Assessment of the Cost-Effectiveness of a Brief Video Intervention for Sexually Transmitted Disease Prevention.

BACKGROUND: Cost-effective, scalable interventions are needed to address high rates of sexually transmitted diseases (STDs) in the United States. Safe in the City, a 23-minute video intervention designed for STD clinic waiting rooms, effectively reduced new infections among STD clinic clients. A cost-effectiveness analysis of this type of intervention could inform whether it should be replicated. METHODS: The cost-effectiveness of a brief video intervention was calculated under a baseline scenario in which this type of intervention was expanded to a larger patient population. Alternative scenarios included expanding the intervention over a longer period or to more clinics, including HIV prevention benefits, and operating the intervention part time. Program costs, net costs per STD case averted, and the discounted net cost of the intervention were calculated from a health sector perspective across the scenarios. Monte Carlo simulations were used to calculate 95% confidence intervals surrounding the cost-effectiveness measures. RESULTS: The net cost per case averted was $75 in the baseline scenario. The net cost of the intervention was $108,015, and most of the alternative scenarios found that the intervention was cost saving compared with usual care. CONCLUSIONS: Single session, video-based interventions can be highly cost effective when implemented at scale. Updated video-based interventions that account for the changing STD landscape in the United States could play an important role in addressing the recent increases in infections.

Observed reactions among patients attending HIV treatment facilities to a brief video intervention on treatment initiation and adherence.

Entertainment-education can affect positive behavior change. Taking Care of Me is an effective, video-based intervention designed to improve patients' continuum of HIV care outcomes. The study's aim was to refine the pre-final video at points where patients stopped watching and missed embedded health messages. We evaluated the video using systematic unobtrusive observations triangulated with electronic medical record (EMR) data. We conducted observations in three HIV treatment facilities' waiting rooms in the southern US in 2016. Using a web-based data collection instrument, one observer spent 8 h at each facility observing patients' engagement with the video. We mapped the embedded messages in each scene and identified the messages that patients missed when they stopped watching. We compared missed messages to treatment initiation, medication adherence, and retention in care data abstracted from each clinic's EMR system. We were able to identify specific scenes where low levels of engagement corresponded to lower than expected retention in care outcomes and edit these scenes to improve engagement. Identifying and editing video scenes to increase viewership potentially could enhance intervention efficacy. Our methods could be used to assess and refine other video-based interventions being developed in resource limited settings.

Sexual abstinence and other behaviours immediately following a new STI diagnosis among STI clinic patients: Findings from the Safe in the City trial.

BACKGROUND: Few studies have assessed patients' sexual behaviours during the period immediately following a new diagnosis of a curable sexually transmitted infection (STI). METHODS: Data were analysed from a behavioural study nested within the Safe in the City trial, which evaluated a video-based STI/HIV prevention intervention in three urban STI clinics. We studied 450 patients who reported having received a new STI diagnosis, or STI treatment, 3 months earlier. Participants reported on whether they seriously considered, attempted and succeeded in adopting seven sex-related behaviours in the interval following the diagnostic visit. We used multivariable logistic regression to identify, among men, correlates of two behaviours related to immediately reducing reinfection risk and preventing further STI transmission: sexual abstinence until participants were adequately treated and abstinence until their partners were tested for STIs. RESULTS: Most participants reported successfully abstaining from sex until they were adequately treated for their baseline infection (89%-90%) and from sex with potentially exposed partners until their partners were tested for HIV and other STIs (66%-70%). Among men who intended to be abstinent until they were adequately treated, those who did not discuss the risks with a partner who was possibly exposed were more likely not to be abstinent (OR, 3.7; 95% CI 1.5 to 9.0) than those who had this discussion. Similarly, among men who intended to abstain from sex with any potentially exposed partner until the partner was tested for HIV and other STIs, those who reported not discussing the risks of infecting each other with HIV/STIs were more likely to be sexually active during this period (OR, 3.5; 95% CI 1.6 to 8.1) than were those who reported this communication. CONCLUSIONS: Improved partner communication could facilitate an important role in the adoption of protective behaviours in the interval immediately after receiving a new STI diagnosis. TRIAL REGISTRATION NUMBER: NCT00137670.

The Program Cost of a Brief Video Intervention Shown in Sexually Transmitted Disease Clinic Waiting Rooms.

