AHP has participated in many studies in the past. Among the most significant of these are the Promoting Safer Sex Practices Study, the Changing Sexual Behavior Study, and the HIV Oral Transmission (HOT) Study, all three of which were collaborations among researchers from AHP, the UCSF Center for AIDS Prevention Studies (CAPS), and the San Francisco Department of Public Health.
Adapting Personalized Cognitive Counseling (PCC) to drinking in gay and bisexual men
Investigators: James W. Dilley, MD, Martha Shumway
Research Assistants: Emily Martin, Jaspreet Uppal, Lindsey Williams
PCC is an intervention originally developed to reduce high-risk sexual behavior in men who have sex with men by investigating how they rationalize engaging in risky behavior in the heat of the moment. By evaluating these rationalizations after the fact, men can discuss better ways to protect themselves in the future. We believe PCC may be effective in reducing binge drinking, since similar justifications have been shown to be predictive of both high-risk sexual behavior and binge drinking behavior. Additionally, PCC is similar to various cognitive behavioral therapy interventions proven to be effective in drug and alcohol treatment.
No study has been done to date to address binge drinking among gay and bisexual men in the context of reducing high-risk sexual behavior. We are currently conducting interviews to get a better understanding of gay and bisexual men’s thoughts and feelings about drinking. In determining effective ways to reduce binge drinking episodes, we hope to reduce the incidence of high-risk sexual behavior and HIV transmission withing the population.
Mindfulness-Based Eating Awareness
Training for Lesbians and Queer Women
Investigators: Danielle Schlosser, PhD, James W. Dilley, MD, and Martha Shumway, PhD
Eating can become a habitual pattern, dissociated from internal cues of satiety. Eating in response to external cues, such as television ads or other media, and internal cues such as boredom and stress, can trigger weight gain. Mindless eating is common but has rarely been the focus of intervention.
Mindfulness-Based Eating Awareness Training (MB-EAT) is a group intervention developed by psychologist Jean Kristeller that addresses mindless eating, stress-related eating, disordered eating patterns, and obesity through the application of mindfulness meditation. MB-EAT is informed by Jon Kabat-Zinn’s Mindfulness-Based Stress Reduction (MBSR) work, and basic principles of food intake regulation. It employs mindfulness meditation, experiential eating exercises, didactic instruction, and self-reflection to cultivate mindful awareness and a more balanced and positive relationship to eating and weight. Multiple NIH-supported clinical trials have demonstrated the efficacy of MB-EAT in the general population. The intervention seems appropriate for lesbians and queer women, but has not been tested in this group.
This pilot study is evaluating the feasibility, acceptability, and impact of MB-EAT for lesbians and queer women. Twelve women will take part in thirteen 2-hour group meetings and monitor their activity levels using digital activity trackers. A variety of health, activity, and satisfaction outcomes will be measured.
ACT on HIV Stigma
Investigator: Matthew D. Skinta, PhD
If you were enrolled in this group and wish to find out more about how the data from this study will be used, please call the research hotline at 415-502-3500 or e-mail Matthew Skinta.
(Funded by the New Investigator award of the Center for AIDS Prevention Studies Innovative Grants program, 2010)
Late Testers Study
Investigators: Sandra Schwarcz, MD, MPH and
James W. Dilley, MD
The results of this study have been published: Schwarcz S, Richards TA, Frank H, Wenzel C, Hsu LC, Chin CS, Murphy J, Dilley J. Identifying barriers to HIV testing: Personal and contextual factors associated with late HIV testing. AIDS Care. 2011; 23(7): 892-900.
Schwarcz S, Hsu L, Dilley JW, Loeb L, Nelson K, Boyd S. Late diagnosis of HIV infection: Trends, prevalence, and characteristics of persons whose HIV diagnosis occurred within 12 months of developing AIDS. Journal of Acquired Immune Deficiency Syndromes. 2006; 43(4): 491–494.
Investigator: Gary Humfleet, PhD
The results of this study have been published:
Humfleet, GL, Delucchi, K, Kelley, K, Hall, SM, Dilley, J, & Harrison, G (2009). Characteristics of HIV-positive cigarette smokers: A sample of smokers facing multiple challenges. AIDS Education and Prevention, 2009; 21(S3): 54–64.
(Funded by the NIDA-funded Treatment Research Unit at UCSF, 2004)
The Red Studies:
Developing Personalized Cognitive Counseling
We observed that risk reduction counseling was not working for these men, specifically those who tested three or more times. At the same time, Australian researcher Ron Gold had undertaken a series of studies that looked at the thoughts and feelings gay men experienced that enabled them to engage in sexual activities that they knew put them at risk for HIV. In response to these two insights, AHP developed an intervention and a series of studies—The Red Studies—to test the intervention. At the core of the intervention is Gold’s idea that by looking at the rationalizations gay men use to justify behaviors in which they, in fact, do not want to engage, these men can better carry out their own desires to protect themselves. We have since tested this intervention under numerous conditions.
