A new evidence review is arming local health agencies with the most effective ways of stopping the spread of HIV - role-playing, better personal communication and proper condom use, for example.
But the government-backed study excluded from consideration needle-exchange and substance-abuse programs because they are not eligible for federal funding despite evidence of their effectiveness.
Researchers at the Centers for Disease Control and Prevention examined 100 HIV prevention programs tested between 2000 and 2004 and found 18 that seem to work and could be adopted by local agencies with federal money.
The approaches target several high-risk groups, including minorities and HIV-positive people, and work in various ways. But they do tend to share one thing in common —they're intended to not only teach people about AIDS and HIV but to also help them learn what to do in specific situations, such as when risky sex is on the horizon.
"It's enhanced education, where you actually build their skills and don't just give them information," said review lead author Cynthia Lyles, a prevention researcher at the CDC.
Role-playing, for example, could help people learn how to avoid getting infected during sexual encounters.
As of late 2004, an estimated 415,193 Americans were HIV-positive or had gone on to develop AIDS. Forty-three percent were black; 58 percent of the men were infected through homosexual sex, while heterosexual sex infected 64 percent of the women.
In order to give local agencies a better handle on the latest research, the CDC launched a review of studies that examined prevention strategies. The findings appear in the January issue of the American Journal of Public Health.
"We were basically trying to target the prevention-providers that are looking to the CDC for funding," Lyles said. "They can decide if one of these is best suited for them."
Only programs that could be funded by the CDC's HIV-prevention department were considered, so they don't include needle-exchange programs — which provide clean needles to IV-drug addicts — or substance-abuse programs.
Nor do the programs examined include those aimed specifically at kids in school (because they're funded separately) or those that rely solely on HIV testing or counseling of sexual partners of HIV patients. (The CDC already requires agencies to do testing and counseling if they get grants).
Of the 100 studies examined, only 18 were "best evidence studies." According to the review, these programs "were determined to have sufficient quality and strength of evidence to infer a significant effect on reducing HIV risk."
Most of the prevention programs taught participants how to do something — such as use of a male condom (14 programs) or a female condom (four programs). Others provided instruction on relaxation, stress reduction and better communication with others.
Nine programs taught people how to avoid falling into the trap of "risky sex," the review found, while "communication skills, such as negotiation or assertiveness for safer sex, were demonstrated, practiced or role-played in 13 interventions."
"It's not that new strategies have been discovered," Lyles said. Instead, existing strategies "have been incorporated into new interventions based on solid behavioral science theory, and the research has been of a higher quality."
Thirteen of the studies focused entirely or mostly on minorities and eight targeted women exclusively. "We still need to work on research focusing on testing and identifying interventions that work for African-Americans, minority populations (of men who have sex with men) and substance-using populations," Lyles said. "Those are some of the key gaps."
For the time being, the CDC is packaging six of the intervention programs together and will soon be teaching local agencies about them, Lyles said.
A. David Paltiel, a professor at the Yale School of Public Health, said the review is weakened by the long list of intervention strategies that are not included, such as needle exchange.
The review authors acknowledge that previous research has shown needle-exchange programs to be effective, but the CDC doesn't fund them.
"This isn't really providing guidance on what works in some absolute sense, or how societal resources might be allocated," Paltiel said. Also, he added, the review doesn't examine the cost of the programs. "If I were a decision maker faced with a constraint on resources, this really doesn't tell me what kind of value I'm getting. It just says these things work."
Still, "I don't think what they've got there is wrong," Paltiel said. Indeed, he added, agencies are creating "portfolios" of intervention programs instead of just using one. Nothing is perfect, but these things reinforce one another," he said. "You want to start putting together packages of these imperfect programs."