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Bryant Rueda

California State University, Long Beach

Theodora Papachristou

Health Education Evaluation and Measurement

HSC 405 Section 03

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Background and Significance

a) Importance of topic

It is vital to understand the severity of the human immunodeficiency virus (HIV), and

treating it before the disease becomes acquired immunodeficiency syndrome (AIDS). AIDS is

applied to the term of HIV when it is in the most advanced stages of the infection. According to

the World Health Organization (2017), 36.7 million people were living with HIV at the end of

2016; the same year, 1.8 million people were newly infected while another million people died

due to complications arising from HIV infection. Just in the United States, an estimated 37,600

new HIV infections sprung up in 2014 (CDC, 2018). The highest new HIV diagnoses in the

United States in 2016 among men were Black males who had sex with other males, with 10,223

new cases (CDC, 2018). Next, Hispanic/Latino males who had sex with other males had 7,425

new cases (CDC, 2018), and lastly, White males who had sex with other men presented 7,390

cases (CDC, 2018).

The previous data paints a grim picture of how much this disease affects the population.

Gay and bisexual men made up 67% (26,570) of all HIV diagnoses and 83% of diagnoses among

males. By race/ethnicity, African Americans and Hispanics/Latinos are the most affected by

HIV. In 2016, African Americans represented 12% of the population, but accounted for 44%

(17,528) of HIV diagnoses (CDC, 2018). Hispanic/Latinos made up 18% of the United States

population, yet were responsible for 25% (9,766) of HIV diagnoses (CDC, 2018). HIV and AIDS

do not discriminate when it comes to age. According to the CDC (2018), 14,740 of the new

diagnoses in the United States of HIV were in the age demographic of 20-29 year olds. Young
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people were at higher risk of not knowing their diagnoses, with an estimated 44% of people aged

13-24 not knowing they were infected. Lastly, HIV rates are not equally spread across the

country. Per 100,000 people, the highest rates of HIV were present in the South (16.8), then the

Northeast (11.2), followed by the West (10.2), and the Midwest (7.5) (CDC, 2018).

According to Zingmond, Arfer, Gildner, & Leibowitz (2017), the cost of treatment for

people living with HIV has risen; this is in part due to comorbidities and the disease that come

with aging. In their study, Zinmond et al. (2017) examined expenses for 9,767 HIV positive

Californians who were enrolled in Medicare in 2010 (7,208 patients were covered by Medicare

and Medicaid, while 2,559 only had Medicare). They found the average cost for these patients

were $47,036, with prescribed drugs accounting for 2/3 of the cost. “About 64% of the sample

had at least one comorbidity in addition to HIV” (Zinmond et al., 2017). Antiretroviral therapy

and hospitalizations added most to the cost. The study concluded since many people are living

longer lives without HIV turning into AIDS, the cost to manage and treat non-HIV comorbidities

have risen. They added that future spending estimates should include comorbidities to accurately

predict the cost of treatment (Zinmond et al., 2017).

b) Critical Review on Similar Programs

Reid, Dovidio, Ballester, & Johnson (2014) in their study “HIV prevention interventions

to reduce sexual risk for African Americans: The influence of community-level stigma and

psychological processes”, found that stigma had a lot to do with the effectiveness of health

promotion programs, in this case, condom use among African Americans. When it came to

younger African American participants, stigma strongly affected the sample (Reid et al., 2014).

The study was conducted with at least half of the participants being African American. They
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found the effectiveness of condom use programs depended on two factors, “Whites' attitudes

toward African Americans and residential segregation in the communities where interventions

occurred” (Reid et al., 2014). Lastly, they found the interventions only worked when residential

segregation was low and Whites’ attitudes on African Americans were more positive (Reid et al.,

2014). Similarly, Brinkley-Rubinstein, L. (2015) in her study titled “Understanding the Effects of

Multiple Stigmas Among Formerly Incarcerated HIV-Positive African American Men”, found

that stigma of having HIV among this population severely affected the general and mental health

of these individuals. On top of experiencing stigma, participants’ dealt with the problems they

encountered differently, leading them to experience diverse reactions (Brinkley-Rubinstein,

2015). This all affected the participants’ process of reintegration into society. Sayegh et al.

(2016) in their study titled “Medication Adherence in HIV-Positive African Americans: The

Roles of Age, Health Beliefs, and Sensation Seeking”, found that two constructs, health beliefs

and sensation seeking, influenced how much the participants’ would adhere to antiretroviral

therapy protocol. Sensation seeking behaviors included injection of drugs and unprotected sex.

This study used the Health Belief Model (HBM) to understand why participants did not pursue

treatment. The study showed that older African Americans may be at a higher risk of not sticking

to treatment protocol due to negative sociocultural beliefs about receiving treatment (Savegh et

al., 2016). They also found that HIV positive African American males aged 50-67 were “more

likely than their Caucasian counterparts to endorse doubt about their physicians’ ability to

competently manage their HIV medication regimen” (Savegh et al., 2016).

