The initial intervention trial (Rotheram-Borus et al., 2004
) was aimed at designing an efficacious intervention to reduce transmission risk and examining whether the delivery format for an intervention makes a difference. This question is particularly important as care providers for this population design and implement programs to improve the health and mental health outcomes, as well as reduce the transmission risk behaviors of this population. Overall, the trial found that the in-person delivery of the intervention resulted in more healthy behavior changes among young people living with HIV. However, it was unclear if this was always the case, or if there were contexts or individuals who would benefit more from the telephone sessions. Given the probable differential costs in delivering the interventions (e.g., convenience, access, transportation, etc.), it is important to determine who is likely to benefit from which delivery modality.
Increasing the amount of condom protected sex that young people living with HIV engage in is an important strategy for reducing HIV transmission risk. When examining the factors that moderate increasing the percentage of protected sex, use of antiretroviral medications (ARV), time since HIV diagnosis, and mental health were important. YPLH who were not taking ARVs, reported lower emotional distress, and had know their HIV diagnosis for a longer period of time were more likely to benefit from the in-person intervention. The in-person intervention appears to be most effective for those youth who may be most difficult to engage in prevention and healthcare services. These youth are likely to be difficult to engage because they are not highly motivated by their current context to seek, help as illustrated by not taking medications, not needing mental health services and having lived with the virus for a long time. However, while difficult to engage, these youth can benefit from preventive interventions. Therefore, increasing the motivation of these youth to attend in-person sessions is crucial. Emphasizing the benefits of in-person sessions, for example, the opportunity to decrease isolation, make a personal connection with someone else, and the opportunity to discuss life challenges with others, are possible techniques for increasing the motivation of youth to attend in-person sessions.
In contrast, while youth not on ARVs and youth that knew their HIV status for longer benefited from the in-person intervention, they did not appear to benefit from the telephone intervention. Given these youth may not be highly motivated to seek help and more difficult to engage, providing services via the telephone is problematic. These youth are likely to be less attentive and engaged by telephone discussions. One of the primary benefits of in-person sessions is the opportunity to personally connect, which is not easily accomplished over the telephone. Further, in an in-person intervention, the personal relationship is fostered by the facilitators’ ability to read the affect of a youth and employ engagement strategies accordingly. This is much more challenging to do over the telephone.
Those YPLH who were taking ARVs and reporting more emotional distress were more likely to benefit from the telephone intervention. YPLH taking medications for their HIV are actively involved in healthcare settings. It might be expected that these youth are more likely to receive preventive information compared to those not regularly seeing their healthcare provider. Consequently, prevention for these youth could easily be overlooked. However, these data suggest that remaining in contact with these youth and providing preventive interventions is important and beneficial when delivered via the telephone. In addition, youth who are emotionally distressed may be more difficult to engage and may not benefit from interventions that require them to come in to an office. It is important to realize that while these youth may not come into an office because of their mental health issues, they can still benefit from intervention that is provided via the telephone.
In contrast, while the telephone intervention was useful for youth recently diagnosed and those taking ARVs, these youth did not benefit from the in-person intervention. This is surprising because it would be expected that recently diagnosed youth would be most in need of in-person communication and interaction. However, recently diagnosed youth may be experiencing heightened affect such as depression or anxiety which could interfere with their ability to engage in an interpersonal setting. This is consistent with the finding that YLPH with heightened emotional distress benefited most from the telephone intervention. It is less clear why those youth taking ARVs did not benefit from the in-person intervention. These youth are already engaged in healthcare settings and are presumably interacting with providers on a one-on-one basis. It may be these youth are overwhelmed or overloaded by the ongoing in-person interaction and conveying preventive information may require less interpersonally demanding modalities.
When examining reductions in the number of sexual partners, these data suggest that mental health status is an important consideration for the success of the intervention. For YPLH who were experiencing high levels of emotional distress or anxiety, the in-person intervention was most effective in reducing the number of sexual partners. However, low levels of emotional distress did not significantly moderate reductions in the number of sexual partners. It appears that the in-person intervention is most beneficial in reducing number of sexual partners for YPLH experiencing high levels of mental distress. This finding contrasts with the results indicating YPLH experiencing high levels of emotional distress benefited from telephone delivery to increase the percentage of protected sex. It may be that for YPLH who become connected to healthcare services or interventions delivered in-person, they reduce contact with potential sex partners. On the other hand, emotionally distressed youth who are not connected to services and who benefit from telephone delivered intervention may seek social support and continue to have sex partners; however, with intervention, they may increase the percentage of protected sex with those partners.
A number of variables were not significant moderators for any of the major intervention outcomes, including age, coping skills, conduct problems, or quality of life. Given that the focus of the intervention included increasing HIV-specific coping and medication adherence, which would positively impact health indicators such as quality of life, these variables may have been mediators rather than moderators of the interventions success. The intervention may have had a positive impact on YPLH by increasing positive coping skills and increased health behaviors, producing mediating rather than moderating effect. Alternatively, both negative coping and quality of life were highly correlated with emotional distress, suggesting these variables were not independent moderators of the effects of the intervention. It would appear that emotional distress exerted the stronger effect on intervention efficacy. In addition, there appears to be a lack of intervention effect for black and white youth. However, this finding is likely due to a lack of power given the small sample size.
The current analysis had several limitations. The main technique for data collection was self-report. Although the self-report outcome of sexual risk acts is subject to demand of social desirability, this potential threat was countered by assurances of confidentiality, careful construction of assessment items, and use of ACASI, as recommended by the National Institutes of Health. There are background characteristics, such as socioeconomic status, that were not included in the analysis that may have moderated the intervention’s success. Unfortunately, this analysis is limited by the data that were collected. While the demographics of our sample closely reflect those of reported AIDS cases in the United States, the sample was not probability-based and was conducted in only three U.S. cities. Thus, generalizability is difficult to assess.
Regardless of these limitations, this analysis provides important knowledge. The intervention was successful in decreasing transmission behavior among YPLH, and illustrates that different delivery strategies are viable. When deciding which delivery strategy is most appropriate and beneficial for an individual young person, consideration must be given to the types of services the youth currently accesses and the youth’s mental health. This research supports the importance of continuing to examine the best modality for engaging youth in prevention activities. While traditional in-person sessions are the most common means of providing services and may be the most beneficial for some youth, in-person sessions may not be the most effective way to provide prevention services for everyone. Further research is needed to examine the possible contexts in which intervention works best.