BACKGROUND: Patients in sexually transmitted disease (STD) clinic waiting rooms represent a potential audience for delivering health messages via video-based interventions. A controlled trial at 3 sites found that patients exposed to one intervention, Safe in the City, had a significantly lower incidence of STDs compared with patients in the control condition. An evaluation of the intervention's cost could help determine whether such interventions are programmatically viable. MATERIALS AND METHODS: The cost of producing the Safe in the City intervention was estimated using study records, including logs, calendars, and contract invoices. Production costs were divided by the 1650 digital video kits initially fabricated to get an estimated cost per digital video. Clinic costs for showing the video in waiting rooms included staff time costs for equipment operation and hardware depreciation and were estimated for the 21-month study observation period retrospectively. RESULTS: The intervention cost an estimated $416,966 to develop, equaling $253 per digital video disk produced. Per-site costs to show the video intervention were estimated to be $2699 during the randomized trial. CONCLUSIONS: The cost of producing and implementing Safe in the City intervention suggests that similar interventions could potentially be produced and made available to end users at a price that would both cover production costs and be low enough that the end users could afford them.

Assessing Patient Exposure to a Video-Based Intervention in STD Clinic Waiting Rooms: Findings From the Safe in the City Trial.

Safe in the City, a video intervention for clinic waiting rooms, was previously shown to reduce sexually transmitted disease (STD) incidence. However, little is known about patients' recall of exposure to the intervention. Using data from a nested study of patients attending clinics during the trial, we assessed whether participants recalled Safe in the City, and, if so, how the intervention affected subsequent attitudes and behaviors. Analyses were restricted to responses to a 3-month follow-up questionnaire among participants who were exposed to the video (n = 708). Impact was measured as participants' reports of the video's effect on behaviors and attitudes. Associations were evaluated using multivariable logistic regression. Of participants who were exposed, 685 (97%) recalled viewing the video, and 68% recalled all three vignettes. After watching the video, participants felt more positive about condoms (69%) and comfortable acquiring condoms (56%), were reminded of important information about STDs and condoms (90%), and tried to apply what they learned to their lives (59%). Compared with those who recalled viewing one or two vignettes, participants who recalled viewing all three vignettes reported more positive attitudes toward condoms and peer/provider communication. These findings demonstrate that a low-resource video intervention for waiting rooms can provide sufficient exposure to positively influence STD-related attitudes/behaviors.

Consistency of Condom Use During Receptive Anal Intercourse Among Women and Men Who Have Sex With Men: Findings From the Safe in the City Behavioral Study.

BACKGROUND: Unprotected receptive anal intercourse poses HIV risk for men who have sex with men (MSM) and heterosexual women. Little is known about differences in consistent condom use during anal intercourse among these populations. METHODS: Data were analyzed from a nested study conducted from 2004 to 2005 within a behavioral intervention trial of approximately 40,000 urban US sexually transmitted disease clinic patients. Analyses were restricted to women and MSM who reported receptive anal intercourse with at least 1 partner in the prior 3 months at baseline, or 3-month follow-up surveys. Condom use was categorized as consistent (100% of receptive acts) or inconsistent/nonuse (0-99% of receptive acts). Multivariable regression with general estimating equations was used to identify factors associated with consistent condom use within each population. RESULTS: Approximately 31% of women and 70% of MSM reported receptive anal intercourse at least once in the past 3 months. Men who have sex with men were significantly more likely to report consistent condom use compared with women. For women, intention to use condoms, partner support for condom use, the belief they could stop having sex when condoms were unavailable, and believing their partner had not given them a sexually transmitted infection (STI) were associated with using condoms consistently. For MSM, intention to use condoms, condom use self-efficacy, perceived partner support for condom use, having a nonmain partner, believing their partner had not given them an STI, and fewer sex acts were associated with consistent condom use. CONCLUSIONS: Findings confirm the importance of considering anal intercourse when assessing STI/HIV risk in MSM and heterosexual women.

Drug Use, Sexual Risk, and Syndemic Production Among Men Who Have Sex With Men Who Engage in Group Sexual Encounters.

OBJECTIVES: We surveyed men who have sex with men (MSM) to determine whether sexual risk behaviors, recent drug use, and other psychosocial problems differed between men who engaged in one-on-one and group sexual encounters. METHODS: We conducted an Internet-based cross-sectional survey of 7158 MSM aged 18 years or older in the United States recruited from a gay-oriented sexual networking Web site in 2008. Among MSM who engaged in group sexual encounters, we compared their past-60-day sexual behaviors in one-on-one encounters and group sexual encounters. We also compared risk profiles and syndemic production between men who did and did not participate in group sex. RESULTS: Men reporting a group-sex encounter had significantly higher polydrug use and sexual risk than did the men not reporting group sex in the past 60 days. The odds of engaging in group sex with 4 or more sexual partners significantly increased with the number of psychosocial problems, supporting evidence of syndemic production. CONCLUSIONS: We identified a particularly high-risk subgroup in the MSM population with considerable psychosocial problems that may be reached online. Research is needed on how to engage these high-risk men in combination prevention interventions.

