Introduction to Special Section on HIV/AIDS and Substance Use in the Caribbean (Part 3): Perspectives on Substance Abuse Treatment as HIV Prevention and Implementation Science in the Youth Culture of Web 2.0

The year August 2010 to 2011 was observed as the International Year of Youth (IYY), created by the United Nations to elevate the importance of integrating the world’s youth in decision making, including decisions related to HIV/AIDS prevention. The Joint United Nations Programme on HIV/AIDS (UNAIDS) commemorated IYY with a synthesis report called Securing the Future Today published online in July 2011 on HIV and young people aged 15 to 24 years. ¹ The epidemiology of the report was clear: 41% of new infections occur among young people; 5 million are living with HIV; and more than half of the world’s sexually transmitted infections (STIs) are diagnosed in young people (in the United States, it is approximately half). The Caribbean and Latin America constitute the third most HIV prevalent region in the world, preceded by Eastern and Southern Africa, West and Central Africa, and South Asia. HIV prevalence among young people is highest in the Caribbean (0.8% female and 0.4% male) compared with Central and South America (0.2% male and female) and can vary widely and alarmingly between countries.

The report’s recommended prevention strategy is a combination approach with commitment to engaging young people in all aspects of programming and planning. Coverage and uptake of HIV testing and related services, including testing for STIs, remain low globally. HIV knowledge, behavioral change, and service integration lag considerably. Although it is clear that evidence-based interventions exist, when these are unpacked and examined closely, actual behavioral and biological outcomes in recent trials have been frequently disappointing.

An illustration of this divergence is the MEMA kwa Vijana (Good things for young people) project in rural Tanzania. ² This was a sexual and reproductive health intervention trial for adolescents that sought to reduce HIV seroincidence and the seroprevalence of herpes simplex virus type 2 (HSV-2). The intervention was a combination approach, consisting of condom distribution and promotion, community activities, peer-assisted with teacher-led in-school education, and health services designed to be youth friendly. While there were significant effects on certain theoretical precursors of risk reduction, the impacts on behavior were limited and insufficient to produce any evidence of reductions in HIV incidence or HSV-2 prevalence, even after a 3-year follow-up. Thus, the authors’ opening statement still held true after the trial: “The ability of specific behavior-change interventions to reduce HIV infection in young people remains questionable.”

The Regai Dzive Shiri Project in rural Zimbabwe had similar results. ³ This was a cluster randomized trial of 30 communities to evaluate a combination HIV prevention intervention for young people that involved trained peer educators and a program to train providers. There were impacts on knowledge and attitudes, but no significant effects on behavior or detectable improvements in HIV or HSV-2 prevalence. This pattern is not unusual. For example, a recent systematic review of school-based behavioral interventions for youth aged 13 to 19 years concluded that such programs could be expected to improve outcomes such as knowledge and self-efficacy. ⁴ However, there was no evidence that they could alter sexual risk behavior or infection rates for STIs, at least within what the review considered short follow-up periods. Another recent review examining peer-led interventions found some evidence of positive impact on norms and attitudes but could not reach a definitive assessment of the effectiveness of this approach for reducing sexual risk behavior or STI rates because of design limitations in the studies. ⁵

Recently, Johnson et al provided an updated meta-analysis of HIV-related behavioral intervention trials involving adolescents, offering a more optimistic assessment. ⁶ Based on 98 interventions from 67 studies, they found that these interventions did succeed in reducing sexual risk behavior, and results tended to be durable. Effect sizes were larger in studies using a more intense intervention, targeting an institutionalized sample, or including a comparison group with non-HIV material. Otherwise, effect sizes were modest for outcomes such as sexual frequency, number of partners, or condom use. A review of the state of the field presented at the 2011 International AIDS Society’s annual conference in Rome reported that school-based and peer-led approaches tended to have modest behavioral outcomes and noted promising evidence in the areas of Internet-based interventions and structural interventions involving cash transfers. ⁷ Sznitman et al recently showed the importance of mass media messaging in support of community-based adolescent interventions. When included, such messaging made outcomes more durable. However, the impact of STI screening and counseling programs on risk behavior was still considered to be modest. ⁸

Although the meta-analysis by Johnson et al found unexpectedly larger effect sizes in high-risk adolescent populations that were institutionalized, the typical experience in individual studies has indicated that high-risk subgroups of young people remain a formidable challenge in HIV prevention. For example, Tolou-Shams and colleagues recently found in their systematic review that interventions for juvenile offenders can produce significant outcomes but that effect sizes are modest, with most studies still unable to integrate comorbidities such as mental health or substance use problems with HIV risk reduction. ⁹

Thus, as in adult HIV prevention, the focus is on combination interventions tailored to not only the individual psychosocial needs of the target population but also the structural context, and tying results to biological and community-wide HIV-related outcomes. Biomedical advances have only redoubled this focus, particularly since there is concern that the supply of antiretroviral treatment (ART) will remain too constrained to meet the opportunities presented by the latest trials such as HPTN 052. ¹⁰ However, there are indications that the strategy of combination approaches is not a “cure” for national HIV programs, even with the aid of early ART, PrEP, circumcision, and other biomedical innovations.

