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The successful two-drug combination therapy in 1994 and protease inhibitors in 1995 set the stage for a new era in treatment of HIV disease, creating a burst of optimism over the prospect that HIV might be a controllable disease. Initial studies of protease containing triple-drug regimens suggested that these combinations could, in some cases, slow clinical progression of the disease and prolong the lives of patients. In anecdotal reports, physicians and patients described a kind of "Lazarus" effect in which previously disabled individuals found themselves regaining lost functions, returning to work and planning their futures, instead of preparing for death. There are still many unknowns about these multi-drug regimens, including their durability of effect and how many individuals for whom they will be effective. Nonetheless, the drugs have proven quite effective in clinical trials and are helping many people stay alive longer and experience better quality of life while they are alive. We thought it important to understand better why people do and do not take advantage of these therapeutic advances. Developing the medications may be only half of the battle; the other half involves making sure that HIV infected individuals have access to the drugs and that they make thoughtful decisions about whether or not to take them. If some of the barriers to taking the drugs can be addressed, they should. We conducted in-depth qualitative interviews with 114 individuals in the HIV community--75 HIV infected men and women, 18 hotline operators and supervisors, 11 case managers, and 10 physicians and nurse practitioners.

HIV transmission is disproportionately on the rise among economically poor, African American men who have sex with men (MSM) in the United States . Although this trend has been observed for over a decade, prevention efforts have apparently been unable to adequately address the needs of this population. Existing support systems for MSM have often failed to consider cultural and family differences, perceptions of sexual orientation, economic disparity, and differential access to education and information among African American MSM . Disenfranchised African American MSM are often isolated both by homophobia in the African American community and racism in the predominantly white gay community . In addition to this, many African American MSM self-identify as either bisexual or heterosexual, thus possibly eluding HIV prevention efforts which target gay men. The crisis of HIV in the African American community and in communities of color cannot be separated from the crises of poverty, racism, and drugs . The presence of crack and other drugs plays a continuing role in the social disintegration of many of these communities. However, relatively little is known about the role of substance use in HIV sexual risk behaviors.

The National Roundtable on Evaluation of Multilevel/Combination HIV Prevention Interventions had the goals of examining the present state of the art of multilevel and combination HIV prevention interventions, both domestically and internationally; to define the significant challenges and scientific gaps in current evaluation methods and identify the most promising methodological approaches to address these gaps; and to guide the future agenda for HIV prevention research. To address these methodological gaps, we must combine the methodological and statistical rigor associated with clinical trials, the conceptual framework of implementation science, the on-the-ground strategies of programmatic monitoring and evaluation, and the strengths of pre- and post-intervention mathematical modeling. In looking at the HIV epidemic in the US, the group discussed current initiatives guided by the National HIV/AIDS Strategy and the increased optimism over treatment as prevention. We noted that considerable progress has been made in developing core metrics to evaluate outcomes along the “treatment-as-prevention cascade” that could be captured through public health surveillance—number of new HIV cases detected and proportion linked to care, retained in care, on active treatment, and virally suppressed. Our understanding of the optimum package of interventions with regard to both effectiveness and efficiency remains incomplete. Progress was reported, however, in the collection of process data at the local level to better assess how to improve programs. Devising epidemic impact measures to quantify reductions in HIV incidence attributable to combination interventions remains challenging, mostly due to barriers to testing impact through methods like community cluster randomization in the US. Looking globally, the group discussed a number of planned clinical trials of combination interventions also spurred by optimism over treatment as prevention. Common elements of combination approaches included expansion of voluntary counseling and testing, adult male circumcision, prevention of mother-to-child transmission, and management of sexually transmitted infections, along with expanding ART treatment. Outcome measures were generally framed in terms of the treatment-as-prevention cascade, though these data are not available from current surveillance systems, pointing to the need to create improved systems of data collection. The most common approach to measuring epidemic impact was clustered community randomization, with incident infections measured through cohorts or newer cross-sectional, multi-assay algorithms. Recommendations from the roundtable include the following:

• A new coalition of interventionists, implementation scientists, public health program and surveillance specialists, mathematical modelers, and behavioral scientists is needed to adequately address the evaluation of multilevel/combination HIV interventions at the community-level.
• The use of the conceptual frameworks of the HIV prevention continuum and engagement-in-HIV-care cascade should be used in structuring evaluation of combination HIV interventions.
• Common public health surveillance systems to evaluate combination HIV prevention interventions at the community level are recommended, and this capacity should be further developed internationally.
• Mathematical modeling before, during, and after multilevel/combination HIV interventions should be incorporated in the design, implementation, and interpretation of intervention results.
• Because an emphasis on efficiency as well as effectiveness from implementation science is helpful, costing and cost-effectiveness evaluations of combination HIV prevention interventions are recommended and are important to policy makers.
• Use of innovative trial and observational study designs outside of the traditional randomized, controlled trial paradigm should be used to account for the complex multilevel and combination nature of new HIV prevention interventions, and emerging design and analysis methods (e.g., stepped-wedge designs, adaptive trial designs, causal inference modeling of “natural experiments”) should be considered to address the challenges of community-level effectiveness evaluation.
• Because social factors and human behaviors are integral factors all along the HIV care and treatment cascade, it is crucial to include social and behavioral science in the design, implementation, and evaluation of combination interventions (e.g., community engagement and mobilization interventions).
• Mixed methods, including qualitative data collection (e.g., key informant interviews with implementers, in-depth interviews with target population members), are recommended to increase our understanding of how and why interventions are successful or not.
• Increased funding opportunities for methods development, whether as standalone projects or as supplements to large trials, is recommended as is funding for career development in methods research (e.g., methods-focused K awards).

NOTE: The HOT Project ended in 1995. For a list of more recent, effective school-based sexuality/HIV education programs, please see - 

• ETR Associates’ Evidence-Based Programs
• CDC’s Best Evidence Interventions
• CDC’s DEBI programs for youth: CLEAR, Focus on Youth, Street Smart, TLC, the Mpowerment Project

The Healthy Oakland Teens Project (HOT) began in the fall of 1992 at an urban, ethnically diverse junior high school. The project’s goal is to reduce adolescents’ risk for HIV infection by using peer role models to advocate for responsible decision making, healthy values and norms, and improved communication skills. (posted 4/98)

• Peer Curriculum (file below)
• Adult Curriculum

Internal and external coalition functioning is an important predictor of coalition success that has been linked to perceived coalition effectiveness, coalition goal achievement, coalition ability to support evidence-based programs, and coalition sustainability. Understanding which aspects of coalition functioning best predict coalition success requires the development of valid measures of empirically unique coalition functioning constructs. The goal of the present study is to examine and refine the psychometric properties of coalition functioning constructs in the following six domains: leadership, interpersonal relationships, task focus, participation benefits/costs, sustainability planning, and community support. The authors used factor analysis to identify problematic items in our original measure and then piloted new items and scales to create a more robust, psychometrically sound, multidimensional measure of coalition functioning. Scales displayed good construct validity through correlations with other measures. Discussion considers the strengths and weaknesses of the refined instrument.