Anal intercourse without condoms among HIV-positive men who have sex with men recruited from a sexual networking web site, United States.

BACKGROUND: The changing landscape of HIV prevention in the United States underscores the need to improve our ability to efficiently reach HIV-positive men who have sex with men (MSM) who engage in behaviors that could transmit HIV. METHODS: We examined the prevalence of anal intercourse (AI) without condoms with HIV-negative or unknown serostatus partners ("at-risk partners") among 1319 HIV-positive adult male members of a sexual networking Web site for MSM. Sexual behaviors and substance use were measured over a 60-day recall period. Logistic regression was used to identify correlates of insertive and receptive AI without condoms with at-risk partners. RESULTS: Approximately 25% of the men had been diagnosed as having HIV 12 months or less before study enrollment. Overall, 32% of men engaged in AI without condoms with at-risk partners. Multiple logistic regression identified behavioral predictors of insertive AI without condoms with at-risk partners, including HIV diagnosis within the last 12 months, sex with multiple male partners, substance use in conjunction with sex, and use of phosphodiesterase type 5 inhibitors. Receptive AI without condoms with at-risk partners was associated with younger age (19-24 years), residing outside metropolitan cities, substance use in conjunction with sex, and having multiple male partners. CONCLUSIONS: High levels of sexual risk were found among these MSM. Increased Internet-based HIV prevention marketing efforts and prevention strategies should be considered to efficiently reach HIV-positive MSM who engage in serodiscordant AI without condoms.

Newly identified HIV infections in correctional facilities, United States, 2007.

We used Centers for Disease Control and Prevention HIV Counseling and Testing System data from 2007 to determine the percentage and characteristics of persons newly identified as HIV-positive in US correctional facilities. The newly identified HIV positivity was 0.7%, and 30% of detainees newly identified with HIV were categorized as having low-risk heterosexual contact or no acknowledged risk. Correctional facilities should provide detainees with routine opt-out HIV testing, unless the prevalence of previously undiagnosed HIV infection has been documented to be less than 0.1%.

'Never testing for HIV' among men who have sex with men recruited from a sexual networking website, United States.

HIV testing was assessed online among men accessing a sexual networking website for men who have sex with men. Most of the 8,040 participants reported HIV testing (58.2% ≤ 1 year; 33.1% > 1 year) and 17.1% were HIV-positive. Overall, 8.6% of men including 24% of those 18-24 years of age had never been tested. Among never testers, 25% did not know where to get tested. Predictors of never being tested included younger age (18-24), bisexual or heterosexual orientation, living outside of large metropolitan areas, and not having a healthcare provider. Increasing access to and knowledge of HIV testing sites is needed.

Costs and Consequences of Eliminating a Routine, Point-Of-Care HIV Screening Program in a High-Prevalence Jail.

INTRODUCTION: This study aims to assess the public health impact of eliminating a longstanding routine HIV screening program and replacing it with targeted testing. In addition, costs, outcomes, and cost effectiveness of routine screening are compared with those of targeted testing in the Fulton County Jail, Atlanta, Georgia. METHODS: A published mathematical model was used to assess the cost effectiveness and public health impact of routine screening (March 2013-February 2014) compared with those of targeted testing (January 2018-December 2018) from a health system perspective. Costs, outcomes, and other model inputs were derived from the testing programs and the published literature, and the cost effectiveness analysis was conducted from 2019 to 2020. RESULTS: Routine screening identified 74 more new HIV infections over 1 year than targeted testing, resulting in an estimated 10 HIV transmissions averted and 45 quality-adjusted life-years saved, and was cost saving. The missed opportunity to diagnose infections because routine screening was eliminated resulted in an estimated 8.4 additional HIV transmissions and $3.7 million in additional costs to the healthcare system. CONCLUSIONS: Routine HIV screening in high-prevalence jails is cost effective and has a larger impact on public health than targeted testing. Prioritizing sustained funding for routine, jail-based HIV screening programs in high-prevalence areas may be important to realizing the national HIV prevention goals.

