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Healthy Oakland Teens (HOT)

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

 

The Center for AIDS Prevention Studies began providing innovative HIV prevention education in Oakland, CA in 1989. The Healthy Oakland Teens Project (HOT) began in the fall of 1992 at an urban, ethnically diverse junior high school. The project's goal was 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. The HOT program was very successful.

After extensive training, the ninth grade peer helpers delivered weekly interactive sessions in seventh-grade science classes, focusing on values, decision-making, communication, and prevention skills. The program trained 30 ninth grade peer helpers who in turn taught 300 seventh graders each year.

Each semester the peers designed their own group logo which was printed on T-shirts worn enthusiastically by the peer helpers. During eighth grade, the students received two "booster" sessions - a reminder of what they learned in seventh grade. HIV-positive young people visited each eighth-grade classroom helping the students realize that HIV infection does happen to teenagers. The eighth-graders also saw a theater presentation, Secrets, sponsored by the Kaiser Permanente Medical Center, which tells the story of a high school student who becomes infected with HIV.

Curriculum

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

Staff

For more information e-mail: Maria Ekstrand Project Director Center for AIDS Prevention Studies [email protected]

Resource

Healthy Oakland Teens

Healthy Oakland Teens Description and Explanation of Study Instrument

A questionnaire based on findings from earlier surveys was developed and pilot tested on junior high school students. The content and wording of the survey was modified based on pilot study results and participant feedback and used in the present study to assess demographic characteristics, HIV/AIDS/STD-related knowledge, attitudes, and beliefs, sexual behaviors and drug and alcohol use. The final instrument included 102 items at pretest and 97 items at follow-up, and required approximately 40 minutes to complete. The instrument contained the following sections that were used to develop scales. Sexual behaviors were assessed including dating, kissing, deep kissing, breast touching, and genital touching. These individual-item measures were dichotomous assessments for lifetime behaviors and for practices during the past two months. Those students who had experienced sexual intercourse were asked about their lifetime and prior two months practice of vaginal, anal, and oral sex. Demographics, including gender, age, ethnicity, and the primary language spoken at home were measured. Socioeconomic status was assessed by examining the proportion of students who participated in the school district's free lunch program. An AIDS -related knowledge score was created by adding the number of correct answers to 11 true-false questions regarding AIDS transmission, general medical aspects of AIDS, and knowledge of preventive behaviors. Examples of items included, "Only people who look sick can spread the AIDS virus," "A person can get the AIDS virus even if he or she has sexual intercourse just one time without a condom," and "Birth control pills prevent a woman from getting the AIDS virus." (scale range 0 to 11, seventh grade baseline mean=7.9, Cronbach's alpha=.64). The perceived costs and benefits of preventive behaviors scale combines statements about the negative and positive aspects of condom use. Examples of items include "It would really bother me to stop having sexual intercourse to put on a condom," "Condoms would be too much trouble to use," and "Condoms slip off easily." Responses are in the Likert format ranging from "definitely" to "definitely not" (range 0 to 21, seventh-grade baseline mean=11.1, Cronbach's alpha=.43; for negative aspect items only, six items, Cronbach's alpha=.47). We decided to retain this scale even though it has a relatively low reliability, since perceived barriers have previously been shown to be related to sexual behaviors and were specifically targeted in our intervention. The perceived peer norms scale used the CDC's national survey of adolescent AIDS-related attitudes (CDC, 1988). This scale measures the perceived prevalence of risk behaviors among the friends of adolescents, using Likert response options. Examples of items include, "How many of your friends do you think have had sexual intercourse?" and "How many of your friends think condoms are too much trouble to use?" A high score indicates that friends are believed to have the lowest risk behaviors and attitudes regarding condom use (five items, range 0 to 20, seventh grade baseline mean=15.1, Cronbach's alpha =.62) The attitudes regarding sexually active students scale consists of three statements referring to sexually active boys and girls (for a total of six statements), "Having sexual intercourse makes a boy (a girl) popular," "Having sexual intercourse at my age is a `cool' thing for a boy (a girl) to do," and "Having sexual intercourse with someone besides his (her) steady partner makes a boy (a girl) 'cool' or popular." Students responded on a 4 point Likert format scale ranging from "strongly agree" to "strongly disagree." (Six item scale, range 0 to 18, seventh-grade baseline mean=13.5, Cronbach's alpha=.88) The partner norms scale combines three items regarding attitudes toward a sexual partner who suggested using a condom, (i.e. "If the person I was about to have sex with suggested using a condom, I would feel like that person cared about me,"), (3 items, range 0 to 9, seventh grade baseline mean=7.3, standardized Cronbach's alpha=.69) The self-efficacy scale measures confidence in one's ability to refuse unsafe situations or use of a condom in appropriate situations. Examples of items include "I would refuse to have sexual intercourse without a condom," and "I would use a condom even if I were drunk or high." A high score reflects the strongest refusal and condom use self-efficacy (range 0-15, seventh grade baseline mean=11.2, Cronbach's alpha=.62) Alcohol consumption. Students were asked at what age they had consumed their first drink (open-ended), their frequency of drinking and their frequency of getting "really drunk" (7 response categories ranging from "never" to "almost every day"). Questions about marijuana smoking included the age at first use, frequency of use, and frequency of getting "really high." These questions used the same format as for alcohol consumption.
Resource

