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Systematic Review of HIV Behavioral Prevention Research in Latinos
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Summary
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Background
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transparent imageHIV Infection and AIDS Among Latinos
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transparent imageGay Men and Men Who Have Sex with Men
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transparent imageInjection Drug Users
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transparent imageHeterosexuals
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transparent imageYouth/Adolescents
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Methods
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transparent imageObjectives
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transparent imageCriteria for Including Studies in This Review
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transparent imageTypes of Studies
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transparent imageTypes of Participants
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transparent imageTypes of Interventions
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transparent imageTypes of Outcome Measures
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transparent imageSearch Strategy for Identification of Studies
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transparent imageMethods of the Review
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transparent imageMethodological Quality of Included Studies
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Results
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transparent imageSearch Results and Description of Studies
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transparent imageDescription of Studies Including Latino Participants
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transparent imageInjection Drug Users
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transparent imageHeterosexuals
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transparent imageYouth/Adolescents
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Discussion
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transparent imageComponents of Effective Interventions
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transparent imageGaps in Research
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transparent imageOngoing Studies
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Conclusions and Recommendations
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References
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Tables
Table 1.AIDSLINE, MEDLINE, and PsycINFO Search Strategies
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Table 2.Criteria for Scanning Search Results From Electronic Searching (AIDSLINE, MEDLINE, PsycINFO)
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Table 3.Tracking Form for Coding
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Table 4.Codebook For Registry-Level Coding, OMH Project
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Table 5.Intervention Studies Comprised of 100% Latino Participants (Randomized Controlled Trial Design)
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Table 6.Intervention Studies Comprised of 100% Latino Participants (Non-Randomized Trial Design)
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Table 7.Intervention Studies with At Least Some Percentage of Sample Comprised of Latino Participants, with Separate Analyses (Randomized Controlled Trials)
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Table 8.Intervention Studies with At least Some Percentage of the Sample Comprised of Latino Participants, with Separate Analyses (Non-Randomized Controlled Trial Design)
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Table 9.Citations of Studies with At Least 50% of Sample Comprised of Latino Participants, But No Separate Analysis
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Table 10.Sources Searched and Number of Possibly Relevant Studies Identified
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Table 11.Race/Ethnicity of Study Population of Possibly Relevant Studies
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Related Resources
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Summary
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We conducted a systematic review of the HIV prevention intervention literature for Latinos in the United States. We focused on the four major risk groups (men who have sex with men (MSM), injection drug users (IDU), heterosexuals, and youth/adolescents). We utilized the techniques of evidence-based medicine in order to help us identify the best evidence for effective HIV prevention interventions. We developed a standard set of inclusion and exclusion criteria based on the methodological quality of the study, and our ability to extract information specific to Latino participants. Following a rigorous search of the literature and an application of our inclusion criteria, we identified a total of 15 methodologically sound controlled intervention trials.

We found several consistencies across interventions that produced positive results. The most successful interventions were typically grounded in theory, provided the participants with skills training, were culturally sensitive to the needs of Latinos and were conducted over multiple sessions and longer periods of time. Examples of positive outcomes included increasing condom use, decreasing the number of sexual partners, decreasing the sharing of needles, delaying the onset of intercourse, increasing self-efficacy for protective behaviors, and improving communication with partners regarding safer sexual practices. All of these outcomes are associated with decreasing HIV infection. In general, the studies were of high methodological quality. Significant attrition was a common limitation of the results, but not surprising, as the risk groups of interest tended to be extremely difficult to retain in research studies over long periods of time. Successful interventions were theory-based, culturally sensitive, gender sensitive, and of longer duration (both in number of sessions and actual length of time) and included skills training. The most significant research gap we identified was regarding interventions targeted toward Latino men who have sex with men (MSM). We did not identify any published intervention for this group. In sum, we found some evidence that interventions aimed toward decreasing HIV risk infections in Latinos can be successful, though the actual number of studies is relatively small. We also found that some components tested in the formal research studies might be easily employed in community settings (eg, the use of peer educators and videotape presentations). Future interventions should incorporate those components that have been demonstrated to be effective in order to better prevent further harm to the Latino community from the HIV epidemic.

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Background
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Evidence-based medicine is "the conscientious, explicit, and judicious use of current best evidence in making decisions about the care of individual patients." This model of medical practice has been extended to public health practice, such as the Centers for Disease Control and Prevention's (CDC) recent community preventive services guidelines project. Central to this practice is the identification of the best evidence to answer specific clinical questions, and the critical appraisal of that evidence. One such approach is to conduct a systematic review. Systematic reviews cull from the methods of meta-analysis and combine a comprehensive and detailed search for relevant studies, a critical appraisal of the quality of included studies, a qualitative synthesis of study findings and, if appropriate, a meta-analysis of the data to determine the combined effect size of similar interventions. Using these methods, we have prepared the present report to identify the best evidence for effective HIV prevention interventions that are of use in Latino populations throughout the United States and Puerto Rico.

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HIV Infection and AIDS Among Latinos
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Although we are entering the third decade of the HIV pandemic, there is as yet no cure or vaccine. At this time, our principal means for deterring the further spread of HIV remains behavioral prevention interventions. Thus, developing and implementing interventions that focus on behavioral prevention are of utmost importance.

Although the epidemic has reached into most segments of society, its disparity continues to be striking. Recent statistics have demonstrated that there is a significant over-representation of people of color among individuals with new HIV infections. With regard to Latinos specifically, this disparity has been evident since the first reports of what we now call HIV/AIDS.(1)

This overrepresentation of Latinos is consistent across the major behavioral risk groups for HIV infection (men who have sex with men (MSM), injection drug users (IDU), heterosexuals, and youth/adolescents). For example, a recent CDC study of MSM in New York found that 14% of men testing positive for HIV were Latino.(2) In a national study of young MSM, this figure was found to be slightly higher at 15%.(3) Through June 2000, Latinos accounted for 18% of total AIDS cases and 20% of total AIDS cases among women. From July 1999-June 2000, Latino adults and adolescents comprised 19% of reported AIDS cases. However, as of the 2000 Census, Latinos represent only 12.5% of the U.S. population.(4)

The AIDS case rate for Latino men is almost 3 times that for white non-Hispanic men, while for Latina women the rate is 6 times higher.(5) In addition, Latinos are a diverse group, comprised of multi-generational Americans and immigrants from countries or commonwealths such as Mexico, Puerto Rico, Cuba, and the Dominican Republic. The cultural differences among Latinos make prevention efforts more complicated, as efforts may need to be targeted for different ethnicities. Furthermore, the Latino population is younger, of lower socioeconomic status, and less educated than the U.S. population as a whole,(6) which may place it at increased risk for HIV. A potential language barrier also exists, which may also hinder prevention efforts. These factors underscore the necessity for examining evidence for prevention interventions aimed at Latinos, focusing on the primary risk groups.

However, differences in risk are also present within the Latino population itself. According to the National Minority AIDS Council,(1) Latinos born in the U.S. comprised the highest proportion of AIDS cases in 1998 (29%), representing only a slightly higher percentage than those born in Puerto Rico (27%). These two largest groups are followed by Latinos born in Mexico (10%), Central/South America (7%), and Cuba (2%). Additionally, 22% of the new AIDS cases in 1998 were among Latinos of unknown birthplace. With regard to risk groups, MSM and gay men make up the largest risk group among Latinos born in Mexico (48%), the U.S. (37%), Central or South America (36%), and Cuba (34%). In Puerto Rico, injection drug use is the largest risk category (46%). Injection drug use is the second highest risk group among U.S.-born Latinos (28%). Finally, heterosexuals comprise 25% of the cases among those born in Puerto Rico, 17% of those born in Central/South America, 12% of those born in the U.S., 11% of those born in Mexico and 8% of those born in Cuba.(1) In more general figures, Mexican Americans comprise the largest subgroup of Latinos in the U.S. (57%). Puerto Ricans are the second largest subgroup representing 20% of Latinos (including those residing in Puerto Rico).