In this section, we have listed the two original Red Studies, the Red-Plus study, which tested the intervention among people with HIV, and the translational research grant to develop a training from the intervention protocol as part of the CDC’s Replicating Effective Behavioral Interventions program and which led to the designation of Personalized Cognitive Counseling as a CDC-approved DEBI (one of the approaches listed in its selective Diffusion of Effective Behavioral Interventions program).
If you were a participant in any of the Red studies, thank you for the time you spent with us. If you would like a copy of the results of the study or if you want to contact the research staff, please call us at 415-502-8500 or e-mail us at firstname.lastname@example.org.
Red 1 Study: Promoting Safer Sex Practices Among High-Risk Repeat HIV Testers in San Francisco: 1997–2000
Investigators: James W. Dilley, MD; William Woods, PhD; and Willi McFarland, MD, PhD
The Promoting Safer Sex Practices Study was the first trial. This four-year study asked HIV-negative participants to explore the thoughts and feelings they held during a recent instance of unprotected anal sex with an HIV-positive partner or a partner of unknown HIV status. Licensed mental health providers then helped participants explore their thoughts and feelings in relation to their sexual behavior. The study followed 248 participants for one year after the initial counseling session. The sample was randomly divided into four groups of participants based on the intervention they received:
- Cognitive-behavioral intervention added to standard HIV test counseling
- Cognitive-behavioral intervention and the assignment to keep a sexual diary added to standard HIV test counseling
- Standard HIV test counseling only
- Standard HIV test counseling and the assignment to keep a sexual diary
We conducted follow-up evaluations six months and 12 months after the test counseling session. We asked participants in the two groups that kept the sexual diary to write about their sexual behavior in the 90 days following the initial test counseling session.
Three of the tested prevention strategies significantly decreased the frequency of unprotected anal sex, when added to standard client-centered HIV counseling and testing: the 90-day sexual diary, the cognitive-behavioral counseling session focusing on thoughts and feelings before unprotected anal intercourse, or the combination of both. Further, the prevention effects of these three interventions persisted through to the 12-month follow-up. In contrast, standard counseling alone appeared to have, at best, only a small, short-term prevention effect.
This cognitive-behavioral counseling strategy has strong, practical appeal. First, it can be implemented in one session. Second, the magnitude of the prevention effect—roughly decreasing unprotected anal sex with partners of unknown or discordant HIV status by three episodes in a 90-day period—may produce substantial decreases in personal risk for HIV acquisition.
The results of this study have been published in several journal articles. The most comprehensive article is:
Dilley JW, Woods WJ, Sabatino J, Lihatsh T, Adler B, Casey S, Rinaldi J, Brand R, McFarland W. Changing sexual behavior among gay male repeat testers for HIV: A randomized, controlled trial of a single-session intervention. Journal of Acquired Immune Deficiency Syndromes. 2002; 30(2): 177–86.
Investigators: James W. Dilley, MD; William Woods, PhD; Joseph Mullan, PhD; and Nicolas Sheon, PhD
The Changing Sexual Behavior Study was based on the findings of the Promoting Safer Sex Practices Study. This randomized controlled trial involved more than 300 volunteers who sought HIV testing between October 2002 and September 2004. Each participant came to the clinic three times, for a baseline interview, a six-month follow-up interview, and a 12-month exit interview. The interviews were conducted by a computer (using audio computer-assisted self-interview technology) rather than by a live interviewer, and each man received an HIV test at baseline and at exit.
The type of counseling the participant received was assigned at random. Half of the participants received the experimental intervention. Half received standard HIV test counseling. Preliminary analysis indicates that participants in the experimental group decreased their risk by half from the baseline interview to the six-month follow-up, while the control group’s behavior did not change. Further, this study demonstrated that the intervention could be delivered by trained paraprofessionals as well as licensed professionals without compromising the efficacy of the intervention. This is particularly important because a significant amount of HIV antibody counseling and testing is delivered by paraprofessionals.
This new intervention is intended to be quick (taking under one hour to deliver), highly acceptable to clients, and effective at helping men who have sex with men and who repeatedly test to decrease their risks of acquiring HIV.