Voluntary HIV Counseling and Testing Efficacy Study

Is HIV Counseling and Testing Effective for Prevention?

While voluntary HIV counseling and testing has been demonstrated to be useful for care and support, the effectiveness of counseling and testing for prevention has not been conclusively demonstrated [1-6]. There have been very few studies of the effectiveness of counseling and testing for prevention, and even fewer randomized trials [7-8], despite repeated calls for controlled studies[1,6,9]. While speculation continues regarding the potential usefulness of counseling and testing despite its relatively high cost, there are currently insufficient data to determine either the efficacy or the true cost of the intervention in relation to the number of infections that could be prevented by it (cost-effectiveness). Arguments in favor of more widespread HIV testing and counseling include that counseling and testing provides an opportunity for education and behavior change and that knowledge of serostatus allows individuals to plan, make important life decisions and to seek care and support [10]. On the other hand, HIV counseling and testing is an expensive intervention compared to health education and other potentially effective prevention strategies. In addition, there are potentially negative social consequences of counseling and testing including family and relationship disruption, sexual violence, stigma and discrimination [11-12]. The Voluntary HIV Counseling and Testing Efficacy Study was a clinical trial conducted in 1995-1997 to test the effectiveness and consequences of Voluntary HIV Counseling and Testing for the prevention of new HIV infections. This is an important policy issue, particularly in countries where health care resources are limited. More specifically the purpose of the study was to determine if counseling and testing, whether given to individuals or couples, might be effective in reducing risk behavior for the sexual transmission of HIV.