In examining AIDS figures for Mexico (the country for which the most extensive epidemiological information is available), the largest risk group is MSM, most of whom live in large cities.(7) However, there has been a recent increase in AIDS among heterosexuals, particularly women. Finally, although the practice of injection drug use is fairly uncommon in most of Mexico, in the areas where it is observed more frequently (eg, the northern border states) seroprevalence rates are rising.

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Gay Men and Men Who Have Sex with Men
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MSM represent the largest risk category for HIV infection in the United States.(8) MSM comprise 40% of the cases of AIDS among Latinos since the beginning of the epidemic.

Engaging in anal intercourse increases the risk of HIV transmission when condoms are not used. During the late 1980s and early 1990s, dramatic increases in condom use for anal intercourse among MSM were observed.(9) For example, statistics from the San Francisco Men's Health Study demonstrated that between 1984 and 1988 the rates of unprotected anal intercourse declined from 69% to 10% (for insertive partner) and from 65% to 9% (for receptive partner). However, those promising changes have not continued. Recent statistics have documented a significant increase in unprotected anal intercourse among MSM, and an increase in HIV infections has followed. A recent study among MSM in New York City found that 14% of young Latino MSM surveyed and tested were found to be HIV-infected-compared to 2% of White men.(2) However, some have suggested that these numbers are a result of more longstanding deficits in adequate prevention measures for people of color and that current efforts will not show significant impact on HIV infection rates for some time to come. A study conducted by CDC found similar results in 6 U.S. cities (Baltimore, Dallas, Los Angeles, Miami, New York City, and Seattle). Valleroy and colleagues reported that among their sample of young MSM, there was an HIV seroprevalence of 15% among Latinos (compared to 7% among Whites).(3)

Overall, MSM represent the largest risk group for Latino men (37% of new AIDS cases, 44% of all cases reported).(6) As discussed above, specific Latino ethnicities may be at differential risk, and statistics from the CDC indicate that MSM represented 34% of Cuban-Americans, 48% of Mexican-Americans, and 18% of Puerto Rican AIDS cases in 1998.(10)

During most of the epidemic, Latinos have been notably lacking as participants in most of the studies investigating HIV risk behavior among MSM. Furthermore, lessons learned from the primarily White gay community may not apply to the Latino gay community.(11) In addition, specifically Latino gay communities are also fewer in number. However, when HIV risk behavior has been examined specifically for Latino gay men, they have exhibited relatively increased risk.(12) Other issues that serve to complicate prevention efforts geared toward Latino MSM include racial discrimination, poverty, language, and homophobia. In particular, Diaz has written extensively about the influence of machismo and homophobia on the sexuality and sexual behavior of Latino gay men.(11,13) Given the statistics specifically regarding HIV infections combined with other, more longstanding, societal problems, prevention efforts specifically targeting Latino MSM are all the more imperative.

One important issue to address is that of terminology. While many have adopted the term "MSM" to encompass both those men who identify as being homosexual, as well as men who may have sex with men, but not identify as homosexual, there are some in the Latino community who argue against using this term. Diaz has written extensively on the disadvantages of using "MSM" rather than "gay" when describing the Latino gay community and prevention efforts.(13) Diaz argues that the societal context of being homosexual in the Latino community is an integral aspect of Latino gay men's identities, and that ignoring this context is "deeply insensitive, insulting".(13) He goes on to argue that prevention efforts should be differentially tailored for true Latino "MSM" and gay-identified Latinos. Diaz's argument addresses the need for prevention for the otherwise heterosexually-identified men who may engage in anal intercourse with other men who would not identify as "gay" and, therefore, would not be reached by prevention messages targeted towards the Latino gay community. We identified no published interventions targeted towards either Latino gay men or Latino MSM. The ongoing research that we identified is targeted towards gay-identified Latinos.

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Injection Drug Users
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Drug use presents particular risks for HIV transmission. Indeed, injecting is a far more efficient mode of transmitting HIV than sexual intercourse.(14) The practice of sharing drug injection equipment and an increased likelihood of engaging in unprotected vaginal, oral, or anal sex with multiple sexual partners are both possible outcomes of injection drug use. Some studies have reported that during the initial period of the epidemic, needles and syringes were used up to an average of nine times before they were discarded.(15) Drug use, especially crack cocaine use, has also been associated with high rates of reported sexual activity.(16) In addition, drug use is often practiced among networks of people, which can facilitate the sharing of needles. Due to factors such as these, drug and alcohol use in general and injection drug use in particular have been major risk factors for HIV infection in the United States.(17) Currently, injection drug use accounts for approximately 25% of annual new infections.(8) This percentage has been previously reported as being between 33% and 50%.(17)

Among Latinos, injection drug use is a major risk factor for HIV transmission. Through June 2000, 35% of cumulative AIDS cases and 19% of cumulative HIV infections among Latino men were in IDU. For the same time period, for Latinas, 40% of the cumulative AIDS cases and 20% of the cumulative HIV infections were among IDU.(8) The cumulative cases of HIV infection for Latino men who were classified as IDU are higher than for White men (9%) and comparable to rates for African Americans (18%).(8) For Latinas, cumulative cases of HIV infection among injection drug users are somewhat lower than Whites (27%) and comparable to African Americans (17%). However, national HIV reporting does not include data from several large states with significant HIV and injection drug use epidemics in Latinos, such as New York, and therefore, probably underestimates the number of infections. Among female IDU the cumulative proportion of AIDS cases by exposure category is similar: (White, 42%; African American, 42%; and Latina 40%).(8)

However, many researchers believe that the true percentage of HIV infections due to injection drug use is difficult to estimate given the illegal nature of drug use and the hesitancy of injection drug users to admit to this behavior. Thus, evidence regarding the relative efficacy of behavioral interventions targeting drug use among Latinos is important to evaluate in order to continue to positively impact rates of HIV infection in this group and to ensure that all injection drug users have access to prevention programs.

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Heterosexuals
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Although heterosexual contact is the primary mode of HIV transmission around the world, in the U.S. it accounts for only approximately 33% of new infections at present. Nonetheless, it is the fasting growing route of infection.(8) Among Latinos, a large gender difference is evident. For Latino men, heterosexual contact accounts for 7% of the cumulative cases of HIV infection and 6% of the cumulative cases of AIDS cases. However, for Latinas, heterosexual contact was identified as the primary source of infection in 44% of the cumulative cases of HIV infection and 47% of cumulative AIDS cases.(8) The rates for Latino men are higher compared to Whites and lower compared to African Americans while the rates for Latinas are higher than both White women and African-American women.

In addition to the rates of HIV infection and AIDS cases described above, several survey studies have found increased HIV risk behavior in heterosexually active Latinos, for example in the AIDS in Multiethnic Neighborhoods Study(18) and the National AIDS Behavioral Surveys.(19) Additionally, Latino men have reported high rates of heterosexual anal intercourse,(20,21) and Latino men are more likely than Latinas to report having multiple sexual partners.(18) Thus, as heterosexual contact is the source of a significant proportion of the new cases of HIV infection and is the largest mode of transmission of HIV infection for Latinas, evaluating prevention programs that address this population is a priority.

