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

1. HIV Prevention among Adolescents: Diffusion of Innovation in a Community Trial 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

2. About 14,000 New HIV Infections a Day In 2003 • More than 95% are in developing countries • Almost 2000 are in children under 15 years of age • About 12 000 are in persons aged 15 to 49 years, of whom: • almost 50% are women • about 50% are 15–24 year olds

3. Community-Level Trials • Change social networks and communities to reinforce risk avoidance and risk reduction efforts • Potential to reach large numbers of people • Be cost-effective • Feasible for implementation in areas with limited resources

4. Community-Level Interventions • Diffusion of Innovation Theory (Rogers) • Social Cognitive Theory (Bandura)

5. What is Diffusion? • Innovation: idea, practice or object perceived as new • Communication channels by which messages are exchanged • Time, or process • Social system: structure and function of relations among individuals

6. Diffusion Concepts for Targeted Groups • Process over Time • Opinion Leaders • Decentralized Diffusion Systems • Change Agents • Compatibility

7. Community Intervention Projects: United States • Men from gay bars in small cities • Women in low-income housing developments • Adolescents in urban housing developments

8. Gay 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.

9. Women in Low-Income Housing Developments Sikkema KJ, Kelly JA, Winett RA, et al. Outcomes of a randomized community-level prevention intervention for women living in 18 low-income housing developments. American Journal of Public Health. 2000; 90: 57-63.

10. Scope of Project Seattle/Tacoma, WA Milwaukee, WI Rochester, NY Cleveland, OH Roanoke, VA • 18 Housing Developments • Moderate size (80-175 units); • cluster-type developments • Female heads of household

11. Research Design Baseline Community Intervention Follow-Up Brochures And Condoms Baseline Follow-up 18 months

12. Community Intervention Elements • Women’s Health Council • Skills Training Workshops • Community Activities and Events

13. Baseline Results • 1,265 females • Mean age – 33.8 (range 15-86) • 75% African American 20% White 3% Hispanic/Latina 2% Other • Mean number of children – 2.8 (range 0-15)

14. Intercourse Occasions with Condoms Significance with development as unit of analysis, df=1, 16; p<.01 Percent

15. HIV Prevention Among Adolescents • Skills training interventions are state-of-the-science • Interventions focused on individuals • Limited studies targeted to pre- or early adolescence • Focused on abstinence outcomes with conflicting findings • Most are school-based • Long term effectiveness is limited • Need for interventions that change social networks and communities

16. Can HIV prevention efforts be improved and better maintained by…? • Skills training to enact behavior change AND • Community-level intervention that provides modeling, peer norm and social reinforcement for reducing or avoiding HIV risk behavior

17. Scope of Research Seattle/Tacoma, WA Milwaukee, WI Roanoke, VA • 15 Housing Developments • 5 sets of three matched developments • 56-350 adolescents

18. Research Design Community: Baseline Skills Short-term Follow-up Community Component Long-term Follow-up Skills: Baseline Skills Short-term Follow-up Long-term Follow-up Control: Baseline Education Short-term Follow-up Long-term Follow-up 18 months

19. Baseline Results • 1172 adolescents (587 males, 585 females) • Average age = 14.5 • 7th grade education • 99% attending school • 73% not yet in high school Study Cohorts vs. Baseline Only • Younger; lived in development longer • Less likely to : have had sex use substances have had an STD

20. Racial/Ethnic Characteristics(n = 1172)

21. Sexual Activity Among Cohort Adolescentsat Baseline • 25% had sexual intercourse • 76% condom use last intercourse • Average age first intercourse: 12.5 years • Average of 6 sexual partners past year • 11% had anal intercourse past 3 months • 9% ever had STD

22. Skills Training • Skills Training Group Intervention (4ME) • “State-of-the-Science” cognitive- behavioral skills training • Condoms and brochures available • Two sessions (6 hours total) • Groups by age and gender • Delay/refrain from sexual activity • Consistent condom use if sexually active

23. Pre-Community Component Activities • Social Events/Movies • Follow-up Session • Systematic Selection of Peer Leaders • Focus Group and Team Building

24. Community Component • Teen Health Council of Peer Leaders • Program Activities: 4ME participants • Small Media: Prevention messages • Community Wide Events • Parent Workshops: HIV/AIDS and Talking to Your Children