References

[1] Higgins DL, Galavotti C, O'Reilly K, et al. Evidence for the Effects of HIV Antibody Counseling and Testing on Risk Behaviors. JAMA 1991; 266:2419-2429. [2] DeZoysa I, Phillips KA, Kamenga MC, et al. Role of HIV counseling and testing in changing risk behavior in developing countries. AIDS 1995: S95-S101. [3] Landis SE, Earp JL, Koch GG. Impact of HIV Testing and Counseling on subsequent sexual behavior. AIDS Education and Prevention; 1992; 4:61-70. [4] Zenilman JM, Erickson B, Fox R, Reichart CA, Hook III EW. Effect of HIV posttest Counseling on STD incidence. JAMA 1992; 267:843-845. [5] Otten Jr MW, Zaidi AA, Wroten JE, Witte JJ, Peterman TA. Changes in Sexually Transmitted Disease Rates after HIV Testing and Posttest Counseling, Miami 1988 to 1989. American Journal of Public Health 1993; 83:529-533. [6] Beardsell S. Should wider HIV testing be encouraged on the grounds of HIV prevention? AIDS Care 1994; 6:5-19. [7] Wenger NS, Linn LS, Epstein M, Shapiro MF. Reduction of High-Risk Sexual Behavior among Heterosexuals Undergoing HIV Antibody Testing: A Randomized Clinical Trial. American Journal of Public Health 1991; 81:1580-1585. [8] Wenger NS, Greenberg JM, Hilborne LH, Kusseling F, Mangotich M, Shapiro MF. Effect of HIV Antibody Testing and AIDS Education on Communication about HIV Risk and Sexual Behavior. Annuals of Internal Medicine 1992; 117:905-911. [9] Phillips KA & Coates TJ. HIV counseling and testing: research and policy issues. AIDS Care 1995; 7:115-124. [10] Müller O, Barugahare L, Schwartländer B, et al. HIV prevalence, attitudes and behavior in clients of a confidential HIV testing and counseling center in Uganda. AIDS 1992; 6:869-874. [11] Colebunders R & Ndumbe P. Priorities for HIV testing in developing countries? The Lancet 1993; 342:601-602. [12] van der Straten A, King R, Grinstead O, Serufilira A, Allen S. Couple communication, sexual coercion and HIV risk reduction in Kigali, Rwanda. AIDS 1995; 9:935-944.

Prevention Services for HIV+ Patients Methods

These surveys have been designed and tested by CAPS scientists and are made available for use by HIV prevention program planners and designers.
Warning: Survey needs vary from population to population and project to project. Please consider carefully the needs of your particular intervention before using one of these instruments. We encourage researchers and service providers to use these instruments, adapting and modifying as you see fit. Please cite CAPS as the source in any presented or published work, and, if the instruments were modified in any way from their original (as downloaded from the CAPS Web site) please note that in any presentations.

Instruments for Prevention Services for HIV+ Patients

The following exit survey instruments were developed to assess frequency and variation of prevention services as reported by HIV positive patients at Ryan White-funded clinics across the US.

Reliability and Validity

This instrument is in a preliminary stage. Therefore, reliability, validity, and scoring systems are not available. The instrument was not designed to have psychometric properties that would enable its use outside of the immediate research setting of the study for which it was designed; however, it is posted in case that provides a platform for other researchers to develop new instruments.

Methods

Exit surveys were conducted in 16 Ryan White funded clinics across the country to 618 HIV-infected patients as they left routine visits with their primary care providers. The inclusion criteria were HIV-positive status, patient at the HIV primary care clinic, and able to provide informed consent. The number of patients surveyed ranged from 9 to 69 (mean=39) depending on the patient volume at each clinic and the number of patients who agreed to be surveyed within one-week field visits. Fifty-six (9%) of the exit interviews were conducted in Spanish and the remainder in English. These surveys were anonymous and pre-coded with participant identification codes. Participants received a $10.00 stipend for their participation in this 20 minutes survey. Participants were either recruited directly by interviewers from UCSF or referred by clinic staff, depending on the setting and the confidentiality procedures at each clinic. The exit surveys were formatted using Teleforms and faxed into a database housed on a web server.

Computer Based techniques for quantitative data collection for RWPP

A standardized data management system was used to collect, transfer, store, and edit data for the duration of this project. All components of the data system either read or wrote to a Microsoft SQL Server database. The survey instrument was modified to be machine readable using Cardiff Teleform Software, and all scannable forms were manually filled in by interviewers at the time of the interview, submitted via fax, and identified and evaluated by Teleform Reader. A data verifier then correctly entered any data in fields that the software had difficulty reading. A data querying component, consisting of a custom-written Visual Basic program, then queried the database for problems and generated a table with a record of each problem found. Quantitative interviewers underwent group and individual training to access data queries and modify errors made in survey collection. An audit trail was automatically created for each change made to any field in the database. The final SQL database was then directly read by SAS (Statistical Analysis Software) via an ODBC connection for data analysis. These methods of quality control and assurance ensured data that was of high caliber and timely.
Resource