HIV Data to Care-Using Public Health Data to Improve HIV Care and Prevention.

BACKGROUND: "Data to Care" (D2C) is a public health strategy that uses surveillance and other data to improve continuity of HIV care for persons with HIV (PWH) by identifying those who are in need of medical care or other services and facilitating linkage to these services. The primary goal of D2C is to increase the number of PWH who are engaged in care and virally suppressed. METHODS: Data to Care can be implemented using several approaches. Surveillance-based D2C is usually initiated by health departments, using HIV surveillance and other data to identify those not in care. Health care providers may also initiate D2C by identifying patients who may have fallen out of care and working collaboratively with health departments to investigate, locate, and relink the patients to medical care or other needed services. RESULTS: Although D2C is a relatively new strategy, health department D2C programs have reported both promising results (eg, improved surveillance data quality and successful linkage to or re-engagement in care for PWH) and challenges (eg, incomplete or inaccurate data in surveillance systems, barriers to data sharing, and limitations of existing data systems). CONCLUSIONS: Data to Care is expected to enable health departments to move closer toward achieving national HIV prevention goals. However, additional information on appropriate implementation practices at each step of the D2C process is needed. This JAIDS Special Supplement explores how CDC funding to state health departments (eg, technical assistance and demonstration projects), and partnerships across federal agencies, are advancing our knowledge of D2C.

Effect of a brief video intervention on incident infection among patients attending sexually transmitted disease clinics.

BACKGROUND: Sexually transmitted disease (STD) prevention remains a public health priority. Simple, practical interventions to reduce STD incidence that can be easily and inexpensively administered in high-volume clinical settings are needed. We evaluated whether a brief video, which contained STD prevention messages targeted to all patients in the waiting room, reduced acquisition of new infections after that clinic visit. METHODS AND FINDINGS: In a controlled trial among patients attending three publicly funded STD clinics (one in each of three US cities) from December 2003 to August 2005, all patients (n = 38,635) were systematically assigned to either a theory-based 23-min video depicting couples overcoming barriers to safer sexual behaviors, or the standard waiting room environment. Condition assignment alternated every 4 wk and was determined by which condition (intervention or control) was in place in the clinic waiting room during the patient's first visit within the study period. An intent-to-treat analysis was used to compare STD incidence between intervention and control patients. The primary endpoint was time to diagnosis of incident laboratory-confirmed infections (gonorrhea, chlamydia, trichomoniasis, syphilis, and HIV), as identified through review of medical records and county STD surveillance registries. During 14.8 mo (average) of follow-up, 2,042 patients (5.3%) were diagnosed with incident STD (4.9%, intervention condition; 5.7%, control condition). In survival analysis, patients assigned to the intervention condition had significantly fewer STDs compared with the control condition (hazard ratio [HR], 0.91; 95% confidence interval [CI], 0.84 to 0.99). CONCLUSIONS: Showing a brief video in STD clinic waiting rooms reduced new infections nearly 10% overall in three clinics. This simple, low-intensity intervention may be appropriate for adoption by clinics that serve similar patient populations. TRIAL REGISTRATION: http://www.ClinicalTrials.gov (#NCT00137670).

Effects of a brief video intervention on treatment initiation and adherence among patients attending human immunodeficiency virus treatment clinics.

BACKGROUND: Persons with human immunodeficiency virus (HIV) who get and keep a suppressed viral load are unlikely to transmit HIV. Simple, practical interventions to help achieve HIV viral suppression that are easy and inexpensive to administer in clinical settings are needed. We evaluated whether a brief video containing HIV-related health messages targeted to all patients in the waiting room improved treatment initiation, medication adherence, and retention in care. METHODS AND FINDINGS: In a quasi-experimental trial all patients (N = 2,023) attending two HIV clinics from June 2016 to March 2017 were exposed to a theory-based, 29-minute video depicting persons overcoming barriers to starting treatment, taking medication as prescribed, and keeping medical appointments. New prescriptions at index visit, HIV viral load test results, and dates of return visits were collected through review of medical records for all patients during the 10 months that the video was shown. Those data were compared with the same variables collected for all patients (N = 1,979) visiting the clinics during the prior 10 months (August 2015 to May 2016). Among patients exposed to the video, there was an overall 10.4 percentage point increase in patients prescribed treatment (60.3% to 70.7%, p< 0.01). Additionally, there was an overall 6.0 percentage point improvement in viral suppression (56.7% to 62.7%, p< 0.01), however mixed results between sites was observed. There was not a significant change in rates of return visits (77.5% to 78.8%). A study limitation is that, due to the lack of randomization, the findings may be subject to bias and secular trends. CONCLUSIONS: Showing a brief treatment-focused video in HIV clinic waiting rooms can be effective at improving treatment initiation and may help patients achieve viral suppression. This feasible, low resource-reliant video intervention may be appropriate for adoption by other clinics treating persons with HIV. TRIAL REGISTRATION: http://www.ClinicalTrials.gov (NCT03508310).