Brooks et al. (2017), in their study titled “HIV/AIDS conspiracy beliefs and intention to

adopt preexposure prophylaxis among black men who have sex with men in Los Angeles”,

emphasized how the adoption of the use of Pre-exposure prophylaxis (PrEP) is an important step
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to reduce the incidence and prevalence of HIV infections among black men who have sex with

men (MSM), since this group of people are the most affected by this epidemic. This study

examined 224 black MSM to see if they had any conspiracy beliefs about HIV/AIDS. They

found more than half of the participants had intention of using PrEP (60%), but 63% believed

one out of the eight conspiracies presented (Brooks et al., 2017). These participants had a lower

intention of adopting PrEP into their regimen. The researchers suggested addressing these

conspiracies early on so more participants would be willing to use PrEP (Brooks et al., 2017).

Gwadz et al. (2015), in their study “Behavioral Intervention Improves Treatment Outcomes

Among HIV-Infected Individuals Who Have Delayed, Declined, or Discontinued Antiretroviral

Therapy: A Randomized Controlled Trial of a Novel Intervention”, examined the reasons why

many ethnic minorities were not engaged in taking antiretroviral therapy nor involved in HIV

care. The study strove to show how a culturally tailored approach can help overcome barriers to

receive HIV care set by emotional, attitudinal, societal, and structural barriers (Gwadz et al.,

2015). Components of the program included group-work that drew on social and cultural values

and norms (Gwadz et al., 2015). Corbie-Smith et al. (2010) created Project GRACE (Growing,

Reaching, Advocating for Change and Empowerment) to implement interventions utilizing a

community-based participatory approach. Like Gwadz et al. (2015) study, this approach used

culturally sensitive interventions to reduce the spread of HIV in rural African American

communities (Corbie-Smith et al., 2010).

Pollini, Blanco, Crump, and Zúñiga (2011) studied why many who get diagnosed delay

treatment in their study “A Community-Based Study of Barriers to HIV Care Initiation”. “Study

participants were mostly male (78.0%), and persons of color (54.9% Latino, 26.3% black), with

median age 37.8 years” (Pollini et al., 2011). They found that socioeconomic status; HIV testing
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experiences; perceived barriers to care; and knowledge, attitudes, and beliefs regarding HIV led

participants to not seek treatment. Like previous studies, stigma of the disease was a significant

barrier to starting HIV care in communities primarily made up of persons of color (Pollini et al.,

2011). Hidalgo et al. (2014) were interested in creating an intervention method for young MSM.

They targeted young men aged 16-20 years old. Participants were randomized into two groups

(HIV and STI prevention), taking part in an interactive program tailored to their age group, while

the control groups participated in a non-interactive, lecture-based program (Hidalgo et al., 2014).

They found participants in the experimental groups were less likely to engage in sexual behavior

under the influence of substances (Hidalgo et al., 2014). Hall, Espinoza, Benbow, and Hu (2012)

found that while many of the cities the HIV epidemic is affecting usually are in urban areas,

strategies for combating this crisis differ from city to city. HIV prevention efforts should include

tailored “public health goals and planning for treatment and prevention services for people living

with HIV” (Hall et al., 2012). Lastly, Radcliffe, Beidas, Hawkins, and Doty (2011) examined

how experiences of trauma among young African American MSM were linked to increased

depressive symptoms and riskier sexual behaviors. The 40 participants were recruited from an

adolescent HIV medical program, ranging from ages 16-24 years old.

c) Linking goals and objectives to their Theoretical Relevance

The theoretical model that I will be using for my program is the Transtheoretical Model

(TTM), also known as Stages of Change. “The TTM is an integrative framework for

understanding how individuals and populations progress toward adopting and maintaining health

behavior change for optimal health” (McKenzie, Neiger, & Thackeray, 2013, p. 181). As

previously mentioned, this model is made up of stages: precontemplation, contemplation,

preparation, action, and maintenance. “The stage construct is an important part of the
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trasntheoretical model because it represents the temporal dimension of change (McKenzie et al.,

2013, p. 181).

The precontemplation stage is defined as when people do not intend to change their

behavior or take action in the near future, usually within six months (McKenzie et al., 2013, p.

181). People might be in this stage due to not knowing or being uninformed about what their

behavior is causing, or they have previously tried to change many times and do not want to do it

again. Many times, people in this stage avoid thinking or talking about said behavior. The

contemplation stage is when people intend to change their behavior within the next six months.

