HIV Prevention among Adolescents: HIV Prevention among Adolescents: Diffusion of Innovation in a Community Diffusion of Innovation in a Community

TrialTrial

Kathleen J. Sikkema, Ph.D.Yale University School of Medicine

Eileen S. Anderson, Ed.D.²; Jeffrey A. Kelly, Ph.D.¹; Richard A. Winett, Ph.D.²; Cheryl Gore-Felton, Ph.D.¹;; Roger Roffman,

DSW ³; Timothy G. Heckman, Ph.D.Raymond Hoffmann, Ph.D.¹ Michael J. Brondino, Ph.D.¹

¹Medical College of Wisconsin, Milwaukee, WI; ²Virginia Tech, Blacksburg, VA; ³University of Washington, Seattle, WA;

Research was supported by grant R01-MH42908 from the National Institute of Mental Health (NIMH) and by NIMH Center grant P30-MH522776

About 14,000 New HIV About 14,000 New HIV Infections a Day In 2003Infections a Day In 2003

• More than 95% are in developing More than 95% are in developing countriescountries

• Almost 2000 are in children under 15 Almost 2000 are in children under 15 years of ageyears of age

• About 12 000 are in persons aged 15 About 12 000 are in persons aged 15 to 49 years, of whom:to 49 years, of whom:− almost 50% are womenalmost 50% are women− about 50% are 15–24 year about 50% are 15–24 year

oldsolds

Community-Level TrialsCommunity-Level Trials

• Change social networks and Change social networks and communities to reinforce risk communities to reinforce risk avoidance and risk reduction avoidance and risk reduction efforts efforts

• Potential to reach large numbers Potential to reach large numbers of peopleof people

• Be cost-effectiveBe cost-effective• Feasible for implementation in Feasible for implementation in

areas with limited resourcesareas with limited resources

Community-Level Community-Level InterventionsInterventions

• Diffusion of Innovation Theory Diffusion of Innovation Theory (Rogers)(Rogers)

• Social Cognitive Theory Social Cognitive Theory (Bandura)(Bandura)

What is Diffusion?What is Diffusion?

• Innovation: idea, practice or object Innovation: idea, practice or object perceived as newperceived as new

• Communication channels by which Communication channels by which messages are exchangedmessages are exchanged

• Time, or processTime, or process• Social system: structure and function Social system: structure and function

of relations among individuals of relations among individuals

Diffusion Concepts for Diffusion Concepts for Targeted GroupsTargeted Groups

• Process over TimeProcess over Time• Opinion LeadersOpinion Leaders• Decentralized Diffusion SystemsDecentralized Diffusion Systems• Change AgentsChange Agents• Compatibility Compatibility

Community Intervention Community Intervention Projects: United StatesProjects: United States

• Men from gay bars in small citiesMen from gay bars in small cities• Women in low-income housing Women in low-income housing

developmentsdevelopments• Adolescents in urban housing Adolescents in urban housing

developmentsdevelopments

Gay Bars in Small CitiesGay Bars in Small Cities

Kelly JA, Murphy DA, Sikkema KJ, et al. Randomized, controlled,community-level HIV prevention intervention for sexual risk behavior among homosexual men in US cities. The Lancet. 1997; 350: 1500-1505.

Women in Low-Income Women in Low-Income Housing DevelopmentsHousing Developments

Sikkema KJ, Kelly JA, Winett RA, et al. Outcomes of a randomizedcommunity-level prevention intervention for women living in 18low-income housing developments. American Journal of PublicHealth. 2000; 90: 57-63.

Scope of ProjectScope of Project

Seattle/Tacoma, WA

Rochester, NY

Roanoke, VA

Cleveland, OH

Milwaukee, WI

18 Housing Developments

•Moderate size (80-175 units); cluster-type developments•Female heads of household

Research DesignResearch Design

BaselineCommunityIntervention Follow-Up

Baseline

BrochuresAnd

Condoms Follow-up

18 months

Community Intervention Community Intervention ElementsElements

• Women’s Health CouncilWomen’s Health Council

• Skills Training WorkshopsSkills Training Workshops

• Community Activities and EventsCommunity Activities and Events

Baseline ResultsBaseline Results

• 1,265 females1,265 females

• Mean age – 33.8 (range 15-86)Mean age – 33.8 (range 15-86)

• 75% African American75% African American20% White20% White3% Hispanic/Latina3% Hispanic/Latina2% Other2% Other

• Mean number of children – 2.8 Mean number of children – 2.8 (range 0-15)(range 0-15)