Shifting Resources and Focus to Meet the Goals of the National HIV/AIDS Strategy: The Enhanced Comprehensive HIV Prevention Planning Project, 2010-2013.

In September 2010, CDC launched the Enhanced Comprehensive HIV Prevention Planning (ECHPP) project to shift HIV-related activities to meet goals of the 2010 National HIV/AIDS Strategy (NHAS). Twelve health departments in cities with high AIDS burden participated. These 12 grantees submitted plans detailing jurisdiction-level goals, strategies, and objectives for HIV prevention and care activities. We reviewed plans to identify themes in the planning process and initial implementation. Planning themes included data integration, broad engagement of partners, and resource allocation modeling. Implementation themes included organizational change, building partnerships, enhancing data use, developing protocols and policies, and providing training and technical assistance for new and expanded activities. Pilot programs also allowed grantees to assess the feasibility of large-scale implementation. These findings indicate that health departments in areas hardest hit by HIV are shifting their HIV prevention and care programs to increase local impact. Examples from ECHPP will be of interest to other health departments as they work toward meeting the NHAS goals.

A qualitative study of substance use and sexual behavior among 18- to 29-year-old men while incarcerated in the United States.

The article describes men's perceptions of and experience with substance use and sexual behavior during incarceration. Grounded theory content analyses were performed on qualitative interviews conducted with 80 men, aged 18 to 29, in four U.S. states. Participants believed that drugs were easily available in prison. Half reported using substances, primarily marijuana or alcohol, while incarcerated. Key themes included the role of correctional personnel in the flow of substances in prison and the economic significance of substance trafficking. With regard to sexual behavior, most men acknowledged that it occurred but were hesitant to talk in-depth about it. There was a strong belief in "don't look, don't tell," and sex in prison was often associated with homosexual behavior or identity. Sex during incarceration was reported by 12 men, mostly with female partners. Participants were pessimistic about HIV/STD/hepatitis prevention efforts inside correctional facilities. These findings highlight the need for risk reduction programs for incarcerated men.

Relationship between social cognitive theory constructs and self-reported condom use: assessment of behaviour in a subgroup of the Safe in the City trial.

OBJECTIVES: Previous studies have found social cognitive theory (SCT)-framed interventions are successful for improving condom use and reducing sexually transmitted infections (STIs). We conducted a secondary analysis of behavioural data from the Safe in the City intervention trial (2003-2005) to investigate the influence of SCT constructs on study participants' self-reported use of condoms at last intercourse. METHODS: The main trial was conducted from 2003 to 2005 at three public US STI clinics. Patients (n=38,635) were either shown a 'safer sex' video in the waiting room, or received the standard waiting room experience, based on their visit date. A nested behavioural assessment was administered to a subsample of study participants following their index clinic visit and again at 3 months follow-up. We used multivariable modified Poisson regression models to examine the relationships among SCT constructs (sexual self-efficacy, self-control self-efficacy, self-efficacy with most recent partner, hedonistic outcome expectancies and partner expected outcomes) and self-reported condom use at last sex act at the 3-month follow-up study visit. RESULTS: Of 1252 participants included in analysis, 39% reported using a condom at last sex act. Male gender, homosexual orientation and single status were significant correlates of condom use. Both unadjusted and adjusted models indicate that sexual self-efficacy (adjusted relative risk (RRa)=1.50, 95% CI 1.23 to 1.84), self-control self-efficacy (RRa=1.67, 95% CI 1.37 to 2.04), self-efficacy with most recent partner (RRa=2.56, 95% CI 2.01 to 3.27), more favourable hedonistic outcome expectancies (RRa=1.83, 95% CI 1.54 to 2.17) and more favourable partner expected outcomes (RRa=9.74, 95% CI 3.21 to 29.57) were significantly associated with condom use at last sex act. CONCLUSIONS: Social cognitive skills, such as self-efficacy and partner expected outcomes, are an important aspect of condom use behaviour. TRIAL REGISTRATION NUMBER: clinicaltrials.gov (NCT00137370).