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Youth/Adolescents
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The challenge of how to improve prevention programs targeted toward sexually active youth/adolescents is a very important one, as this group exhibits high levels of sexual risk behavior. A large proportion of the young adults currently infected with HIV or diagnosed with AIDS were most likely infected during their adolescence.

Psychological factors unique to this age group place adolescents at increased risk due to their lack of perceived vulnerability. Changing risk behavior inherently involves identifying oneself as being at risk, and most surveys of adolescents have found that this age group does not perceive themselves to be at risk for most negative outcomes (eg, car accidents, HIV/STD infection, pregnancy, etc).(22,23) Adolescents are also at risk through several pathways; thus, interventions need to be tailored to the specific population of youth that is being targeted (eg, MSM, heterosexually active youth, etc.).

In addition, adolescents represent a significant proportion of Latino HIV infections. Twenty-one percent of HIV infections among Latinas is among 13- to 24-year-old women, and 14% of infections among Latino men is in this age group. Across all racial and ethnic groups the majority of both recent and cumulative HIV infections in 13-19-year-old males was among MSM (50%). For 13- to 19-year-old females, however, heterosexual contact accounted for 50% of the new and cumulative cases of HIV infection.(8) The prevalence of AIDS in 13- to 19-year-old Latino adolescents is five times more than White adolescents of the same age. For all of the above factors, an evaluation of effective behavioral interventions aimed at Latino adolescents is also urgently needed to identify best practices to prevent further increases in HIV infection.

In sum, Latinos are at increased risk for HIV via all the major modes of transmission. Thus, it is imperative to systematically review our current knowledge of prevention interventions for the major behavioral risk groups, in order that future research efforts can be implemented in the most effective manner, thereby preventing additional negative consequences from HIV in the Latino community.

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Methods
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Objectives
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The objectives of this review were fivefold:

  1. To locate and describe available randomized controlled trials, controlled clinical trials, and other types of controlled intervention studies evaluating the effects of behavioral prevention interventions for HIV in Latinos in the U.S.

  2. To undertake a critical review of these studies

  3. To synthesize the broad question of prevention effectiveness for reducing HIV risk behavior in four identified sub-populations of Latinos (MSM, IDU, heterosexuals, and youth/adolescents)

  4. To summarize the effectiveness of these interventions among Latinos and identify the best evidence for effective interventions for future research, policy, and public health practice priorities and directions

  5. To identify gaps in rigorous research in the field

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Criteria for Including Studies in This Review
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Types of Studies
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We included studies that evaluated the effects of behavioral, social, or policy interventions on at least one outcome measure related to HIV transmission. We included randomized controlled trials (RCTs), controlled clinical trials and studies utilizing a comparison group (including pre-test, post-test design).

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Types of Participants
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We included the following types of studies:

  1. Studies with 100% Latino participants in their samples

  2. Studies with less than 100% Latino participants in their samples with separate analyses for the Latino participants

  3. Studies with at least 80% Latino participants in their samples with no separate analyses for the Latino population

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Types of Interventions
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We included three types of interventions:

  • Behavioral interventions: These are interventions that aim to change individual behaviors only, without explicit or direct attempts to change the norms of the community or the target population as a whole.

  • Social interventions: These are interventions that aim to change not only individual behaviors but also social norms or peer norms. Strategies such as community mobilization, diffusion, building networks, and structural and resource support are usually used to bring about changes in social norms and/or peer norms.

  • Policy interventions: These are interventions that aim to change individuals' behavior, peer, or social norms or structures through administrative or legal decisions. Examples include needle exchange programs, condom availability in public settings, and mandated HIV education in all schools in a district.

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Types of Outcome Measures
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We included studies that reported any type of outcome measure related to HIV transmission (including knowledge, attitudes, intentions, self-reported risk behavior, and biological outcomes).

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Search Strategy for Identification of Studies
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We conducted systematic, comprehensive searches on electronic databases through hand searching key journals, by scanning reference lists of reports of relevant outcome evaluation studies and reviews, and by directly contacting researchers/research organizations. The aim was to identify published and unpublished reports of U.S.-based studies that evaluated HIV/AIDS behavioral prevention interventions with study populations that included ethnic minorities (African American, Latino, Asian/Pacific Islander and American Indian/Alaskan Native). (This report incorporates only studies for Latinos, reports of other ethnic minority populations have either been previously submitted or are pending.) For studies up to 1996, we searched the Behavioral Prevention Register of the Cochrane Collaborative Review Group on HIV infection and AIDS.(24) We identified more recent studies (1996 - 2000) from searches on AIDSLINE, the Cochrane Controlled Trials Register, EMBASE, MEDLINE, PsycINFO, and Sociofile. For each of these databases, we developed sensitive search strategies consisting of both controlled vocabulary terms (where available) and free text terms (see Table 1 for full search strategies).

We subsequently entered or downloaded all search results into an electronic register (using BiblioScape, CG Information, Duluth, Georgia). We scanned the titles and abstracts where available and classified them according to their relevance to the review (relevant, not relevant, unclear) and for those citations deemed to be relevant also according to the study population (minority population, other population, unclear) and the type of study (outcome evaluation, other study, unclear) (see Table 2 for definitions).

In addition, we contacted researchers whom we knew to have conducted relevant research. We identified these researchers by their having published studies that had been identified as meeting the inclusion criteria (eg, HIV prevention intervention research with minority participants). We identified additional investigators through agency Web sites as having (or having had) grants funded in the area of HIV prevention intervention research. Overall, we contacted 45 researchers; 17 (38%) responded with information regarding current research and/or manuscripts (both published and unpublished).

We obtained full reports for all relevant outcome evaluation studies deemed to be relevant. We reassessed these reports for confirmation of their relevance to the review, and we coded them using a standardized coding strategy (see Table 3 and Table 4 for full coding strategy). The aim was to describe the key characteristics of each of the relevant studies in terms of the city or cities where the study was conducted, the type of intervention, the target population, ages of the study population, the sex of the study population, the percent race/ethnic make-up of participants, the intervention setting, the intervention components, the research design, and the outcome types.

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Methods of the Review
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We reviewed studies for relevance based on types of participants, interventions, outcome measures and study design.

Two independent reviewers abstracted appropriate information using a standardized data abstraction form. Information retrieved from the studies included details of the interventions and other study characteristics. Any disagreements were resolved between the two reviewers, and when necessary, by a third party.

We stratified studies according to percentage of Latino population, study design, targeted risk group of intervention, and quality in order to better evaluate and summarize outcome information. Table 5 includes all studies with randomized controlled design with 100% Latino participants; this table also includes one study that was conducted in Puerto Rico. Table 6 includes studies conducted with 100% Latino participants that are not randomized controlled trials. Table 7 includes studies of randomized controlled design with less than 100% Latino participants but which had separate analyses for the Latino participants. Each of these studies are discussed in the text below with the highest quality studies listed first and studies of lesser quality ratings in descending order. Table 8 includes studies with any percentage of Latino participants with separate analyses that are not randomized controlled trials. These studies are not discussed in the text. For studies with at least 50% Latino participants in the sample and no separate analyses (all randomized controlled trials or controlled clinical trials), the bibliographic information is included in Table 9. These studies are not discussed in the text or in tables.

