# Presentation: 205926

## Connect to Protect®

- Adolescent Prevention Trials Network (ATN) Protocols 016a, 016b & 040
- Funded by NICHD
- Co-Funded by NIDA, NIMH & NIAAA

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## Background

- Behavioral interventions focused on changing youths’  sexual behaviors are efficacious
- Increase condom use
- Decrease STIs
- Limitations of such interventions
- Difficult to sustain changes
- Difficult to reach most at-risk youth
- Difficult to translate into policies
- Focused on acquisition and not transmission of HIV
- Interventions focused on making structural changes may address these limitations

## Structural Changes

- Structural determinants of health
- Programs, practices, or policies
- Institutions, organizations, or government
- Potential structures to target
- Direct link to HIV transmission
- e.g., policies around condom availability in schools
- Indirect link to HIV transmission
- e.g., dedicated funding for substance abuse treatment programs
- Challenging to trial interventions designed to change structures
- Cost
- Time
- Rigor

## Goal of Connect to Protect®

- To reduce transmission and acquisition of HIV by catalyzing the mobilization of communities to make structural changes directly or indirectly linked to HIV transmission and acquisition

## Objective 1 

- To determine whether community mobilization catalyzed by C2P staff results in structural changes in the selected communities over 4 years

## Objective 2

- To determine whether structural changes in selected communities result in reduced HIV transmission and acquisition in the target population over the 4-year project period as indicated by
- Reduced risk reported by youth at venues over time
- Improvement in public health indicators in selected communities compared to non-selected communities over time

## Target

- 12-24 years old
- Residents of communities with highest prevalence of HIV, STD, and other morbidities
- Special emphasis
- Men who have sex with men (MSM)
- Transgender youth
- Homeless youth
- Women who have sex with older partners, IDUs or MSM

## Selection of Communities

- Definition
- Communities are defined as geographical areas within ATN cities that public health data sources reveal have highest HIV and other co-morbidities
- Selection process
- Map rates of HIV/AIDS, STDs, and poverty using GIS software
- Identify administrative areas with highest morbidity
- Restrict size of area based on available community partners and target population

## Morbidity Data: AIDS Prevalence Rates in 2001

**Morbidity Data: AIDS Prevalence Rates in 2001**

**Data provided by the Maryland State AIDS Administration**

**Mapped by the STAR TRACK Program and Connect to Protect: Baltimore**

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**Sandtown/ Winchester**

**Upton/ Druid Hts**

**1**

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**3**

**Mapped by the STAR TRACK Program** **and Connect to Protect: Baltimore**** **

## Selection of Population

- 12-24 years old
- Residents of selected communities
- May not hang out in selected communities
- Special emphasis
- Men who have sex with men (MSM)
- Transgender youth
- Homeless youth
- Women who have sex with older male partners, IDUs, or MSM

## Selection of Community Partners

- Create list of community-based organizations and service providers
- Conduct brief survey of organizations about mission, target population, and services provided
- Conduct in-depth interviews with subset to determine main, supporting, and advisory partners

## Selection of Venues

- Social network interviews with HIV-infected youth in care and discussion with community partners
- Identify initial set of venues
- May or may not be within selected community
- Brief venue interviews and ethnographic assessments
- Select final set of venues

## Needs Assessment

- Outreach staff will recruit at selected venues and obtain informed consent
- Staff will administer anonymous survey using Audio-Computer Assisted Self Interview (A-CASI)
- Topics covered similar to 040

## Intervention Framework

- Community
- Mobilization

- _Sample Structural Changes_
- Improved quality and availability of mental health services and drug addiction services
- Improved STI/HIV screening
- Expanded youth development activities

- _Indicators of Reduced Risk_
- Increased STI/HIV Testing
- Decreased selection of high risk sex partners
- Increased condom use

- Focused CDC Program

- Reduced HIV incidence and prevalence in selected communities

## Community Mobilization

- Definition
- Collaborative problem solving resulting in changes to the environment that lead to reduced health or other social problems.
- Strategic planning process
**V**ision statement
**M**ission statement (actionable)
**O**bjectives (what structural changes, when, and by whom)
**S**trategies
**A**ction Plan
- Continuous evaluation and feedback
- Need successes
- Focused activity

## Structural Changes

- Definition
- New or modified programs, practices, or policies
- Examples of relevant structural changes
- Expanded VCT, PCM, ART programs
- Improved quality and availability of mental health and addiction treatment programs
- Improved provider STD screening practices
- Changes in policies around public sex venues

## Focused CDC Program

- CDC community-level interventions
- Promise
- Mpowerment
- Common elements
- Health marketing components
- Proven efficacious
- Replication materials available
- Training available

## Evaluation of Structural Changes

- Community change logs
- Key community leader interviews

## Evaluation of Changes in Risk

- Annual anonymous community-based interviews of targeted youth
- Substance abuse
- Depression
- Parental monitoring
- STD care
- HIV testing
- Sexual risk
- Redo maps and compare to baseline maps

## Analysis

- Quasi-experimental design
- Different levels of mobilization will occur naturally
- Outcome
- HIV risk over time in venues and communities
- Multi-level model
- Adjust for venues within cities
- Adjust for individual-level variables that are thought to be associated with the outcomes *a priori*.
- Account for structural changes external to C2P

## Challenges and Solutions

- Mobilizing community
- Training C2P staff
- CDC program
- Continuous feedback
- Funding for partners
- Adapting and implementing CDC program
- Collaboration with CDC dissemination of effective behavioral interventions project
- Training C2P staff and community partners
- Understanding of relevant structural change
- Training of C2P staff and community partners
- Stability of venues
- Monitor shifting networks
- Make adjustments