An online randomized controlled trial evaluating HIV prevention digital media interventions for men who have sex with men.

BACKGROUND: As HIV infection continues unabated, there is a need for effective interventions targeting at-risk men who have sex with men (MSM). Engaging MSM online where they meet sexual partners is critical for HIV prevention efforts. METHODS: A randomized controlled trial (RCT) conducted online among U.S. MSM recruited from several gay sexual networking websites assessed the impact of 2 HIV prevention videos and an HIV prevention webpage compared to a control condition for the study outcomes HIV testing, serostatus disclosure, and unprotected anal intercourse (UAI) at 60-day follow-up. Video conditions were pooled due to reduced power from low retention (53%, n = 1,631). No participant incentives were provided. PRINCIPAL FINDINGS: Follow-up was completed by 1,631 (53%) of 3,092 eligible men. In the 60 days after the intervention, men in the pooled video condition were significantly more likely than men in the control to report full serostatus disclosure ('asked and told') with their last sexual partner (OR 1.32, 95% CI 1.01-1.74). Comparing baseline to follow-up, HIV-negative men in the pooled video (OR 0.70, 95% CI 0.54-0.91) and webpage condition (OR 0.43, 95% CI 0.25-0.72) significantly reduced UAI at follow-up. HIV-positive men in the pooled video condition significantly reduced UAI (OR 0.38, 95% CI 0.20-0.67) and serodiscordant UAI (OR 0.53, 95% CI 0.28-0.96) at follow-up. CONCLUSIONS/SIGNIFICANCE: Findings from this online RCT of MSM recruited from sexual networking websites suggest that a low cost, brief digital media intervention designed to engage critical thinking can increase HIV disclosure to sexual partners and decrease sexual risk. Effective, brief HIV prevention interventions featuring digital media that are made widely available may serve as a complementary part of an overall behavioral and biomedical strategy for reducing sexual risk by addressing the specific needs and circumstances of the target population, and by changing individual knowledge, motivations, and community norms. TRIAL REGISTRATION: ClinicalTrials.gov NCT00649701.

Safe in the city: effective prevention interventions for human immunodeficiency virus and sexually transmitted infections.

BACKGROUND: The public health literature documents the efficacy-effectiveness gap between research and practice resulting from the research priority of demonstrating efficacy at the expense of testing for effectiveness. PURPOSE: The Safe in the City video-based HIV/sexually transmitted infection (STI) prevention intervention designed for sexually transmitted disease (STD) clinic waiting rooms is presented as a case study to demonstrate the application of a new framework to bridge efficacy and effectiveness. The goal of the study is to determine the extent to which clinics are implementing the intervention. METHODS: As part of the case study, data were collected from a convenience sample of 81 publicly funded STD clinics during program implementation to determine whether clinics were showing the video. A baseline telephone survey was administered to clinic directors from November to December 2008, and a follow-up was conducted from March to May 2009. Data analysis was completed in 2009. RESULTS: At baseline, 41% of STD clinics were showing Safe in the City, which increased to 58% at follow-up. None reported previous implementation of behavioral interventions delivered in waiting rooms. Almost one fourth of clinics adapted the intervention by showing the video on laptop computers in examination rooms or in other venues with different audiences. CONCLUSIONS: The Safe in the City intervention was implemented by the majority of STD clinics and adapted for implementation. The framework for HIV/STI prevention intervention illustrates how measures of effectiveness were increased in the development, evaluation, dissemination, implementation and sustainability phases of research and program.

Girlfriends: evaluation of an HIV-risk reduction intervention for adult transgender women.

This study evaluated Girlfriends, a behavioral HIV intervention, developed for male-to-female transgender persons, for whom there are few scientifically evaluated prevention programs. The Girlfriends intervention included four group-level sessions. We used a single group, pre-post test design to assess changes in sexual risk behaviors at 3-month follow-up. We enrolled 63 transgender women into the study. Forty-six percent were Hispanic and 35% were African American. Three months after the intervention, participants had fewer sexual partners (p = .043) and were less likely to have any unprotected anal intercourse (UAI) with male exchange partners (p = .013) and unprotected sex at last vaginal or anal sex episode with female and male partners (p = .039). The findings of this study are promising. We observed behavioral effects among a largely ethnic minority sample of transgender women. Replication with a larger sample and a control group is needed.