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

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Findings and Recommendations

The Community Preventive Services Task Force (CPSTF) recommends group-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 community 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

Group-level HIV behavioral interventions to prevent acquisition of HIV in men who have sex with men (MSM) promote individual behavior change. Trained counselors, educators, or other facilitators provide information and lead activities that are reinforced by peer pressure and support from other group members.

About The Systematic Review

The CPSTF finding is based on evidence from a systematic review of 13 studies (search period 1988 – 2005).

The review was conducted on behalf of the CPSTF by a team of specialists in systematic review methods, and in research, practice, and policy related to HIV prevention.

Study Characteristics

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

  • Were designed to influence individual risk behavior by changing knowledge, attitudes, beliefs, and self-efficacy in a small group setting
  • Focused on the development of skills through live demonstrations, role plays, or practice
  • Taught skills that may have included learning how to use condoms correctly, how to implement personal decisions to reduce risk, and how to negotiate safer sex effectively with partners.

Summary of Results

Detailed results from the systematic review are available in the published evidence review. (Update to AJPM link in Stacks)

The systematic review included 12 studies that reported on 15 interventions.

  • Following intervention, there was a 27% reduction in odds for having unprotected anal intercourse (UAI)
    • These effects were significant at both short-term (median 3 months) and long-term (median 12 months) follow-ups

Summary of Economic Evidence

The economic review included two studies that showed group-level interventions were cost saving. Estimates are reported in 2003 U.S. dollars.

  • One study compared the cost effectiveness of a safer sex lecture plus skills training intervention with that of a safer sex lecture alone. They found the skills training component had a cost savings of $9757 per discounted quality-adjusted life year (QALY).
  • Another study found that averted medical care costs were significantly higher than intervention program costs.

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

CPSTF identified several areas that have limited information. Additional research and evaluation could help answer the following questions and fill remaining gaps in the evidence base. (What are 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 following considerations are drawn from studies included in the evidence review, the broader literature, and expert opinion.

  • 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
  • The availability of financial and nonfinancial resources affects implementation.
    • When the availability of professional counselors to deliver individual or group interventions is limited, MSM can be trained to deliver many of those interventions.
  • 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.