HIV: Interventions to Reduce Sexual Risk Behaviors or Increase Protective Behaviors to Prevent Acquisition of HIV in Men Who Have Sex with Men Community-Level Interventions

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Findings and Recommendations

The Community Preventive Services Task Force (CPSTF) recommends community-level HIV behavioral interventions for adult men who have sex with men to reduce unprotected anal intercourse.

The CPSTF has related findings for HIV behavioral interventions at the individual level (recommended) and group level (recommended).

The full CPSTF Finding and Rationale Statement and supporting documents for Interventions to Reduce Sexual Risk Behaviors or Increase Protective Behaviors to Prevent Acquisition of HIV in Men Who Have Sex with Men: Individual-, Group-, and Community-Level Behavioral Interventions are available in The Community Guide Collection on CDC Stacks.

Intervention

Community-level HIV behavioral interventions to prevent acquisition of HIV in men who have sex with men (MSM) are designed to influence individual risk behavior by changing knowledge, attitudes, and beliefs in a defined community.

About The Systematic Review

The CPSTF finding is based on evidence from a systematic review of 3 studies (search period 1988 — 2005).

Study Characteristics

In the included studies, HIV behavioral interventions at the community level

  • Aimed to motivate and reinforce behavior change in individuals who did not participate directly in the intervention by promoting norms that support safer sex through popular opinion leaders, community mobilization, or social networks
  • May have had several components, requiring complex coordination and several years or longer to implement

Following are characteristics of studies included in the reviews of HIV behavioral interventions at individual, group, and community levels.

  • Most of the included studies were conducted in the United States, though some were conducted in Brazil, the United Kingdom, New Zealand, or Canada.
  • Of the 19 included studies, 13 were conducted before 1996, the year highly active antiretroviral treatment (HAART) was introduced.
  • Participants were recruited in a variety of settings, including clinics, community-based organizations, and gay community venues such as bars and public cruising areas.
  • Most studies evaluated interventions with follow-ups longer than 3 months, and only two studies failed to achieve at least 80% retention.
  • The median age across all study samples was 33 years, and in the 15 studies reporting education, at least 50% of participants had some college.

Summary of Results

The systematic review included three studies that reported on three interventions.

  • Unprotected anal intercourse (UAI): 35% reduction in odds at follow-up intervals ranging from 4 months (two studies) to 1 year (one study)
  • Condom use during anal intercourse: 59% increase in odds (two studies)

Summary of Economic Evidence

The economic review included three studies that found that potential savings in HIV-related medical costs exceeded the costs of implementing the intervention. Estimates are reported in 2003 U.S. dollars.

  • In two of the studies, the average of costs per HIV infection averted was $45,418. Although the source of cost data and modeling assumptions were different in the two studies, both reported that costs per discounted quality-adjusted life years (QALY) saved were negative, implying the original program was cost saving.
  • The third study reported a range of cost per HIV infection averted using different timeframes, epidemic scenarios, cost perspectives, and modeling inputs. From a societal perspective that included volunteer time, costs per HIV infection averted were estimated to range from $49,580 in 1 year to $7,373 in 20 years, depending on the particular assumption about the HIV prevalence rate.

Applicability

Based on the evidence, this finding should be applicable across a range of settings and MSM populations in the United States, assuming interventions are appropriately adapted to the needs and characteristics of the population.

Evidence Gaps

  • How effective are interventions among particular groups?
    • Nonwhite MSM, and in particular, African-American and Latino populations who are disproportionately affected by HIV
    • Non gay-identified MSM, who may have different HIV prevention needs than gay-identified men
    • MSM who are substance users
  • Given the included studies were set in locations such as gay bars, community-based organizations, health clinics, and research study sites, how effective are they in other settings (e.g., “circuit parties”)?
  • What are intervention effects on health outcomes (e.g., STDs and HIV)? What are the most effective ways to measure such biological outcomes?
  • What are the minimal and optimal variables for intervention effectiveness (e.g., number of sessions, program duration, type of skills training)?
  • How have advances in technology and medicine over the past decade altered the social and behavioral landscape of the MSM community? Has commitment to reducing sex risk behaviors declined since HIV became a more manageable condition?
  • Has the Internet led to elevated levels of sex risk behavior among MSM seeking and meeting sex partners?

Implementation Considerations and Resources

  • The barriers most frequently reported in the included studies and broader literature involved the challenges of recruitment, enrollment, and retention of MSM in HIV behavioral interventions.
    • Some MSM subgroups were particularly hard to reach because of geographic isolation, social isolation, fear of being exposed as an MSM, and failure of the intervention to address the cultural values and practices of the community.
    • Several studies linked difficulties in retaining MSM in HIV behavioral interventions to the frequent perception that interventions are not motivating and captivating, or are irrelevant.
    • Time constraints, competing interests, and substance use have been identified as influences on participation in prevention programs.
    • Barriers to recruitment and enrollment are especially important in low-income minority communities with high HIV seroprevalence, where MSM may not want to acknowledge their homosexual behaviors. MSM may restrict their sexual activity to private clubs, people met through the Internet, or other venues not associated with the gay community.
  • Included studies used the following strategies to address some of these barriers.
    • Interventions were delivered entirely over the telephone to overcome geographic boundaries
    • Peer opinion leaders diffused safe sex messages through social networks to reach isolated MSM
    • A variety of training elements were used to increase salience and appeal.
    • Culturally relevant content was incorporated for subgroups, particularly minority or substance-using MSM
  • Multicomponent community-level interventions require extensive community mobilization and coordination that enables supportive relationships with key stakeholders.
  • Where gay communities lack the resources or community support to mobilize community-level approaches, small-group or network-based interventions may work.
  • The internet can be a useful tool to recruit and enroll MSM into behavioral interventions. Other strategies include the “foot in the door” approach and respondent-driven sampling.

Crosswalks

Healthy People 2030 icon Healthy People 2030 includes the following objectives related to this CPSTF recommendation.