The results of this study have been published:
Dilley JW, Woods WJ, Loeb L, Nelson K, Sheon N, Mullan J, Adler B, Chen S, McFarland W. Brief cognitive counseling with HIV testing to reduce sexual risk among men who have sex with men: Results from a randomized controlled trial using paraprofessional counselors. Journal of Acquired Immune Deficiency Syndromes. 2007: 44(5): 569-577.
A case study, with client identifying information removed, more fully describes the PCC session:
McPhee B, Skinta MD, Paul J, Dilley JW. Single-session personalized cognitive counseling to change HIV risk behavior among HIV-negative men who have sex with men: A two-part case study. Cognitive and Behavioral Practice. 2012; 19(2): 328-337.
Investigators: James W. Dilley, MD; Sandy Schwarcz, MD, MPH; and Jay Paul, PhD
As providers of health care services for HIV-positive men in San Francisco, AHP clinicians often engage with clients who have unprotected sex with partners of a different HIV status or partners whose serostatus is unknown. These men may express a desire to decrease their frequency of unprotected sex. However, there are currently no proven behavioral interventions for us to offer these men.
To address this, AHP developed a brief cognitive-behavioral intervention. The “red” intervention focuses on the thoughts, attitudes, and beliefs that HIV-positive men who have sex with men employ when they decide to have unprotected sex with a partner of a different or unknown HIV status. (“Red” is not an abbreviation; it is simply the common name used to distinguish this study from others.)
We recently presented a comparison of the common self-justifications for having unprotected anal intercourse reported by HIV-positive men that participated in the Red Plus study to the self-justifications HIV-negative men gave in our Red 2 study at the 2009 National HIV Prevention Conference in Atlanta. You can download a copy of that poster here.
The results of this study have been published:
Schwarcz SK, Chen Y-H, Murphy JL, Paul JP, Skinta MD, Scheer S, et al. A randomized control trial of personalized cognitive counseling to reduce sexual risk among HIV-infected men who have sex with men. AIDS Care. 2012; 25(1): 1-10.
For a comparison of self-justifications for HIV-positive and HIV-negative men and used in Red 2 and Red Plus, respectively, see:
Skinta MD, Murphy JL, Paul JP, Schwarcz SK, Dilley JW. Thoughts, attitudes, and feelings of HIV-positive MSM associated with high transmission-risk sex. Health Education and Behavior. 2012; 39(3): 315-323.
(Supported by NIH Grant 5R01MH073425-03; 2004)
Investigators: Allen and Loeb Associates and James W. Dilley, MD
This translational research grant from the CDC supported the creation of a full range of training materials designed to take AHP’s successful counseling intervention, known as Personalized Cognitive Counseling, and develop materials that will give
prevention programs throughout the United States “everything they need” to learn and implement the counseling intervention.
(Supported by the Centers for Disease Control and Prevention, 2007)
The HIV Oral Transmission Study (HOT): 1998–2003
Investigator: Kimberly Page-Shafer, PhD
A key strength of this study is that counselors asked participants about their oral sex activities before disclosing HIV test results. It has been found, consistently, that studies that ask individuals how they got infected after disclosing an HIV-positive result, report a higher proportion of orally acquired infections than can be reliably established.
Using a type of antibody testing that could detect infections that occurred within six months of the test, the study found no recently acquired HIV infections. The estimated probability of orally acquired HIV was 0 (95 percent CI 0, 1.5 percent). (“CI” stands for “confidence interval,” a statistical tool that helps researchers measure the precision of their findings.)
The absence of HIV infections detected in this sample confirms previous research that orally acquired HIV infection is rare. HIV prevalence and incidence among men who have sex with men and who tested at the same anonymous testing sites in San Francisco during a similar time period (December 1999 to February 2001) were appreciably higher: Overall prevalence of HIV infection was 3.3 percent (95 percent CI 2.9–3.9).
These data confirm that the risk of HIV infection attributable to fellatio among men who have sex with men is extremely low.
It is important that health professionals have valid information to impart to their sexually active clients. If individuals believe that the risk of HIV transmission via fellatio is comparable with activities such as unprotected receptive anal sex, they may not feel that sexual behavior choices make a difference. The fact that acquiring HIV through fellatio is significantly less likely than acquiring it from anal sex does not only offer these men a lower risk choice. The simple fact that there are risk reduction choices—oral sex or protected anal sex, among others—offers hope and empowers risk reduction activities more than if there were only one option.
The results of this study have been published:
Page-Shafer K, Shiboski CH, Osmond DH, Dilley J, McFarland W, Shiboski SC, Klausner JD, Balls J, Greenspan D, Greenspan JS. Risk of HIV infection attributable to oral sex among men who have sex with men and in the population of men who have sex with men. AIDS. 2002; 16(17): 2350–2352.