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Methodological Quality of Included Studies
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We assessed quality of the studies in several ways that took into account our inclusion criteria and methods used in previous systematic reviews. We focused on four criteria, which we deemed most appropriate for the types of studies included in this review: randomization, attrition, protection against contamination, and the training/make up of the facilitators of the intervention.(25) We assessed these criteria in the following ways:

We assessed randomization according to the standards of the Cochrane Collaboration.(25) If the method of randomization were clearly described (eg, the use of random number tables or coin flips), the study was given full credit for this category (2 points). If the study merely mentioned the word "random" but did not give an adequate description, it received partial credit for this category (1 point). If the authors did not give any description or described using such allocation methods as a day of the week or dates of birth, the study did not get credit for randomization.

If attrition were less than 20% of the subjects randomized, we gave the study full credit for this category (1 point). If more than 20% attrition occurred or if the information regarding attrition were unclear, the study did not receive credit.

If proper methods were utilized to protect against any contamination of the intervention (the possibility that participants in different groups could have significant contact with each other, thereby adversely effecting the integrity of the intervention), the study received full credit for this category (1 point). If proper methods were not taken or if the methods taken were unclear, the study did not receive full credit. If the study design did not warrant a need to protect against contamination, this criterion was not used, and the study could receive a maximum of four points.

If the study included information regarding the training or makeup of the facilitators, we credited the study for this category (1 point). If this description were not included, credit was not given. If the study did not utilize facilitators this criterion was not applicable.

We deemed studies that received 66%-100% of points possible "good" studies, studies that received 33%-65% of points possible were "fair", and studies that received less than 33% of possible points scored were rated as having significant methodological limitations. This method of assessing quality by number of limitations has been used by the Center for Disease Control and Prevention's Task Force on Community Preventive Services.(26)

A recent paper described the HIV/AIDS Prevention Program Archive (HAPPA), which details a number of HIV prevention interventions that met stringent criteria (including scientific rigor of evaluation, quality of program implementation, and positive impact on HIV risk behavior) and had been demonstrated to be effective by a panel of scientific experts.(27) The interventions listed in HAPPA focused on adult populations. We will identify those studies in this review that are included in HAPPA, as well. We excluded research programs from HAPPA primarily due to containing an insufficient percentage of Latino participants.

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Results
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Search Results and Description of Studies
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Overall, 271 potentially relevant studies were identified through our searches. Descriptions of source of the studies by database can be found in Table 10. The ethnic and racial breakdown of the study population of the potentially relevant studies can be found in Table 11.

Although 154 studies were potentially relevant for inclusion in this review, we excluded most once we reviewed the full report because the sample was comprised of less than 80% Latino participants with no separate analyses conducted on the effects of the intervention or because there was inadequate study design and lack of methodological rigor. Therefore, we report in detail on 15 studies. Six studies were identified as including 100% Latino participants in their samples. Three of these studies are randomized controlled trials (RCTs) and are listed in Table 5. The remaining 3 studies are non-randomized design and are listed in Table 6. We found that only 9 studies included Latino participants and included an analysis of the effects of the interventions by race/ethnicity for the Latino participants; many of the excluded studies only reported demographic information by race-ethnicity rather than reporting on the effects of the intervention by race/ethnicity. Six of these studies are RCTs and are listed in Table 7 and discussed in the text. The remaining 3 studies are non-RCTs and are listed in Table 8.(28,29,30) These studies are not discussed in the text. We identified no studies that included a significant proportion of Latino participants (eg, between 80% and 100%).

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Description of Studies Including Latino Participants
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Injection Drug Users
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'Good' Studies
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Studies with 100% Latino Participants

Puerto Rico has an AIDS incidence rate greater than any U.S. state or territory and second only to Washington D.C..(12) Puerto Rico's highest risk group for HIV is IDU. Puerto Rican researchers have conducted large-scale interventions to address these high rates of HIV infection. Colon et al. report on the results of one such intervention conducted with out of treatment drug users in San Juan (N=2,144).(31) The participants were recruited from high-drug-using neighborhoods, "shooting galleries", and bars. The sample was 80% male. The investigators compared a standard intervention, which included HIV testing and counseling and health and drug treatment services, to an enhanced intervention in a randomized clinical trial. The enhanced intervention included all of the above components plus three additional education sessions presenting information, risk-reduction strategies and implications of HIV test results. Specially trained peer educators (most often ex-addicts) delivered some components of the intervention. The intervention was delivered in small groups that lasted approximately 30-60 minutes.

At 7-month follow up, the enhanced intervention group did not show much change compared to the standard intervention. There were significant changes only in the discontinuation of drug injection (p=.032) and in the sharing of cookers (p=.015) among participants in the enhanced intervention. The investigators also examined results for 9 risk behaviors just among those participants in both groups who had received the results of their HIV tests. For these participants, there were differences between the 2 groups only in 2 behaviors; the standard group decreased their number of visits to shooting galleries (p=.005), and the enhanced group decreased the frequency of borrowing needles (p=.046). When examining behaviors across groups, both groups significantly decreased their initiation of several high-risk behaviors (eg, borrowing needles, daily drug injection) from baseline to follow-up, and both groups also improved their frequency of protective acts (eg, bleaching needles, use of condoms). The only behavior that did not improve in either group was having multiple sex partners.

The authors posit that both groups produced positive results and that their results only indicate that the enhanced intervention did not produce significantly different changes in the participants. They also discuss the issue that while both groups showed improvement in their drug-use risk behaviors, there was less positive change with regard to sexual behavior (eg, multiple partners). They caution that, as this is the vector through which HIV may be transmitted out of the IDU population, future interventions should focus on decreasing sexual risk behavior. Overall, this was a well-designed and executed study that did produce positive changes and demonstrated that it is possible to recruit and maintain a very difficult and hard-to-reach population (attrition was a relatively low 13%).

Latinas are primarily infected via heterosexual sex and injection drug use. Nyamathi et al. conducted an intervention with this population in Los Angeles, California.(32) They recruited 233 women from homeless shelters and drug recovery programs. The majority of the women were born either in the U.S. (39%) or Mexico (44%). The investigators compared a "traditional" intervention to a "specialized" intervention. Both groups received HIV education and HIV testing and counseling by a Latina nurse. The specialized group also received information on coping strategies, enhancing self-esteem and risk-reduction strategies, and also included important culturally-sensitive components. The specialized program was 2 hours in length, compared to 1 hour for the traditional program. The specialized program was guided by the Comprehensive Health Seeking and Coping Paradigm,(33) which combines aspects of the Lazarus and Folkman Stress and Coping Paradigm(34) and Schlotfeldt's Health Seeking and Coping Paradigm.(35)

At 2-week follow-up, women in both groups reported significantly less injection drug use (p=.001). Both groups demonstrated improvements in their knowledge (perfect knowledge scores increased from 17% to 76% of the sample in the specialized intervention group, and from 19% to 82% in the traditional group) and attitudes (positive attitudes increased from 63% at baseline to 91% at follow-up in both groups combined) and a decrease in their distress (from an average score of 49 to 31 in both groups combined). A decrease in number of partners was also found for both groups (statistics not reported). In addition, when level of acculturation was considered across both groups combined, highly acculturated Latinas reported greater use of problem-focused (p=.001) and emotion-focused coping (p=.001) than Latinas with less acculturation.

