Interventions with proven efficacy in reducing HIV-transmission by people with HIV have been costly in terms of time and resources. But a US study now indicates that self-monitoring – checking one's own behaviour over time - “is a relatively low cost and easily implementable strategy” that can be implemented in a clinic setting.
Reducing HIV transmission from HIV-positive people is particularly important with treatment advances, because extended lifespans “can result in more time and opportunities for transmission of HIV to occur”, note Marguerita Lightfoot and colleagues in the July issue of AIDS Care.
Proven interventions are based on cognitive-behavioural, skills-building approaches that aim to motivate behaviour change, but may cost US$250-1500 per participant and are highly staff-intensive.
Although such interventions can result in large reductions in unsafe sexual behaviour (around 70-80%), they may only influence a small proportion of HIV-positive people who are able to participate. So the team from the University of California, Los Angeles, proposed self-monitoring as a cost-effective way of producing smaller reductions (up to 30%) in unsafe sexual behaviour among a larger proportion of people with HIV.
Lightfoot and co-workers noted that in HIV prevention clinical trials, the control group also decreased their unsafe sexual behaviours over time, “by as much as 30% among varied groups”, with the sole intervention of repeated behaviour assessments.
Such questions brought up issues patients often had not considered, said Lightfoot. "In other studies, we often heard participants say, 'Oh, I never really thought about my behavior like that' when they completed study assessments . . . It appeared that by completing the self-assessments, people reflected on their own behavior and changed their behavior”, she said in a press release.
Self-monitoring has been used successfully in other disorders such as diabetes and smoking cessation. So the team recruited 365 HIV-positive people who had had more than one clinical assessment prior to the intervention.
Participants completed a self-assessment interview while waiting for regular medical appointments at their clinics, roughly one every 3 months for up to four sessions. Interviews were conducted by audio computer-assisted self interview (ACASI) at a computer sited away from the waiting area.
Participants reported demographic data, then completed questions on sexual behaviour, including number of sexual partners, and for the first five partners, their partners' HIV status, number of sexual acts, and condom usage. Finally, participants rated their risk of another sexually transmitted infection.
The findings showed that the more self-assessments completed, the higher the odds were that participants would use condoms when having sex with HIV-negative partners or partners whose HIV status was unknown (p = 0.01), circumstances where new HIV transmission is most likely to occur.
The researchers also found that sexual activity tended to decrease over time, with more completed assessments.
Participants also rated their risk of contracting other sexually transmitted diseases more highly (p = 0.05). But neither the number of sex partners nor the fraction of protected acts with all partners showed any significant changes over time with increases in the number of self-assessments.
“Our results support the use of computers and self assessments as a tool for HIV prevention,” the authors write. Such straightforward interventions are more likely to be sustained, are easier to implement, and utilise far fewer resources than complex interventions that require considerable staff skills.
A key limitation of the study is use of self-report data, although ACASI offers “a level of privacy that dramatically affects responses about sensitive behaviours”, note the authors.
They conclude that “the computerized self-assessment may also be of value for identifying those people with HIV in need of additional intervention by providing objective summaries of patient’s behaviour.”
Reference
Lightfoot M et al. Self-monitoring of behaviour as a risk reduction strategy for persons
living with HIV. AIDS Care 19: 757-63, 2007.