The TAILORED PROGRAMS listed in the menu to the left of this page share strategies used by rural providers to reduce specific risk behaviors in a defined group of people. Because most of the programs have not been rigorously evaluated in the rural context, they are described here as programs that may work for rural HIV prevention.

Behavioral Interventions

1) sharing information with the whole community about HIV/STD, how it passes from person to person, and encouraging acceptance of those at risk for and infected with HIV and other STDs (Chapter 3);

2) implementing a surveillance system to identify those who are infected and monitor risk behaviors (Chapters 4 and Chapter 5);

3) providing care and treatment for those living with HIV/AIDS and those diagnosed with another STD (Chapter 6); and

4) motivating groups at risk of infection to reduce or eliminate risky behaviors.

All of these activities work best when they take into account community needs, values, and resources as well as the target audience’s needs, values, and experience. This chapter focuses on the fourth activity, behavior change, and introduces interventions intended to motivate individuals to reduce or eliminate risky behaviors to prevent both the transmission and acquisition of HIV and other STDs.

The spread of HIV and STDs depends on two things: the risky things people do, and doing those risky things with people who are infected with HIV, hepatitis, or another STD. The most common behaviors that put people at risk for HIV and other STDs involve: having anal sex without a condom; having vaginal sex without a condom; having more than one sex partner; having an untreated STD; sharing drugs, injection works or needles that have been in contact with an infected person’s blood, and having a sex partner who injects drugs or has had unprotected sex with an infected individual.

Certain realities inherent in rural America can lead some people into risky behaviors. For instance, rural MSM may seek sex partners through the Internet or in a place away from home because there are few potential partners in their rural area or because they want to prevent local disclosure of their sexual orientation. Long-haul truckers and migrant farm workers may engage in unprotected intercourse with a sex worker or casual partner. Rural methamphetamine users may have unprotected sex with multiple partners, some of whom may be sharing injection works. These same partners may also travel between rural areas or to urban areas to buy or sell drugs, exchange sex for drugs, or to party with other drug-users, creating a pathway for the spread of HIV and other STDs into and between rural communities.

HIV/STD behavioral interventions that have been shown to change risk behaviors have some common characteristics. Interventions are considered efficacious if rigorous evaluation has shown that they reduce high-risk sexual and drug use behaviors over time and increase safer sex attitudes, self-efficacy, behavioral intentions, and protective social norms. Interventions work better when they are tailored for a specific target audience. They can target the community, small groups, individuals, or employ strategies at multiple levels to initiate behavior change. Interventions are more likely to change behavior when designed to impact the underlying factors (behavioral determinants) that have been shown through research to contribute to health behavior. For HIV/STD prevention, interventions commonly target behavioral determinants such as knowledge, skills, attitudes, beliefs, perceived risk, perceived severity of consequences, self-efficacy, behavioral intentions, and social norms.

To have the greatest impact, HIV/STD behavioral interventions should target both risky behaviors and people at heightened risk for infection. Epidemiological data can help to identify groups at heightened risk and risky behaviors. For example, more than two-thirds of rural males diagnosed with HIV in 2008 reported they were exposed to HIV through having sex with other men. About 12% of rural males diagnosed with HIV in 2008 reported being exposed by injecting drugs and another 20% reported being exposed by having sex with a woman. In contrast to men, over 80% of rural women diagnosed with HIV/AIDS attribute their disease exposure to having sex with a man; more than 15% attributed their exposure to injecting drugs. In 2008, women living in rural areas diagnosed with HIV were slightliy more likely than women in urban areas to be exposed to HIV by injecting drugs.[1]

In addition to targeting specific risk groups and behaviors, interventions should consider the social and cultural contexts in which risk behaviors occur. Some rural prevention specialists worry that behavioral interventions designed for urban populations may not work the same for rural populations because rural contexts differ from urban contexts. This is a reasonable concern since few evidence-based interventions have been developed for and tested with rural populations. The following sections address that concern by outlining steps to select behavioral interventions that address the risk behaviors in the community regardless of whether it is rural or urban. Then, steps for adapting that intervention to fit the social and cultural contexts are presented. By combining knowledge of local disease patterns, community risks, assets, and needs with the knowledge of what works to change risk behaviors, rural prevention specialists can decide:

1) if a behavioral intervention is needed,

2) what intervention would be best suited to change the risk behaviors, and

3) what adaptations may be needed to make the intervention successful in the rural setting.