Overall, it appears that the "traditional" and "specialized" programs were comparable in producing positive results. This may provide some information regarding feasibility, as the traditional program achieved equally positive results in one-half of the time (1 hour vs. 2 hours). It may be important to note that the traditional program was administered by a Latina nurse. This may have contributed to the success of the program, and this was not compared to an intervention delivered by a facilitator who was not Latina. The biggest limitation of this study is the extremely short follow-up period (2 weeks). This period is insufficient to detect any long-term behavioral change that might have resulted from the intervention. However, given the dearth of literature focusing specifically on Latinas, these positive results are promising. Further research is needed to substantiate and expand upon these findings.

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'Poor' Studies
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Studies in Which Some Proportion of the Sample is Latino and There are Separate Analyses for Latino Participants

Weeks et al. conducted a study comparing culturally targeted interventions for African Americans and Puerto Ricans in Hartford, Connecticut.(36) The sample consisted of 188 IDU (81% male) recruited from the community. Forty-nine percent of participants were Puerto Rican. The investigators compared a standard intervention (2 sessions of information and HIV testing and counseling) to an enhanced intervention (the standard intervention plus an additional 2 to 3 sessions that were tailored toward the participants' ethnic group).

The results of this study for Puerto Rican participants are severely limited due to very small numbers in the standard group (N=6). In addition, the overall attrition was extremely high (over 50%). The authors reported that regardless of which intervention group they were assigned to, Puerto Ricans decreased their injections more than African Americans (31% vs. 3%, respectively). Examining the Puerto Rican participants separately, the cocaine injectors in the standard group increased injections, while the intervention participants decreased injections. Finally, the Puerto Ricans in the enhanced group did not report an increase in using new needles. However, any conclusions that can be made from these findings are extremely limited due to the small sample size and high attrition.

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Heterosexuals
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Many of the studies investigating heterosexual behavior utilize samples recruited from sexually transmitted disease clinics. As an outcome measure, the authors often examine medical records in order to determine whether or not the patients returned to the clinic with a new sexually transmitted infection. This can be used as a proxy for HIV risk behavior, as condom use protects against most sexually transmitted infections as well as HIV infection.

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'Good' Studies
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Studies with 100% Latino Participants

As mentioned, cultural factors may strongly influence risk behaviors of Latinos. For example, machismo may make it more difficult for Latinas to discuss condoms with their partners.(37) This issue was investigated by Suarez-Al-Adam et al.(38) in a sub-sample of Latinas who participated in a larger-scale intervention that recruited participants from sexually transmitted disease clinics and social service agencies in New Jersey.(39) All of the Latinas were recruited from social service agencies. More than half (60%) of the Latina participants had been born in Puerto Rico, 18% were from the U.S., another 18% had been born in Latin America and 4% from the Caribbean. Eighty-three percent of the women chose to be interviewed in English. The investigation compared 2 interventions that both took place over 7 sessions and were conducted in small, all-female groups. The control intervention consisted of a health-promotion information, and the experimental group received an HIV risk-reduction intervention. The sessions were conducted over 3.5 weeks, and follow-up interviews were conducted 3 months later. The HIV risk-reduction intervention provided the women with information and skills training (including communication and negotiation skills) and was based in social cognitive theory.

First, the authors investigated whether the intervention had a significant effect on the sub-sample of Latinas. There was a non-significant decrease in the number of unprotected sexual acts reported by Latinas in the intervention arm (p=.15) and a non-significant increase in the proportion of acts in which the women used a condom (p>.20). There was also a non-significant difference in the percentage of women who were abstinent during the last month (29% in intervention vs. 14% in control). There were also no differences between the groups in frequency of discussions of condoms with partners. However, when the authors examined the overall sample, the average number of unprotected sexual acts significantly decreased from baseline to follow-up (p=.001). They also examined the women who were sexually active at both time points and found that condom use increased significantly from baseline to follow-up (p<.05). The authors suggest that this may be due to participants' reactions to the baseline interview.

The authors also examined psychological and cultural predictors of risk behavior. Given the lack of findings by intervention group, they re-divided the study population into 2 groups, consisting of women who practiced safer sex and those who reported participating in unprotected sex. The authors examined the influence of demographic variables, any history of abuse, partner hypermasculinity and discussing condoms. Again, no statistically significant differences were found between these 2 groups. However, some differences were found in that the women who reported participating in safer sex were more likely to be in the intervention group (73% vs. 47%), to not be married or living with a partner (46% vs. 32%) and to have reported that they discussed condoms with their partner (89% vs. 59%). There were also no differences between these 2 groups in levels of psychological or physical abuse. With regards to hypermasculinity of their partners, this construct was found to be significantly and negatively related to frequency of conversations about condoms for women in the intervention group (p<.10). Also, although there were no significant intervention group differences in discussing condoms with their partners, among women who discussed condoms with their partners those in the intervention group more frequently reported satisfaction with the outcome of the discussion than women in the control condition (100% vs. 50%, p<.01).

The lack of significant findings of this study were probably effected by its small sample size (N=46), and the authors also reported that many of the measures had not been validated with Latina samples. In addition, the women had participated in a larger intervention that was not culturally tailored. However, the focus on culturally relevant factors is important and should be repeated in future studies with larger samples.

As described above, Latinas are most at risk from HIV from unprotected sex with a male partner. Cultural factors, such as hypermasculinity (investigated by Suarez-Al Adam et al.)(38), have also been found to impact risk for Latinas. For example, women with partners who adhere to more traditional roles of masculinity may not be as likely to contradict the wishes of their partner (eg, request a condom). Indeed, Amaro has written extensively about the necessity of the role of empowerment in designing HIV prevention programs for Latinas.(40) While the studies described above incorporated culturally relevant strategies into the intervention programs, Raj et al. were unique in their efforts to incorporate aspects of empowerment theory into an intervention.(41)

This controlled clinical trial consisted of 162 Latinas divided into 3 intervention groups. The women were recruited from housing projects, community service programs, and clinics in Boston, Massachusetts. The women were mostly immigrants (89%), from Puerto Rico (13%), Dominican Republic (55%), Central America and Mexico (13%), and South America (8%). The participants received the intervention in small groups, which were conducted by Spanish-speaking facilitators. All groups were 12 weeks in length, and 90 to 120 minutes in duration. The intervention group focused on HIV and related risk and incorporated elements of empowerment theory and group dynamics and included participatory education strategies (eg, critical reflection, social action). It also included discussions about partner violence and societal risk factors such as poverty and oppression. This program provided approximately 16 hours of discussion of HIV and related risks. The comparison group targeted more traditional HIV education and skills training and lacked the emphasis on empowerment and participatory education strategies described above. Information was provided on general women's health issues and provided approximately 6 to 9 hours of discussion of HIV and related risks. Participants in these 2 groups were compared to women placed on a waiting-list control group.

At a 3-month follow-up, Latinas in both the intervention and comparison groups were more likely than the waiting-list controls to have increased condom use (odds ratio [OR], 2.92 in intervention group; OR, 5.91 in comparison). In addition, both the intervention and comparison group were more likely than the control group to have increased their intent to use condoms (OR, 4.36 in intervention group; OR, 5.54 in comparison). Only the intervention group significantly differed from the control group in the likelihood of reporting increased safer sex communication (69% vs. 41%, OR, 3.26). Finally, the comparison group was significantly more likely than either the intervention or control group to have undergone HIV testing in the past 3 months (OR, 2.50).