Enhancing Prevention with Positives Evaluation Center (EPPEC)

NOTE: This study has ended. The Enhancing Prevention with Positives Evaluation Center (EPPEC) is a technical assistance and evaluation center for 15 demonstration sites funded by the Special Projects of National Significance (SPNS) program of the Health Resources and Services Administration (HRSA). The 15 demonstration sites work with EPPEC and the SPNS program at HRSA to implement and evaluate HIV prevention interventions with HIV-infected patients in primary health care settings. A multidisciplinary team led by the UCSF AIDS Policy Research Center is carrying out the project. Each of the participating sites reports client, provider, organizational setting and intervention characteristics, as well as the results of behavior change surveys and other core measures. What is unique about this project is that each of the 15 sites is implementing a different intervention specifically tailored to the local client population and environment. Interventions range from brief counseling delivered by primary care providers during regular visits to individual risk reduction counseling delivered by prevention specialists, and to peer-led group sessions. Some sites are using a combination of models and several sites are delivering intervention services in more than one clinical setting. The specific aims for EPPEC are:

  1. Evaluation: To facilitate and conduct evaluation research that will have maximum impact on practice and policy of HIV prevention across 15 demonstration sites.
  2. Technical Assistance: To provide methodological (both quantitative and qualitative) research design and technical assistance on the development of behaviorally based interventions, assist sites in design of data collection and management systems, and provide a central database for measurement of outcomes.
  3. Dissemination: To synthesize and disseminate findings from demonstration projects to maximize their impact on further prevention research, practices and policies.
  4. Capacity: To stimulate innovative projects, scientific excellence, and organizational capacity to ensure integrity of research and sound fiscal operations.

EPPEC is working to analyze, synthesize and disseminate findings from demonstration projects so that they have optimum impact on further prevention research, practices and policies.

Findings

Nearing the end of the interventions at the demonstration sites, analysis of quantitative baseline data indicates that providers of primary care and support services in HIV clinical settings have a potential role in HIV prevention. Providers are more likely to deliver PwP if they feel responsible for doing so; providers are less likely to deliver PwP if they express prevention fatalism, the belief that no matter how much counseling is delivered, some HIV+ patients will still infect others. Among all HIV+ patients enrolled in the study–MSM, MSW and women–stimulant use is associated with risk. Through analysis of pre-implementation qualitative data collected through interviews with project staff and interventionists at the demonstration sites we identified the following common elements to successfully implement complex behavioral interventions in clinical settings:

  • Internal leadership and authority to overcome resistance and foster interest and motivation on the part of clinical providers and clinic staff,
  • Shared belief in importance, need, viability, and appropriateness of PwP in clinical setting,
  • Adequate attention to creating flow between clinic practice and intervention,
  • Ongoing training within the clinic that can address clinician and staff needs as prevention programs become a regular part of the care.

Successful implementation depends on the complementary fit between the intervention model and the clinical setting. Assessing the feasibility of whether or not a clinic has the support of providers, staff and patients–as well as the financial resources–is the first step in determining the potential success of implementing an intervention. Developing interventions that resonate with the patient population and the clinical environment will lead to great willingness from and meaningful experience for participants. Please see the following articles for more detail:

Staff

HRSA-SPNS funding for EPPEC began in October 2002 and will continue until September 2007. The funding for the 15 demonstration project sites began in October 2003 and will continue until September 2007. For more information, please contact: Jennifer Bie, Project Assistant Center for AIDS Prevention Studies 50 Beale Street, Suite 1300 San Francisco, CA 94105 415/597-9213 - fax 415/597-9285 - phone jennifer.bie at ucsf.edu