Adapted from DiClemente and Peterson (1994), Kirby (2001), Herbst (2005) and Noar (2008) [2-5]

When should HIV behavioral interventions be used?

How does a community decide whether and when to implement a behavioral HIV/STD intervention? The first step is to gather information to assess the community’s health needs, available resources, and cultural views about HIV/STD. However, this process requires a person, organization, or task force to coordinate the collection, analysis, and interpretation of community information. This role can be filled by a public health official, community activist, local medical care provider or group of providers, community-based organization, or a community task force that includes a multitude of people who are invested in HIV/STD prevention.

During the assessment process, it may become evident that there are competing health needs and inadequate resources to address all the existing needs fully. To justify allocating resources for HIV/STD prevention, rural communities need HIV/STD information from two surveillance systems: one that detects, reports, and responds to incident and prevalent cases of STDs and HIV/AIDS and a second that tracks behaviors that increase the risk of HIV and STD transmission. That said, gathering disease surveillance data in rural areas may be less than straightforward due to health department policies that limit the release of data when reporting small numbers of infections could compromise confidentiality. Consequently, the DIS may become an important channel for identifying a change in disease incidence or exposure in a rural community. Tracking risk behaviors may also be challenging since national survey data may not be applicable to some rural areas. Community assessment teams may need to look for innovative data sources (social services records, key informant interviews, or local observations) to document existing and changing risk behaviors.

If disease surveillance shows that HIV and sentinel STDs are not very prevalent in a rural community at a particular point in time, then surveillance and community activities that increase awareness and reduce stigma may suffice for the time. (See Chapter 3 for more information about community awareness campaigns and Chapters 4 and 5 for more information about early detection and how to respond to new cases of HIV/STD.) In areas with low disease prevalence, local health care providers need to at least be asking patients about risk behaviors, screening for HIV/STD among those at heightened risk, providing treatment or linking to care, reporting new infections, providing individual risk reduction counseling, and initiating partner services. Consequently, improving risk assessment and HIV/STD screening practices among health and mental health care providers may be a reasonable place for rural communities with low HIV/STD prevalence to start. Training for providers is available through regional AETCs and STD/HIV Prevention Training Centers.

On the other hand, an increase in new cases of STDs, particularly syphilis or hepatitis B and C, may warrant expending resources on an HIV/STD behavioral intervention. There are many options for primary and secondary HIV/STD prevention that are appropriate for the needs in rural areas, and behavioral interventions are one option when an HIV/STD problem has been identified. The key is to have a process in place by which a rural community can determine when there is an increase in infection, who is being infected, how infection is spreading, what resources are available to conduct an intervention, and what behaviors contributing to transmission can be modified by an intervention of some kind.

Interventions promoted through the Diffusion of Effective Behavioral Interventions (DEBI) project have been designed to target a wide range of populations and risky behaviors. DEBIs target the community, small groups, individuals, or use multiple intervention levels to reduce risk behaviors among individuals at heightened risk for HIV/STD. DEBIs require varying levels of resources to implement and sustain. Expenses involved in implementing DEBIs may include costs associated with program materials, travel for training personnel or for participants, and developing adequate organizational infrastructure to implement and evaluate the program.

One concern voiced by those in rural areas is that allocation of government funds for the implementation of DEBIs may be prioritized based on HIV/STD prevalence or spikes in incidence of disease or risk behaviors, which generally are higher in urban areas. Although this perception may oversimplify the allocation process, it highlights the importance of rural areas having a system in place to track emerging risk behaviors and incident STDs in order to document a new problem and secure intervention funding when needed. In addition, the system needs to specify who is responsible for routinely reviewing these data and what level of change might warrant intervention. Lastly, such a system needs to define the process by which an intervention would be selected that would meet the identified need and be feasible given the resources available.

Selecting an HIV/STD Behavioral Intervention

After a community decides that disease and behavioral surveillance justify the need for a behavioral intervention, the following four-step process should guide selection of a program that is likely to change the desired behavior in the specific at-risk population.