The authors conclude that both the intervention and comparison groups had a positive impact on the HIV risk behavior of the participants, but that the different emphases of the groups may have produced different results. For example, they posit that the intervention group produced a unique improvement in safer sex communication with their partner due to that programs' focus on the role of partners.

Although this study has limitations (eg, no random assignment), it did produce positive results with interventions that could be easily reproduced in community-based settings with a high-risk population. Thus, its results are encouraging.

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Studies in Which Some Proportion of the Sample is Latino and There are Separate Analyses for Latino Participants

The National Institute of Mental Health reported on the results of a very well-designed and executed study in which participants were recruited from community-based, inner-city clinics.(42) It was conducted in 7 urban areas around the country and was comprised of 3,706 male and female patients recruited from community-based clinics (25% Latino). There were 2 groups, a control group in which participants received 1 hour of HIV/AIDS education and an intervention group in which participants received 7 sessions focused on HIV risk reduction. The sessions were 90 to 120 minutes in length and were conducted 2 times per week in small groups that were separated by gender. Follow-ups were conducted at 3, 6, and 12 months after the intervention. The enhanced intervention participants reported a reduced frequency of unprotected intercourse across each follow-up point (p< .0001 across all follow-up points), and in this group, unprotected intercourse decreased by 50% from baseline to 12-month follow-up. In addition, the intervention participants reported increased condom use across all time points (p<.0001 across all follow-up points), and they were more consistent condom users (p<.0001). With regard to medical outcomes, according to medical chart review there was less gonorrhea in men (p<.03). Of particular interest is that there was a significant association between how many sessions someone attended and the degree of behavior change later reported; thus, the dose of the intervention seemed to be a significant predictor of response (p=.03 for those who attended 5 or fewer sessions, and p<.0001 for those who attended either 6 or all 7 sessions). Analyses were conducted examining whether or not race was a significant predictor of behavioral outcomes, and it was found to be non-significant. Overall, this was a very well designed and executed study and includes the important aspect of separating men and women for the purposes of delivering an intervention. The intensity of the intervention could pose a feasibility problem, but the positive results make a compelling argument for future interventions. One possible limitation is that there were fairly low rates of sexually transmitted diseases in the population. However, conducting this intervention in populations with higher sexually transmitted disease rates could only serve to strengthen the results, not lessen them. Finally, this study was included in the HAPPA list of well-designed, effective interventions described earlier.(27)

A study by O'Donnell and colleagues utilized a similar theory-based intervention structure with a sample of 3,257 patients (60% male) at a sexually transmitted disease clinic in New York City (38% Latino; of the Latino participants, 71% were Puerto Rican and 19% Dominican).(43) The 3 groups consisted of a control, video-viewing only, and a video plus an interactive group session. The videos were tailored and culturally sensitive to Latino or African-American participants and were based on the theory of reasoned action. Other studies of this type have obtained a biological outcome (reinfection with a sexually transmitted disease), whereas this study examined the redemption of coupons for condoms given to the participants. The video intervention participants were significantly more likely to redeem coupons for condoms than the control participants (OR, 1.15). Further, the video plus group session participants were more likely than video only participants to redeem coupons (OR, 1.11) (except for Latinas). Latino men (OR, 1.28) and women (OR, 1.32) who participated in both video and interactive sessions were most likely to obtain coupons for condoms. In addition, among the Latino participants, Puerto Ricans reported significant increases in redeeming coupons whether they participated in the video only or the video plus interactive sessions (p< .01), while the Dominican participants only increased their coupon redemption in the video plus interactive session group (p< .01). The methodology of this study, like the one above, was strong but it was limited by the outcome of examining condom acquisition rather than report of actual condom use or a biological endpoint.

In sum, these studies demonstrate that patients at sexually transmitted disease clinics can be a receptive audience for messages aimed at lessening their sexual risk behavior. Several methods produced positive results including videotape presentations and small group sessions. An additional strength of these studies is that they often utilize a biological outcome (diagnosis of a subsequent sexually transmitted infection by medical chart review). There appears to be evidence from the above studies that interventions may need to be tailored towards men and women differently. Finally, the interventions were also quite feasible and could probably be implemented at relatively low cost by sexually transmitted disease clinics staff.

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'Poor' Studies
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Studies with 100% Latino Participants

Flaskerud et al. conducted an intervention with 559 Latinas recruited from WIC programs (federal women, infants, and children nutrition programs) in Los Angeles, California.(44) The majority of the women were born outside of the U.S. (Mexico [44%], Central America [43%], South America [4%]). The intervention provided the participants with information, HIV testing and counseling, skills training, risk-reduction materials, referrals, and peer counseling. The intervention group was comprised of 508 women, and the comparison group had 51 women. The intervention was also designed to be culturally and gender sensitive. No information was given as to the length of the intervention program.

At a 2-week post-test, the investigators examined knowledge scores for a random sub-sample of the intervention group and scores from the entire comparison group. The Latinas in the intervention group significantly increased their knowledge (p=.0001), whereas the comparison group participants did not increase their knowledge of HIV. The authors did not provide either an effect size or a test of statistical significance for the intervention group comparison. At re-test (1 year post-intervention), the percentage of intervention group participants who reported no condom use in previous 6 months decreased from 77% to 65%. Also at re-test, the intervention group participants significantly decreased the frequency of sexual intercourse without a condom in the previous 2 weeks (p=.04). Again, direct statistical comparisons between the intervention group were either not conducted or not reported.

Although this study was targeted towards a high-risk population (heterosexual Latinas) and was culturally sensitive, it is difficult to discern the effects of this intervention due to lack of clarity in their reporting of results. In addition, this study is limited by non-random assignment and a small sample size in the comparison (N=51) group. Although they describe results from a re-test 1 year following the intervention, it is unclear as to whether those results are for the entire intervention group or a smaller sub-sample. Because of these limitations, any conclusions that can be drawn from this study are severely limited.

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Youth/Adolescents
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As discussed in the introduction, Latino adolescents are at high risk for HIV infection. The following studies describe interventions conducted with this vulnerable population.

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'Good' Studies
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Studies with 100% Latino Participants

There has been some concern that the provision of condoms and sex education could encourage sexual activity among adolescents. Sellers et al. investigated this issue and reported on the results of a well-conducted community-level intervention trial conducted among adolescents in Boston; the comparison city was Hartford, CT.(45) The intervention was focused in neighborhoods where at least 20% of the residents were Latino. The campaign featured mass media, workshops, and canvassing (which included the distribution of risk-reduction materials). Another feature of the intervention was its use of peer educators, who were specially trained and who implemented several facets of the intervention (eg, workshops in schools). The intervention was implemented over 18 months. The sample (N=586) was derived from a representative probability sample of Latino adolescents in each city and was 94% Puerto Rican.

The authors reported that at follow-up interviews, males from the intervention city were less likely than males in the comparison community to have initiated sexual activity (OR, .08, p< .05). There was no significant increase or decrease in rates of becoming sexually active for females. Sexually active females from the intervention city were significantly less likely to report having multiple partners than sexually active females from the comparison community (OR, .06, p< .01). Frequency of sex for both genders in the intervention city was not significantly influenced. The intervention also increased the likelihood that both boys and girls would have a condom with them (at the time of the follow-up interview) (OR, 2.3, p<.01, boys; OR, 2.0, p=.07, girls).