In their report on a randomized controlled trial and summary of the field, Marsch et al highlight 2 critical facts: (1) evidence-based HIV prevention interventions are not being provided to a majority of adolescents in community treatment programs for substance abuse and (2) academically based HIV interventions are not engaging the daily realities of providers or youth. ¹¹ In other words, while the academic HIV field may be ready to embrace ART treatment as prevention, there is still a paradigm shift needed when it comes to the concept of substance abuse treatment as HIV prevention and how HIV interventions become innovations for young people and their providers.

In “The Unrealized Potential of Addiction Science in Curbing the HIV Epidemic,” Volkow, Baler, and Normand focus on how “the stubbornly high incidence of new HIV infections belies the overwhelming evidence showing that sustained highly active antiretroviral therapy (HAART) has the power to dramatically reduce the spread of HIV infection and forever change the face of this devastating epidemic.” ¹² In addition to undetected cases of HIV, the main driver of new transmissions is substance use, which is the focus of their article. Their opening sentence is worth quoting at length because it dramatizes how unsolved the HIV epidemic can be even in the face of stunning achievements in a biomedical area. In this case, another area of science is needed to truly advance the field, and it involves assimilating the biological power of addiction science by integrating substance abuse treatment with HIV prevention and ART treatment and creating a culture of HIV testing and knowing one’s serostatus. We would argue that the bar should be raised to an outcome of recurrent HIV testing.

Volkow et al’s article is the latest in a series of publications led by her to articulate a strategy of substance abuse treatment as HIV transmission prevention. It is clear that HIV academic researchers must assimilate what addiction science has revealed about the reward network of the human brain, particularly the role of dopamine in substance abuse, the trajectory of cognitive and emotional dysregulation, and sexual risk behavior. In essence, the design of cognitive–behavioral HIV interventions, whether combination or otherwise, is incomplete without testable hypotheses somehow related to the knowledge that has emerged from addiction science. Biobehavioral integration in HIV prevention research, however, is rare in the United States and more so in resource-constrained regions like the Caribbean.

With at-risk youth, adolescent brain development must also be incorporated, which means taking account of the possibility of epigenetic alterations in learning, memory, and decision making, and the possible role of the gene brain-derived neurotrophic factor (BDNF). ¹³ There is evidence that BDNF may be subject to epigenetic modification, which highlights the exciting area of genes as modifiable and not just modifying agents, made possible by our advancing knowledge of the mechanisms of cellular memory that may be particularly heightened during adolescence. BDNF is the focus of a proof-of-concept study recently funded by the National Institute of Nursing Research, which concentrates on its role in decision making and HIV transmission risk behavior in a longitudinal study of Hispanic youth (1R01NR013378-01, PI-Miguez, Co-PI-Malow).

There is also a high comorbidity of substance abuse with conditions characterizing certain youth subgroups such as adolescents with attention-deficit hyperactivity disorder (ADHD). Contrary to common perception, ADHD is not a “Western” disorder. A recent metaregression analysis of global prevalence found that geographic location could not explain the high variability in prevalence estimates worldwide. ¹⁴ Studies of ADHD in middle- and low-income countries are accumulating, ¹⁵ and a recent study shows that ADHD subgroups of adolescents in these countries will also need to be a special focus of HIV prevention. ¹⁶ The study reports that childhood ADHD is predictive of sexual risk behavior in a sample of young adults. There is also evidence of a dopamine connection between risky behavior and ADHD in these youth ¹⁷ but no published studies connecting all these factors in HIV prevention.

In their report and summary of the field, Marsch et al emphasize the need for innovation in HIV prevention design in reaching youth with substance use problems and in integrating HIV risk and substance abuse into service delivery. ¹⁸ The UNAIDS report, Securing the Future Today, emphasizes the need for engagement. As a whole, there is recognition that innovation and implementation should be prioritized in the design of prevention interventions. ¹⁹ Marsch et al pinpoint the core of the challenge when it comes to young people in today’s world. Their article is primarily about findings from a randomized controlled trial of an Internet-based HIV, STI, and hepatitis prevention intervention among youth in community-based substance abuse treatment. Among the possible advantages of computer-delivered interventions, they note that such “technologies also permit temporal flexibility” and “experiential learning environments.” This identifies the fundamental problem facing HIV interventions that seek to engage youth: not only do today’s youth expect a nonstatic experience with technology, they also expect the content and process to improve in small ways over time. ²⁰ This is something that business and marketing enterprises are accustomed to fulfilling but not academic HIV prevention research. On the World Wide Web, this user experience has typically been created by Google, Facebook, and Apple, in which an operating system—or implementation system—has been created that allows for social media or Web 2.0 interaction and feedback and behind-the-scenes learning from user experience with the system.

Karl Krupp and Purnima Madhivanan are an HIV prevention team that has focused on developing combination approaches to scale-up circumcision in India. ^21,22 Their experience has made them particularly attentive to the role of implementation because of the issue of service delivery and integration with maternal and child health and reproductive services. Krupp has created the concept of learning while implementing (LWI) and emphasized the importance of expanding the field’s ability to adopt statistical and other methods from business and marketing to build innovation into the design and implementation of HIV prevention packages. Learning while implementing shares affinity with the conceptual shift advocated by Rotheram-Borus et al that would move away from replication with fidelity and incorporate “principles from marketers and entrepreneurs to facilitate design, diffusion, and utilization.” ²³