Center for AIDS Intervention Research (CAIR)

Narrative Description of Program

AIDS is now the third leading cause of death among adult American women under the age of 45, and impoverished, inner-city minority women are disproportionately threatened by HIV disease. In the absence of an effective HIV protective vaccine, efforts to curtail HIV infection require individuals to make and then sustain changes in behavior practices that confer risk. To have greatest public health relevance, HIV prevention must also be focused on persons at greatest risk for the disease. However, there have been few carefully evaluated health promotion interventions specifically for disadvantaged minority women, and fewer still focused on HIV prevention issues.

Beginning in 1991, and with grant support provided by the National Institute of Mental Health, we developed a small-group HIV prevention intervention model. The program consists of a series of five 90 minute weekly group sessions, each attended by 12 to 15 women and led by two female facilitators. The program was initially offered at the Milwaukee Indian Health Board clinic, a primary care clinic that serves largely unemployed minority women and their children. The intervention, based on social cognitive behavior change principles, includes the following elements:

1. HIV risk education, focused particularly on correcting misconceptions about AIDS risk to women and their children;
2. Sexual decision making, which encourages women to identify and problem solve ways to handle "triggers" that can lead to risky encounters including substance abuse, sexual coercion, or loneliness;
3. Risk reduction skills building, including practice in assertively handling pressures to engage in unwanted sex, communicating AIDS concerns, insisting on condom use, and managing personal circumstances that contribute to risk; and
4. Change empowerment, in which women support one another's change efforts.

Narrative Description of Evaluation Results

Outcome Evaluation Study

To evaluate the intervention's effectiveness, 197 women over a 2 year period were randomly assigned to either the HIV prevention program or a comparison intervention that included standard AIDS counseling but otherwise focused on women's health topics unrelated to AIDS. Women in the project were predominantly African American (87%) and unemployed (97%), and most had not completed high school. All reported multiple sexual partners, injection drug use partners, or STD treatment history. Prior to participation and again at 3-month follow-up, all women were administered confidential measures assessing their AIDS risk knowledge, sexual assertiveness skills, and sexual behavior over the past 3 months. Women in the comparison group showed no change in risk. Women who attended the HIV prevention program gained in risk knowledge and risk reduction skills, reduced their rates of unprotected sex by about 20%, and increased in their use of barrier protection during sex from 26% to 56% of intercourse occasions.

Cost Effectiveness Analysis

We conducted a retrospective cost effectiveness analysis of the program. This analysis took into account the program's cost of delivery, its risk reduction behavior change impact, and factors related to statistically modeling the number of HIV infections averted. The cost of the program uses $269 per client and the base cost-utility ratio was $2,024 per discounted Quality of Adjusted Life Year saved, well within the range of sound cost effectiveness and low compared to other life-saving interventions. The project evaluation article was published in the American Journal of Public Health, and a separate article describing its cost effectiveness is in press in the same journal. Both are attached.

Community Use

Although the formal evaluated program has ended, it is being continued as a service in the clinic, as well as in Milwaukee shelters for homeless women. Program manuals are disseminated at no cost by CAIR to AIDS prevention and health organizations.

• CAIR

The following assessment of program strengths and weaknesses has been abstracted from reviews by the Task Force on Program Selection of The Health Project. Where weaknesses are postulated, it must be taken into account that the review Task Force is very critical, that no programs are perfect, that the Award Winning programs have been selected from over 300 candidate programs and represent the very best, that the materials reviewed may have been incomplete, that suggested deficiencies may have resulted from incomplete understanding of the program by the reviewers or that any problems may have been corrected since the time of review.

Evaluation

The "Center for Aids Intervention Research (CAIR)" of the Medical College of Wisconsin has tackled the frightful problem of AIDS in impoverished, inner-city minority women under 45 with a small-group HIV prevention intervention model and systematic follow-up that includes HIV risk education, sexual decision making, assertiveness in sexual situations and risk reduction skills building. The program has demonstrated extraordinary cost effectiveness compared with other life-saving interventions.

Women in the HIV Prevention Program improved risk knowledge and risk reduction skills, reduced rates of unprotected sex by 20 percent, and increased their use of barrier protection from 26 percent to 56 percent of intercourse occasions. Cost-effectiveness analysis showed program cost to be $269 per client and the base cost-utility ratio was $2024 per discounted QALY saved. The program was funded by the National Institutes of Mental Health. There was random assignment to the educational program; a peer-reviewed study is in press for the American Journal of Public Health, an excellent journal. There is potential for large population and cost-savings and reviewers would like to see it rolled out to more groups. Program goals are clearly delineated. Evaluation included a comparison group. It is a relatively low cost, high reward program. Reviewers liked the concept of the program very much. There are two articles in the journal of the Public Health Association; one on effectiveness and one on cost-effectiveness.

Single focus. Relatively small study. The program is not likely to do much unless it can be sustained and expanded. Five sessions of prevention over two months may be insufficient to produce lasting change.