|A systematic review and meta-analysis of behavioral interventions to reduce HIV risk behaviors of Hispanics in the United States and Puerto Rico
|Herbst J H, Kay L S, Passin W F, Lyles C M, Crepaz N, Marin B V
The authors concluded that interventions reduced unprotected sex, number of sexual partners and new sexually transmitted diseases, and increased condom use. Overall, this was a well-conducted review but the robustness of the authors' conclusion may be undermined by differences among the studies.
To evaluate the efficacy of behavioural human immunodeficiency virus (HIV) prevention interventions among Hispanic residents of the USA or Puerto Rico, and to identify factors associated with efficacy.
AIDSLINE (1988 to 2005), EMBASE, PsycINFO and Sociofile were searched (1988 to November 2005) for published studies. Some details of the search strategy were reported. In addition, 35 key journals were handsearched (June 2004 to January 2006) and the reference lists of all relevant reports were checked. ProQuest Dissertation and Theses Database, published abstracts from relevant national and international HIV/AIDS and STD conferences, the Cochrane Controlled Trials Register and CRISP. Key
investigators in the USA and Puerto Rico were contacted for details of ongoing research and additional published and unpublished studies. Studies were included if they were reported in English or Spanish.
Study designs of evaluations included in the review
Studies that followed up the same group of participants or communities prospectively over time and compared this group with a control group were eligible for inclusion in the review. The duration of follow-up in most studies exceeded 3 months (median 4.5).
Specific interventions included in the review
Studies that evaluated interventions to prevent HIV, acquired immune deficiency syndrome (AIDS) or sexually transmitted diseases (STDs) were eligible for inclusion. Other intervention components included: access to condoms; addressing sexual safety, risk triggers, sexual abstinence and peer norms; teaching skills, problem-solving, negotiation; and HIV counselling and HIV/STD testing. Some studies incorporated Hispanic cultural elements. Control interventions were another intervention or wait-list control. Most of the interventions were delivered to small groups and were delivered in health drug treatment centres, community settings or community-based organisations. The interventions were mostly delivered over a mean of 5 sessions (range: 1 to 5) with an intervention duration ranging from 1 to 24 hours (median 10).
Participants included in the review
Studies in which the majority (>50%) of the patients were Hispanics in the USA or Puerto Rico, or that reported outcomes separately for this population, were eligible for inclusion in the review. Some of the primary studies only included males or females. The studies targeted drug users (including injection
drug users), gay or bisexual men, young couples, adolescent mothers, migrant farm workers, low-income women, STD clinic attenders, women, inner-city youths and adolescents. The mean age of the participants was 27.2 years (range: 14.9 to 38.9).
Outcomes assessed in the review
Studies had to report at least one HIV-related sex, drug injection or biologic (incidence of STD or HIV) outcome and provide sufficient data (either in the original report or directly from the authors) to permit calculation of an effect size. The review assessed sex risk behaviours (condom use, unprotected sexual intercourse and number of sex partners), incident STD infections and drug risk behaviours (frequency of
drug use, needle sharing, and cotton or cooker sharing). The review assessed outcomes at 3 months or more, or closest to 3 months' follow-up. Most of the included studies assessed behavioural outcomes using face-to-face interviews.
How were decisions on the relevance of primary studies made?
The authors did not state how the papers were selected for the review, or how many reviewers performed the selection.
Assessment of study quality
Pairs of trained reviewers independently assessed method of allocation to treatment group, randomisation, length of follow-up, retention rate and intention-to-treat (ITT) analysis. Any differences were resolved through discussion, with the aid of a third reviewer where required.
Pairs of trained reviewers independently extracted the data onto a standardised form. Any disagreements were resolved through consensus, with the aid of a third reviewer where required. Where reported, adjusted data were used for the calculation of effect sizes; failing that, effect sizes were calculated and adjusted for baseline difference between treatment groups. Odds ratios (ORs) were calculated for each study, either directly from dichotomous data or after transformation of standardised mean differences for continuous data. The ORs were then transformed to log ORs. For studies reporting more than one sex risk behaviour measure, unprotected sex was selected where possible; failing that, condom use followed by number of sexual partners were selected.