Intercourse Occasions with Intercourse Occasions with CondomsCondoms

Significance with development as unit of analysis, df=1, 16; p<.01Significance with development as unit of analysis, df=1, 16; p<.01

3 0

4 7

3 3 3 6

0

1 0

2 0

3 0

4 0

5 0

I n t e r v e n t i o n C o m p a r i s o n

P r e -I n t e r v e n t i o n

1 2 - M o n t hF o l l o w - U p

Perc

ent

HIV Prevention Among Adolescents• Skills training interventions are state-of-Skills training interventions are state-of-

the-sciencethe-science• Interventions focused on individualsInterventions focused on individuals• Limited studies targeted to pre- or early Limited studies targeted to pre- or early

adolescenceadolescence• Focused on abstinence outcomes with Focused on abstinence outcomes with

conflicting findingsconflicting findings• Most are school-basedMost are school-based• Long term effectiveness is limitedLong term effectiveness is limited• Need for interventions that change social Need for interventions that change social

networks and communitiesnetworks and communities

Can HIV prevention efforts be improved and Can HIV prevention efforts be improved and better maintained by…?better maintained by…?

• Skills training to enact behavior changeSkills training to enact behavior change

ANDAND

• Community-level intervention that Community-level intervention that provides modeling, peer norm and provides modeling, peer norm and social reinforcement for social reinforcement for reducingreducing or or avoidingavoiding HIV risk behavior HIV risk behavior

Scope of ResearchScope of Research

Seattle/Tacoma, WA

Milwaukee, WI

Roanoke, VA

15 Housing Developments

• 5 sets of three matched developments

• 56-350 adolescents

Research DesignResearch Design

Baseline SkillsShort-termFollow-up

CommunityComponent

Long-termFollow-up

Baseline SkillsShort-termFollow-up

Long-termFollow-up

Baseline EducationShort-termFollow-up

Long-termFollow-up

Community:

Skills:

Control:

18 months

Baseline ResultsBaseline Results• 1172 adolescents (587 males, 585 females)1172 adolescents (587 males, 585 females)• Average age = 14.5Average age = 14.5• 77thth grade education grade education

– 99% attending school99% attending school– 73% not yet in high school73% not yet in high school

Study CohortsStudy Cohorts vs. vs. Baseline OnlyBaseline Only• Younger; lived in development longerYounger; lived in development longer• Less likely to : have had sexLess likely to : have had sex

use substancesuse substances

have had an STDhave had an STD

Racial/Ethnic CharacteristicsRacial/Ethnic Characteristics((n = 1172n = 1172))

African American

Vietnamese

Causasian

Eritrian

Somalian

Asian

Cambodian

Ukranian

Hispanic

Russian

Native American

Ethiopian

Other

Sexual Activity Among Cohort Sexual Activity Among Cohort AdolescentsAdolescents at Baselineat Baseline

• 25% had sexual intercourse25% had sexual intercourse• 76% condom use last intercourse76% condom use last intercourse• Average age first intercourse: Average age first intercourse:

12.5 years12.5 years• Average of 6 sexual partners past yearAverage of 6 sexual partners past year• 11% had anal intercourse past 3 months11% had anal intercourse past 3 months• 9% ever had STD9% ever had STD

Skills TrainingSkills Training• Skills Training Group Intervention Skills Training Group Intervention (4ME)(4ME)

– ““State-of-the-Science” cognitive- behavioral skills trainingState-of-the-Science” cognitive- behavioral skills training– Condoms and brochures availableCondoms and brochures available

– Two sessions (6 hours total)Two sessions (6 hours total)– Groups by age and genderGroups by age and gender

– Delay/refrain from sexual activityDelay/refrain from sexual activity– Consistent condom use if sexually activeConsistent condom use if sexually active

Pre-Community Pre-Community Component ActivitiesComponent Activities

• Social Events/MoviesSocial Events/Movies

• Follow-up SessionFollow-up Session

• Systematic Selection of Peer LeadersSystematic Selection of Peer Leaders

• Focus Group and Team BuildingFocus Group and Team Building

Community ComponentCommunity Component

• Teen Health Council of Peer LeadersTeen Health Council of Peer Leaders

– Program Activities: 4ME participantsProgram Activities: 4ME participants– Small Media: Prevention messagesSmall Media: Prevention messages– Community Wide EventsCommunity Wide Events

– Parent Workshops: HIV/AIDS and Parent Workshops: HIV/AIDS and Talking to Your ChildrenTalking to Your Children