECTIVES

(1) Conduct a needs assessment to a) identify the dynamics of non-adherent behavior and, b) 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 NDEF healthcare settings. (2) Based on the findings from the needs assessment, develop a tailored PwP and ARV adherence-support program that addresses the specific adherence and risk reduction needs of HIV-positive military and spouses in Ethiopia. (3) Train Ethiopian military interveners in the PwP and ARV adherence-support program. (4) Implement the program at multiple military healthcare sites within Ethiopia. (5) Evaluate the effectiveness of the PwP and adherence-support program by comparing the pre-program self-reported HIV transmission risk behaviors and ARV adherence to the post-program self-reported HIV transmission risk behaviors and adherence of 150 to 200 PLWH.

Based on findings from the needs assessment, develop a tailored Prevention-with-Positives program addressing the risk-reduction needs of HIV-positive NDFE soldiers and spouses. The 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. 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 and will continue to provide training at other military healthcare sites in Ethiopia once the US-led portion of the project is completed. Materials will be provided to the interveners to give to the patients to supplement their discussions. (4) Implement the PWP program at two military healthcare sites in Addis Ababa. Each session will consist of a one-on-one patient-centered discussion in which the intervener works with the patient to: (1) identify patient's HIV risk behaviors; (2) understand the dynamics of the behaviors; (3) determine the barriers to consistently practicing safer behaviors; (4) provide critical HIV-prevention information, motivation, and behavioral skills to overcome barriers and reduce risky behavior; and (5) set a specific goal for the patient to accomplish between visits to reduce risky behavior or maintaining safer behavior. Subsequent discussions between the HIV-positive patient and the intervener will occur at each medical visit and will focus on monitoring the patient's progress toward the risk-reduction goal; providing information, motivation, and behavioral skills training; and negotiating a new goal, as appropriate. (5) Evaluate effectiveness of the PWP program by comparing, pre and post intervention, the self-reported HIV transmission risk behaviors. (6) Train Ethiopian healthcare providers as master trainers in the PWP program to allow the PWP program to be disseminated to additional sites and to function independently of the US team. The long-term goal is to provide sufficient training to the master trainer(s) so that they can independently maintain the program.