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Efficacy of a culturally adapted intervention for youth living with HIV in Uganda
Global Health Sciences Literature Digest
Published April 17, 2008
Journal Article

Lightfoot MA, Kasirye R, Comulada WS, Rotheram-Borus MJ. Efficacy of a culturally adapted intervention for youth living with HIV in Uganda. Prev Sci 2007 Dec;8(4):271-3.

Objective

To examine whether a culturally adapted version of a previously evaluated HIV prevention program reduced sexual risk behaviors among youth living with HIV (YLH) in Uganda.

Study Design

Randomized controlled trial

Setting

Kampala, Uganda

Participants

From 2003-2004, a convenience sample of 100 youth living with HIV (YLH) aged 14 to 21 years was randomly assigned to intervention (n=50) or control (n=50) conditions.

Intervention

YLH were randomly assigned to: (1) a culturally adapted, 18-session behavioral intervention based on cognitive behavior therapy or (2) a treatment-as-usual control condition. The intervention was adapted in partnership with staff from a Kampala-based, youth-serving, non-governmental organization (NGO): Uganda Youth Development Link. The intervention was delivered individually by nurses in the homes of YLH and occasionally at the NGO clinic location. The intervention entailed six sessions on each physical health and nutrition, mental health, and reducing HIV transmission. Youth were assessed at baseline and 3 months later, and 90% completed every session of the intervention.

Primary Outcomes

Sociodemographic characteristics, such as age, gender, and education, were assessed. YLH reported whether they had sexual intercourse, the number of sexual partners, the number of vaginal and anal sex acts, whether they always used condoms, and whether they were highly protected (abstinent or always used condoms) for the previous 3 months.

Results

The mean age of YLH was 18.7 years, and most were girls/women (72%). Ninety-six percent of youth had some formal education, but only 34% had attended secondary school. Most youth (65%) had had sexual intercourse in their lifetime. Thirty-four percent of YLH in the intervention and 46% in the control condition were recently sexually active, and this remained similar across conditions at follow-up (35% and 44%, respectively). Compared with the control condition, YLH in the intervention demonstrated a significant decrease in the log number of sexual partners (mean number of partners; baseline=3.1, follow-up=0.7, p <0.01). Significant differences over time were not seen between the intervention and control condition for the total number of sex acts. The rate of consistent condom use was low at baseline and similar in the intervention and control conditions (always using condom; baseline intervention=10%, baseline control=15%), but rose to 93% at follow-up in the intervention condition (p <0.05) and lowered to 12% in the control arm. More than half of YLH in the intervention and control conditions (74% and 65%, respectively) reported being highly protected, and among these youth, the rate rose to 98% at follow-up in the intervention condition (p <0.05) and lowered to 62% in the control arm.

Conclusions

Significantly more YLH in the intervention used condoms consistently and decreased their number of sexual partners in comparison to youth in the control condition.

Quality Rating

Poor. The authors do not discuss the method of randomization. Additionally, given the nature of the intervention, neither study participants nor researchers were blinded to treatment arm allocation. This study also was limited by a small sample size. Finally, it is unclear what the "treatment-as-usual" control condition entailed and whether it was an appropriate control to match the intervention in all non-substantive areas.

In Context

HIV risk reduction programs have been provided successfully for youth living with HIV in the United States.(1,2) Although these interventions have proven useful in the developed world, it was not known whether they would be effective in developing countries. The authors suggest that given the high HIV prevalence and the low provision of ART in many countries in sub-Saharan Africa, including Uganda, behavioral programs are much needed, and efforts to create and adapt behavioral interventions for YLH must be developed and supported.

Programmatic Implications

In this small study, modification of a previous evaluated and successful prevention intervention for HIV-infected persons was effective at reducing the number of sexual partners and at increasing the consistent use of condoms. This study utilized a cognitive behavioral intervention. This type of intervention permits modifications for various cultures and demographic and risk groups. Though the authors conclude that Western interventions can be culturally adapted to retain efficacy in reducing the sexual risk behavior of YLH, this may not hold true for Western interventions that utilized other methodologies. As with all interventions, it is important to consider the feasibility of applying the intervention outside of limited studies. The use of nurses to deliver the intervention individually in the participants' homes is not likely to be feasible on a large scale in resource poor settings. However, the success of this study in effecting some reduction in risk behavior among HIV-infected youth merits replication in a larger and more diverse sample.

References

  1. Rotheram-Borus, MJ, Lee MB, Murphy DA, Futterman D, Duan N, Birnbaum JM et al. Efficacy of a preventive intervention for youths living with HIV. Am J Public Health 2001;91(3):400-5.
  2. Rotheram-Borus MJ, Swendeman D, Comulada WS, Weiss RE, Lee M, Lightfoot M. Prevention for substance-using HIV-positive young people: Telephone and in-person delivery. JAIDS 2004;37(suppl 2):S68-77.