Thus, the intervention (eg, sexual education and risk reduction materials) did not increase the levels of sexual activity, nor did it negatively influence the onset of sexual activity (as some had predicted from these types of programs). Unfortunately, information was not provided regarding specific changes in risk behavior (eg, condom use) for adolescents in the intervention community. However, this well-designed community-based intervention describes promising results for Latino adolescents.

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Studies in Which some Proportion of the Sample is Latino and There Are Separate Analyses for Latino Participants

Hovell and colleagues conducted an intervention testing whether providing adolescents with social skills and didactic training could positively influence their potential HIV risk behaviors.(46) The participants (N=307) were recruited from health clinics, schools, shopping malls, churches, and through the media in San Diego, California. Forty-seven percent were male and 53% female. Overall, 54% of participants were Latino; of the Latino participants, 57% were born in U.S. and 40% in Mexico. There were 3 groups, one provided social-skills training (information and skills training in communication and decision making, and in resisting peer pressure), a second provided didactic training (information only, no skills training) and a third group served as control and received no training. The 2 intervention groups were delivered over 9 weeks in 2-hour sessions in small co-educational groups.

At 10-week post-test, only Latino participants from the social skills group had increased their assertiveness for "say no to sex" (an increase in means from 9.86 to 10.52, compared to Anglos, the authors reported a significant interaction among group, time and ethnicity but did not give the statistics). For both Latino and Anglo youth, the social skills training group improved assertiveness for condom negotiation (p=.002), asking a friend about their sexual and drug use history (p=.0001) and discussing a friend's risk of AIDS (p=.0001). In addition, for all participants, the didactic training significantly increased knowledge when compared to the social skills training group (p= .012).

While these results are promising, this study is limited in that the results are only from posttest, immediately following the intervention, and there is no long-term follow-up. However, it demonstrates that skills training can produce positive behavioral changes. Thus, although the lack of long-term follow-up is limiting, its results are promising and demonstrate that a fairly feasible and general (rather than culturally tailored) intervention can have a positive impact on Latino youth.

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'Fair' Studies
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Studies in Which Some Proportion of the Sample is Latino and There Are Separate Analyses for Latino Participants

Workman and colleagues conducted a study of 60 female adolescents who were attending an inner-city all-female parochial high school.(47) The study was conducted only among African-American and Latina (57%) students. The intervention group received 12 weekly 30-minute sessions on HIV prevention, and the control group received 12 weekly, group seminars on "womanhood development" (which did not emphasize sexual risk reduction). The intervention was based in cognitive-behavioral theory and included information, modeling and skills training. One week following the intervention, the Latinas who received the HIV prevention intervention demonstrated significantly greater knowledge (p<.05). In other outcomes, there were some differences due to ethnicity. For example, across groups there was an increase in sexual assertiveness for African Americans but not for Latinas (p<.001), and a significantly greater proportion of African Americans reported levels of comfort discussing AIDS preventive behaviors than Latinas (p<.01). The authors posit that cultural differences between these two groups could account for these differences. For example, they describe cultural pressure in the Latino community for young women to not display knowledge about sexual matters or to be assertive. There were no significant changes between the intervention groups with regard to AIDS preventive behaviors; however, the baseline levels across groups were already quite high, and a high proportion (68%) of the sample was not yet sexually active. Although this study was well designed, and the intervention was intensive, the follow-up period was only 1 week following the intervention, which did not allow sufficient time to observe long-standing behavior change. Other limitations included a relatively small sample size, and the possibility that there could have been contamination between the two intervention groups. However, its focus on African-American and Latina adolescents is important, and future studies should conduct similar analyses that allow for comparisons to be made between ethnic groups.

In sum, these three studies demonstrate that adolescents can effect positive change that reduces their chances of HIV infection.(45,46,47) These results were consistent across school-based and general adolescent populations. Skills training was found to be an important component of the interventions. The interventions were theory-based and produced positive results for fairly heterogeneous populations (eg, mixed race and mixed gender). As Latino adolescents are a population that could greatly benefit from obtaining skills to negotiate and engage in safer sexual practices, these outcomes, though somewhat limited, are promising.

Walter and colleagues implemented a theory-based intervention among high school students in New York City (N=1,316; 33% Latino).(48) The intervention compared classrooms that received an AIDS-prevention curriculum with comparison classrooms. The curriculum was delivered in 6, single class-period lessons, which were given on consecutive days. It was delivered by the students' regular teachers. The curriculum included both information and skills training.

At three-month follow up the intervention students demonstrated positive changes in knowledge (p<.001); beliefs about susceptibility (p<.01), benefits of protective behaviors and positive social norms (p<.01); self-efficacy (p<.01) and HIV risk behaviors (p<.01). The intervention had the greatest impact on intercourse with high-risk partners, monogamy and condom use. Overall, students who participated in the intervention were significantly more likely to have lower risk scores than the comparison students (OR, 1.4). The investigators examined whether or not the intervention effects differed by ethnicity and found no effect.

Limitations of this study included a high level of non-participation by eligible students and a differential loss to follow-up between groups. In addition, some of the effects found may be due to secular trends because there was no comparison intervention.

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Discussion
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Certain groups of Latinos are at increased risk for HIV infection. We have reviewed 12 studies of varying quality and methodological strength that reported on interventions specifically addressing these risk groups among Latinos. The highest number of the studies focused on heterosexuals (5), followed by adolescents (4), and injection drug users (3). We did not identify any intervention trials that focused on MSM.

Of the 12 studies described, most found some significant levels of behavior change following interventions aimed at decreasing HIV risk behavior. Condom use was a frequent behavioral outcome used to examine risk, along with number of partners and frequency of unprotected intercourse. In addition, a positive impact was often found on drug-using behaviors.(31,32)

Although some positive effects were reported, the often very brief follow-up periods limit the strength of these findings. Thus, it is impossible to discern the lasting impact of interventions for studies that reported positive behavior change but had short follow-ups (less than 3 months).

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Components of Effective Interventions
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Certain components were present in the majority of the interventions that achieved positive behavioral changes. These included cultural sensitivity, gender sensitivity, peer educators, skills training, and interventions that were longer in length. Specific comments regarding these components were reported in the individual descriptions of the studies. However, general statements can be made regarding these components:

  1. Several of the interventions were designed in order to reflect specific needs and/or characteristics of the Latino community. For example, some incorporated aspects of Latino culture into the intervention, and many had Latino facilitators.(32,43) However, there needs to be attention paid in the future to testing these components against less culturally relevant interventions in order to understand better the impact of this feature (eg, Raj et al.).(41)

  2. Interventions that took into account gender differences as well as cultural differences were more effective. Several studies (eg, O'Donnell et al.) reported on differential effects of interventions due to gender.(43)

  3. Interventions that used peer educators reported positive results. This was found in both populations of adolescents(45) and injection drug users.(31) However, peer educators were not directly tested against professional staff in these studies, so we are unable to predict the differential impact that peer educators may have when compared with professional staff.

  4. Interventions that were provided over more than 1 session and/or were longer in duration had, in general, more positive effects(31,42) than interventions that were briefer.

  5. Interventions that incorporated skills training achieved positive results.(46,48) When skills training was compared to purely informational interventions, the skills-training participants reported more positive changes in their risk behavior.(46)

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Gaps in Research
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We identified several gaps in the research. Of deepest concern is the surprising lack of well-designed intervention studies fitting our inclusion criteria that were specifically targeted to Latinos. We identified only 6 high-quality studies consisting of 100% Latino participants (and one of those studies was a sub-sample of a much larger intervention not focused on Latinos). In addition, the majority of the studies that had separate analyses for Latino participants had most often been targeted towards another primary group of interest (eg, African Americans). Given the rates of new infection for Latinos, the lack of studies is cause for concern.

