Educating on the risks of HIV and alcohol

The U.S. Agency for International Development (USAID) is encouraging healthcare providers in developing countries to use an evidence-based intervention designed by researchers at UConn’s Center for Health, Intervention, and Prevention (CHIP) to reduce alcohol-related HIV risk behaviors in South Africa.

USAID recently published a case study on the Phaphama (“Wise Up” in the Zulu language) intervention, developed by Seth Kalichman, a UConn professor of psychology and principal investigator at CHIP, and Leickness Simbayi of the South Africa Human Sciences Research Council, who is also a CHIP PI. The study cites the “dramatic behavior change” Phaphama produced in the months following a single, 60-minute counseling session offered to repeat patients at a sexually transmitted infection (STI) clinic in Cape Town, South Africa.

A randomized, controlled trial funded by the National Institute on Alcohol Abuse and Alcoholism showed that Phaphama reduced unprotected sexual acts by 65 percent – a change that was sustained for a six-month period.

Kalichman and Simbayi conducted the trial, which included 143 STI patients, at the main STI clinic in Cape Town between 2005 and 2009.

USAID describes Phaphama as “unique,” in that the intervention addresses “the convergence of two severe public health problems (harmful alcohol use and HIV) that are well recognized in South Africa but rarely addressed in tandem.” USAID also credits Kalichman and Simbayi for targeting one of the highest-risk populations – STI patients – at a time when they might be most receptive to making positive behavior changes.

“Alcohol and sexual risks are closely associated,” says Kalichman. “There are several reasons why, including clouded decision making, sexual expectations, and social norms, so breaking the alcohol and sexual risk cycle is well recognized as a promising strategy.

“But, for an intervention to work,” he says, “you have to have people’s attention. That is why an STI clinic offers such a promising opportunity for prevention. When people are diagnosed with an STI, like syphilis or gonorrhea, it can be a wake-up call, a teachable moment that opens the door for a brief intervention to reduce HIV risks. In South Africa, where as many as one in five people have HIV and alcohol use is among the highest in the world, the importance of such an intervention is clear.

Kalichman also added that working with the highest-risk individuals in a location with a high prevalence of HIV makes the 65 percent reduction in unprotected sexual acts for six months “quite meaningful from a public health perspective.”

Kalichman and Simbayi’s first step in creating Phaphama was to design an HIV education and risk-reduction counseling program for patients receiving treatment at Cape Town’s main STI clinic.

Then, following input from several clinic nurses who believed alcohol use might be an obstacle to patients’ success with the program, the collaborators added content on alcohol use as a risk factor for HIV to their original HIV risk-reduction counseling program. They did this by adapting the Brief Intervention for Hazardous and Harmful Drinking, an approach promoted by the World Health Organization.

Kalichman and Simbayi also met with relevant clinic staff members and researchers to ensure their content was culturally relevant. For example, they adapted some of the images used in the intervention’s visual aids, added information to counter common HIV myths heard in the townships, and added culturally relevant information on HIV-related stigma.

Before the start of the one-time, 60-minute counseling session, patients completed a 10-question test that assessed their alcohol use behaviors and alcohol risk category.

During the counseling session, a counselor devoted the first 20 minutes to HIV education and another 20 minutes to identifying and analyzing personal HIV risk triggers with the patient and assessing how ready the patient felt to make changes to reduce those risks. Then patients whose test scores suggested they engaged in high-risk drinking received counseling on alcohol use and how it could be a trigger for risky sexual behavior. The alcohol component of the session ended with the counselor asking the patient to document a concrete plan to reduce his or her drinking. The remainder of the session was devoted to skills building in condom use and negotiation, and to role-playing risk scenarios from the patient’s past with the goal of averting similar risks in the future.

Patients in the trial were randomly assigned to receive either the Phaphama intervention or a 20-minute one-on-one HIV education session.

In addition to the 65 percent reduction in unprotected sexual acts, the trial also found Phaphama participants lowered their alcohol use before sex and were less likely to believe alcohol use would enhance sexual pleasure. Those results were sustained for three months, compared to six months for the dramatic reduction in unprotected sexual acts.

USAID credits Kalichman and Simbayi for maximizing Phaphama’s potential for success by adapting evidence-based programs and capitalizing on existing healthcare infrastructure, as well as addressing the two public health problems in tandem at a time when individuals might be most receptive to change. USAID also notes that the counselors and patients appreciated Phaphama’s personalized approach.

Among the challenges USAID flag for healthcare providers interested in adapting and using Phaphama are a lack of community-based support for sustaining risk reduction over time, and a lack of services for the treatment of alcohol dependency in many locations.

“Because it is based on well-researched behavior-change theory and counseling models that have been implemented with success in many parts of the world, programmers may find the content relatively simple to replicate once basic cultural adaptations are made,” the USAID case study states. “However, successful implementation of the program also requires human and financial resources to be made available for training and ongoing monitoring and support of the clinic staff that will implement the program and to ensure adequate clinic space is available for the uninterrupted private counseling sessions.”

Kalichman says his research team has conducted a subsequent, larger trial of Phaphama, which supported the first trial’s results. The results from the larger trial currently are under review for publication.