Methods of synthesis
How were the studies combined?
Pooled log ORs with 95% confidence intervals (CIs) were calculated for the outcomes of interest using fixed-effect and random-effects models. The results for fixed-effect models were reported; the authors stated these were similar to those obtained using random-effects models. The possibility of publication bias was explored using a funnel plot.
How were differences between studies investigated?
Statistical heterogeneity was assessed using the Q statistic. Sensitivity analysis was performed by excluding each study in turn. Stratified analysis was used to examine the effects of study quality criteria, study characteristics, intervention characteristics, participant characteristics and intervention content (including various culturally-associated factors).
Results of the review
Twenty studies (n=6,173) were included: 15 randomised controlled trials, 2 studies that used matching and 3 studies that assigned treatment based on convenience.
Twelve studies retained at least 70% of patients. All but one studies used ITT analysis.
Sex risk behaviours (19 studies).
The interventions were associated with significant reductions in sex risk behaviours compared with control treatments (OR 0.75, 95% CI: 0.66, 0.85). They were also associated with significant
reductions in no or inconsistent use of condoms (OR 0.64, 95% CI: 0.54, 0.75), unprotected sex (OR 0.75, 95% CI: 0.63, 0.89) and number of sexual partners (OR 0.75, 95% CI: 0.66, 0.86). Significant heterogeneity was found for all of these analyses.
Incident STD infections (3 studies).
The interventions were associated with significant reductions in incident STDs compared with control treatments (OR 0.69, 95% CI: 0.54, 0.88). No evidence of significant statistical heterogeneity was found.
Drug risk behaviours (6 studies).
The interventions were associated with significant reductions in injection drug use (OR 0.83, 95% CI: 0.72, 0.96) and sharing cotton or cooker (OR 0.73, 95% CI: 0.63, 0.85). No evidence of statistical heterogeneity was found. There was no difference between treatment and control for sharing or needing needles.
Intervention efficacy was not associated with any quality items. The review also identified factors associated with increased efficacy.
The funnel plot was reported as showing no evidence of publication bias (the funnel plot was not presented).
The interventions reduced unprotected sex, number of sexual partners and new STDs, and increased condom use.
The review addressed a clear question that was defined in terms of the participants, intervention, outcomes and study design. The strategy undertaken to identify trials was extensive and included
attempts to minimise publication bias. The inclusion of only reports in two languages seemed appropriate given the focus of the review. Methods were used to minimise reviewer error and bias in the assessment of validity and extraction of data, but it was unclear whether similar steps were taken when selecting the
studies. Validity was assessed using specified criteria and the results reported.
Statistical heterogeneity was assessed and the influence of various factors (including study quality criteria) on the results was examined . Where significant heterogeneity was found, no forest plots were presented; it is therefore not possible to determine if the direction of treatment effects was consistent among studies. Overall, this was a well-conducted review but the robustness of the authors' conclusion may be undermined by differences among the studies.
Implications of the review for practice and research
Practice: The authors stated that factors found in the review to be associated with increased intervention efficacy can be used to guide HIV prevention programmes.
Research: The authors stated that further research evaluating HIV prevention programmes in Hispanic populations, particularly men who have sex with men, heterosexual men and intravenous drug
users, is required. Researchers should report results stratified by ethnicity and gender.
Prevention Research Branch, Division of HIV/AIDS Prevention.
Herbst J H, Kay L S, Passin W F, Lyles C M, Crepaz N, Marin B V. A systematic review and meta-analysis of behavioral interventions to reduce HIV risk behaviors of Hispanics in the United States and Puerto Rico. AIDS and Behavior 2007; 11(1): 25-47
Subject indexing assigned by NLM
Female; HIV Infections /prevention & control /transmission; Hispanic Americans; Humans; Male; Puerto Rico /ethnology; Risk-Taking; Sexual Behavior; Sexually Transmitted Diseases /prevention & control /transmission; Substance-Related Disorders; United States
Database entry date
This is a critical abstract of a systematic review that meets the criteria for inclusion on DARE. Each critical abstract contains a brief summary of the review methods, results and conclusions followed by a detailed critical assessment on the reliability of the review and the conclusions drawn.