Step one is to look at HIV/STD needs in the community to determine who is getting infected with HIV and other STDs, what behaviors are contributing to disease transmission, where those people gather or would feel safe gathering, how they might be reached, and the context in which risk behaviors are occurring. This assessment should lead to the definition of one or more HIV/STD problems faced by the community and the identification of the at-risk population to be targeted for intervention. This is also the time to assess the resources needed and available to address the problem, as well as the readiness of the community and target group to act or make changes. Much of this assessment may have been completed prior to getting to the selection process.

A crucial part of the first step is to determine which behaviors (e.g., unprotected sex, sharing unclean syringes or injection works) are putting community members at risk for HIV/STD. Equally important is the creation of a list of behavioral determinants that could be modified to initiate behavior change. Focus groups composed of members of the target audience may generate this list of behavioral determinants. The process may also reveal social and structural determinants of risk behaviors such as poverty, stigma, a lack of access to health care, and/or policies that impact risk behaviors (e.g., needle exchange policies). Although social and structural determinants may not be used to select a behavioral intervention, an understanding of those determinants may be useful later when thinking about adapting a prevention program.

A logic model is a useful tool that explicitly shows the rationale that links the HIV/STD problem in the community to the risk behaviors/behavioral determinants and then to the intervention strategies that have been shown effective in creating positive change. Some excellent resources for developing logic models can be found online at Tools for Building Culturally Competent HIV Prevention Programs.[6]

Step two requires matching the target audience, HIV/STD risk behaviors, and behavioral determinants of the community with those targeted by available effective behavioral interventions. Several websites list the intended target audience, targeted behaviors and behavioral determinants, and describe program activities and strategies of effective interventions (www.effectiveinterventions.org/ and www.cdc.gov/hiv/topics/research/prs/evidence-based-interventions.htm). It is important to thoroughly understand the intervention being considered by reviewing the literature that describes the program elements in detail. If the initial matching process identifies multiple programs that target the same audience and behaviors but use different strategies to achieve the desired outcomes, more than one program can be reviewed in step three when required program resources are matched with organization and community capacity.

Step three begins after the initial matching process and involves assessing the organization’s readiness and capacity to implement the different options. Capacity depends, in part, on availability of organizational resources such as staff, space, and funding. It is equally important to assess the capacity of the organization to recruit, retain and work with the target audience, and to overcome challenges unique to the community such as stigma or lack of public transportation.

Step four the final selection, should be guided by matching the capacity of the organization with the requirements of the intervention. It is necessary to have adequate resources to conduct an intervention as designed to achieve the anticipated outcomes. If the organization does not have the capacity to implement the best-matched intervention despite a demonstrated need, the state/territorial AIDS director or STD director may be able to recommend a capacity building assistance provider. If the organization is having difficulty selecting an intervention, the STD/HIV Prevention Training Centers offer training to help organizations select, adapt, and implement effective HIV/STD behavioral interventions.

Throughout the selection, adaptation, and implementation process, planners and implementers must keep issues of cultural sensitivity and program sustainability in mind. Insuring that a program is culturally appropriate for the specific audience(s) will improve the likelihood of that program’s effectiveness. Identifying the correct personnel with the cultural competence, appropriate skills, and connections to the target community is a particular challenge in small communities. The recent publication Tools for Building Culturally Competent HIV Prevention Programs provides excellent tips for adapting tested programs to become culturally appropriate for a given community.6 Planning for a program to be continued long enough to make a difference is important as well since it often takes multiple years to gain the trust of populations at heightened risk of infection. This requires both ongoing funding (whether from repeat or new sources) and the ability to replace staff to maintain program continuity.

Adapting an HIV/STD Behavioral Intervention

Even after the best-matched intervention is selected, there may be a need to adapt it to the unique local context in which the intervention will be implemented. Information gathered in the selection process should help determine what, if any, adaptations might be useful. The CDC recommends that when making program adaptations, it is critical to keep the “core elements” in place. Core elements are key foundations of the program that, if changed, are believed to potentially render the program ineffective.[7, 8, 9] Although each intervention has a unique set of core elements, most have to do with content, the number and order of sessions, and the specific way the intervention is delivered.