In addition, we found no studies focusing on either Latino MSM or gay men. As this is the group within the Latino community most at risk for HIV, intervention trials that specifically focus on this population should be an immediate research priority. While some large-scale studies focusing on HIV prevention in MSM have recently gotten underway (eg, a national multi-site study funded by CDC), additional attention needs to be specifically geared towards this population.

In a previous review of HIV prevention interventions for African Americans and Latinos, it was noted that there were no studies that specifically focused on heterosexual men.(49) This is a research gap that has begun to be addressed, but more studies need to be done. Only 2 studies included heterosexual Latino men,(42,43) and no studies focused exclusively on Latino heterosexual men. And though 4 studies in this review focused exclusively on Latinas, again, this small number indicates that additional studies are needed.

As we were able to identify only four studies that focused on adolescents, additional attention should be given to this group. In addition, within adolescents, there are several sub-populations that warrant attention. For example, younger adolescents may receive many benefits from interventions that could have a substantial impact on behavior as patterns and habits are being formed. Interventions that occur later in adolescence could have less of an impact after risky behaviors have already become a habit (eg, Millstein et al.).(50) In addition, gay-identified Latino youth will likely be an important group to study.

Final gaps in research that we would recommend addressing are methodological in nature. First, many studies did not allow sufficient time for follow-up. Although many of these interventions were conducted with hard-to-reach and, thus, hard-to-follow populations, longer periods of follow-up are necessary in order to determine whether or not effective behavior change has occurred.(49) Intervention studies that include follow-up periods of a minimum of 6 months should be the rule. Second, studies that include some percentage of Latino participants (or indeed a significant proportion of any racial and ethnic group) should report separate analyses for those participants. For example, if an intervention was conducted with both African-American and Latino participants but these participants were not separated in the analysis, it is frequently difficult to ascertain the relative success of the intervention in each group. Third, studies need to obtain large sample sizes in order to better detect results, as too small a sample may result in inadequate statistical power. Finally, more studies should attempt to include a biological outcome (eg, STD reinfection) where feasible.

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Ongoing Studies
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We have identified a few ongoing studies that are conducting interventions to reduce HIV risk behavior in Latinos. This summary is preliminary and will be updated as we continue to identify ongoing studies.

We identified 1 ongoing study of young MSM, the Community Intervention Trial for Youth (CITY) study, funded by CDC. It focuses on Latino youth in New York City and Los Angeles, California. We also identified a study funded by the National Institute on Drug Abuse of HIV risk reduction for Mexican-American IDU and their sexual partners in Tucson, Arizona. It is culturally tailored and will include a 12-month follow-up. Another ongoing study is being conducted with Latino youth in Philadelphia, Pennsylvania, funded by the National Institute of Nursing Research. It is also culturally tailored and includes a 12-month follow up. Two studies being conducted through the University of California, San Francisco are investigating the influence of significant others and/or family members on the HIV risk behavior of Latinas. The first study, funded by the Universitywide AIDS Research Program at the University of California is testing the effects of three intervention groups: a general health intervention, an HIV risk reduction intervention for Latinas only, and an HIV risk reduction intervention involving the participants' male partners. The second study is conducting interventions with mothers and daughters to help mothers talk to their daughters about sex and to educate the mothers about HIV. This study is funded by the Health Care Finance Administration.

We are aware that the Office of AIDS Research, the National Institute of Mental Health, the National Institute on Drug Abuse, CDC, and other governmental agencies have made research investigating HIV risk reduction among communities of color a priority. It is anticipated that the number of research reports describing interventions in Latino populations will continue to increase as the results of these intervention studies become available.

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Conclusions and Recommendations
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In sum, we have identified and reviewed 15 intervention trials of varying methodological quality aimed at reducing the risk of HIV infection for Latinos in the U.S. We conducted a rigorous search of the literature and contacted leading researchers in the field in order to ensure the comprehensiveness of this review. We organized the review by the four major risk groups for HIV infection (MSM, IDU, heterosexuals, and youth/adolescents). We reviewed evidence for interventions in which Latinos comprised 100% of the participants or in which there were separate analyses for Latino participants. We also ranked studies by using standardized quality ratings.

We found some consistencies across studies that produced positive results. These interventions were culturally sensitive to the needs of Latinos, used peer educators, provided the participants with skills training, and were conducted over multiple sessions and longer periods of time. Examples of positive outcomes were increasing condom use, decreasing the number of sexual partners, decreasing the sharing of needles, delaying the onset of intercourse, and improving communication with partners regarding safer sexual practices. All of these outcomes are associated with decreasing HIV infection. In general, the studies were limited by a lack of adequate follow-up time and small sample sizes with a resultant inadequate power to detect effects. We also identified one striking gap in the literature--the lack of any completed intervention study specifically targeting Latino gay men and/or MSM, the group most at risk for HIV infection in the Latino population. Implementing additional intervention studies in this group is an urgent priority.

Our recommendations are as follows:

  1. Additional studies on Latinos are an urgent research priority, with emphasis on Latino MSM and gay men and on heterosexuals. Studies should have sufficiently large sample sizes to identify subtle effects and a sufficiently long follow-up period to discern long-term effects.

  2. Interventions should be culturally sensitive.

  3. Interventions should include skills-training components. This includes practical skills training such as the correct use of a condom but also encompasses techniques such as improving communication and decision-making skills regarding negotiation of safer sex practices and training in resisting peer pressure.

  4. Interventions should be theory-based, and programs that have been grounded in cognitive-behavioral theory have produced the most consistent positive results.

  5. Our recommendations to investigators planning research interventions:

  6. Adequate sample sizes should be obtained in order to increase the chances of discerning the effects of the intervention. Many well-designed and implemented studies that reported null results could have been improved by increasing their sample sizes. Funding agencies should be prepared to make this additional investment.

  7. Studies should attempt to measure behavior change over long periods of time (at least 6 months) in order to determine whether behavior changes were maintained over long periods of time. Funding agencies should be prepared to make this additional investment.

  8. Ideally, behavioral prevention interventions should attempt to demonstrate connections to biological outcomes when feasible (eg, sexually transmitted disease reinfection and/or HIV seroconversion).

  9. Studies that do not use a control group (ie, those that compare 2 interventions) should consider designs (eg, a crossover design) that will allow some comparison to a no-intervention or a standard intervention group.

  10. As Latinos include a vast number of different cultures, studies should identify different demographic information about Latinos (ie, U.S. born or immigrants, and country of origin). Studies should also conduct separate analyses for Latino participants, including separate analyses by demographics as well as the effects of the intervention on Latino participants.

As we enter the third decade of the AIDS epidemic, Latinos continue to be at increased risk for HIV infection. However, this review demonstrates that effective approaches and techniques have been developed that are successful in reducing the HIV risk behavior of the highest risk groups in the Latino population. The scaling up and implementation of interventions that we know to be successful should be a priority, as these interventions have been proven to be effective weapons in the fight against HIV/AIDS. Additionally, funding, designing and implementing interventions specifically targeting Latino gay men and MSM should be an immediate priority for policy makers and researchers.

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References

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1.  National Minority AIDS Council. HIV/AIDS & Latinos, 1999.
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