Adaptation should address contextual, cultural, and structural needs identified during the selection process. Program elements that can be changed to adapt a program to the rural context may include:

• changing elements of the program to better fit rural culture and social contexts
• changing language to terms and phrases used by the target audience
• using examples that reflect the experience of the target audience
• changing the days or times when the program meets to fit the target audience’s needs
• changing location to meet the target audience where they congregate or feel safe

Adaptations should be carefully planned and documented to monitor success or guide future revisions. Adaptations should be piloted and evaluated to see how well they are received by the participants and whether the program, as adapted, results in the expected changes in the behavioral determinants. If the pilot uncovers shortcomings, then the intervention should be modified accordingly and piloted again. Final implementation of the adapted intervention should include monitoring to ensure the core elements are being implemented with fidelity and the desired outcomes are being achieved.9 Organizations may benefit from technical assistance in adaptation from training centers, capacity building assistance providers, and state health departments or other funding agencies.

HIV/STD Behavioral Interventions that May Work in Rural Settings

The TAILORED PROGRAMS listed in the menu to the left of this page share strategies used by rural providers to reduce specific risk behaviors in a defined group of people. Because most of the programs have not been rigorously evaluated in the rural context, they are described here as programs that may work for rural HIV prevention.

The CDC has defined four Tiers of Evidence to distinguish between interventions with strong evidence of efficacy and those with weak or minimal evidence. Tier 1 and Tier 2 interventions have strong evidence of efficacy such as significant behavior changes in the intervention group but not in a comparison group. Tier 1 interventions showed behavior changes that lasted three months or more after the intervention. Tier 2 behavior changes continued one month or more after the intervention. In contrast, Tier 3 and Tier 4 interventions are based on theory and a logic model but lack adequate evidence of efficacy. Tier 3 interventions show evidence of behavior change after the intervention but lack a large enough sample or comparison group. Tier 4 interventions are theory-based and have data showing how well the program is accepted by participants, but they lack behavioral outcome measures. The CDC recommends selecting interventions from Tier 1 and 2.

Many of the programs outlined on this site are adaptations of interventions from the CDC’s DEBI program. The DEBIs adapted for rural areas that are included in this list were developed and evaluated based on earlier standards of evidence that were appropriate for the time but are not as stringent as the tiers of evidence standards applied since 2005. The two individual-level DEBIs described below have been designated as Tier 1 and 2. At this point, the tiers of evidence have not been applied to community-level interventions due to the complexity of those study designs. Consequently, the community-level interventions published in the original 1999 compendium are currently classified as “interventions included in the original compendium” rather than given a tier designation. Many of the programs referenced below fall into that category. Other programs presented on this site could be considered Tier 3 since they are based on theory, a logic model, and have shown statistically significant behavioral outcomes, but lack the required sample size or retention rate for Tier 1 or 2 inclusion. A few Tier 4 interventions are included as examples of what is being done in rural areas, although it is not clear whether they reduce HIV/STD risk behaviors.

The programs described offer an overview of some but certainly not all rural programs that may work. The focus here is on behavioral interventions to reduce HIV/STD in rural settings. Programs were identified for this review from the results of a 2006 online and fax survey soliciting information about prevention programs from 264 rural prevention specialists in the RCAP network from 39 states and the District of Columbia. Additional programs were identified by the rural HIV/STD prevention work group and from presentations at the RCAP HIV/STD Prevention in Rural Communities: Sharing Successful Strategies conference held in April 2007 at Indiana University. In many cases, rural providers have made important adaptations to enable these programs to better “fit” the rural context, and these adaptations are noted. Many rural HIV/AIDS prevention specialists also reported in the 2006 survey that there is a need for evidence-based programs specifically designed for and tested in rural areas. Some of the programs presented here may serve as a foundation for such development. Additional descriptions of the evidence-based programs and guidance for community implementation can be found in the Updated Compendium of Evidence-Based Interventions and the Provisional Procedural Guidance for Community-Based Organizations.[7,8] The CDC’s HIV/AIDS Prevention Research Synthesis website is another excellent resource for best-evidence as well as promising evidence interventions.

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