At this stage, people are realizing a problem exists and are actively thinking about changing, but

have not made a solid commitment to do so. They accept feedback more readily than in the

precontemplation stage. Next is the preparation stage; this is when the individual intends to

change their behavior within the next 30 days. This stage involves intention and behavioral

criteria. “Typically, they have already taken some significant step toward behavior change in the

past year” (McKenzie et al., 2013, p. 183). This is when the individual starts creating a plan of

action, like enrolling in a class, talking to their doctor, or taking accountability and changing on

their own. McKenzie et al. (2013, p. 183) suggest recruiting these individuals for action-oriented

programs like smoking cessation, weight loss, or exercise. When individuals are actively trying

to change their behavior or environment in order to conquer their problem within the last six

months, they have arrived at the fourth stage: the action stage. The action stage consists of the

individual showing consistent behavior change patterns. Change is most observable in the action

stage, and receives the most recognition. A downside of this stage is the chance of relapse is

high, so relapse prevention is key since the change is relatively new (McKenzie et al., 2013, p.

183). Depending on the program the individual is in, not all behavior change can count as being
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in “action”; an example is a smoking cessation program where absolute abstinence is considered

“action”. If these changes are consistent, the individual can move on to the maintenance stage,

where working to prevent relapse is the main focus (McKenzie et al., 2013, p. 183). To be in this

stage, a person would have to have changed their behavior and made serious modifications to

their lifestyle for at least six months, and are self-reliant in themselves. At this stage, the change

is more of a habit and the chance of relapse is lower. There is a final stage called termination,

which is defined as when the individual has no desire to return to their old behavior, and are

confident they will never relapse for the rest of their life. Since many people never reach this

stage with certain behaviors, there has not been much research about the termination stage.

The second construct of the TTM is the processes of change, which is defined as the

“covert and overt activities that people use to progress through the stages” (McKenzie et al.,

2013, p. 183). Some examples of processes of change are self-reevaluation, social liberation,

stimulus control, and reinforcement management; these different processes are useful for the

individual at different stages (McKenzie et al., 2013, p. 183). The third construct of the TTM is

decisional balance, which refers to the pros and cons of the behavior the individual is trying to

change. If there are more pros to changing, the individual is more likely to move from one stage

to the next; if the individual believes there are more cons, they will regress in the stages. The

fourth construct is self-efficacy, which is defined as people’s confidence in their ability to

perform a certain behavior or task” (McKenzie et al., 2013, p. 185). Finally, the last construct of

the TTM is temptation. Temptation has to deal with the urges of wanting to relapse into old

behaviors when confronted in difficult situations.

The HIV Treatment Program will aim to educate African American MSM who currently

have HIV on treatment options currently available to them. The goal is to reduce the amount of
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African American MSM in Los Angeles not receiving treatment. This program is geared for

African American MSM aged 18-30 years old. The program will help raise the decisional

balance and self-efficacy of participants by informing them of the pros of receiving treatment can

be, and connecting participants with the right services. In the beginning of the recruitment

process, it is more than likely that most participants will be in the precontemplation stage, since

they are not receiving treatment. This program will run from January 2019 to December 2019.

The pre-test will include questions to gather the baseline knowledge of participants in regards to

the benefits of treatment, the location of existing services, and the confidence to engage in the

program. Post-test will gauge if participants feel they can continue with healthy behaviors by

memorizing service locations and remembering the benefits of receiving treatment. The learning

opportunities will take place in a series of eight mini-seminar and workshops, where each

workshop will last anywhere from 20-30 minutes. Each of the workshops will be taught by

health educators and key community members who have knowledge of where it would be most

effective to hold these workshops. These workshops will aid participants through the stages of

the TTM, eventually helping them through to the maintenance stage. PowerPoints will also

inform participants on how to seek social support for healthy behavior change, finding new facts

and tips that support healthy behavior change, and any other methods that assist in keeping up

with treatment.

d) Program Objectives and Hypothesis

The HIV Treatment Program is a behavioral change program with three measurable

objectives. These are expected from each participant in the program.

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 Objective 1: At program termination, participants of the HIV Treatment Program will

demonstrate at least 30% increase in knowledge regarding location of services, as

measured by post-test.

 Objective 2: At program termination, participants will demonstrate a 5% increase in the

application of newly acquired behavioral skills, as measured by enrollment in services.

 Objective 3: By the end of the HIV Treatment Program, 50% of the participating students

will be able to identify positive factors as to why treatment for HIV is vital.

Methods

a) Description of the Population and Method of Sample Selection

The target population is going to be African American MSM due the fact that Los

Angeles County continues to have the second largest number of persons living with HIV (CDC,

2018). The lifetime risk of HIV among African Americans is higher than any other ethnic

groups. The socio-economic status of the individual is a significant factor in the incidence of

HIV/AIDS. The lower the SES, the less accessibility to resources they have. We will be

determining the selective representative sample by a cluster sample. We will be gathering data

by recruiting participants using a community-based approach. The eligibility criteria are: 18-30

years of age; HIV infected for >6 months; African American race/ethnicity; gender male; MSM;

currently not receiving treatment for HIV. To determine the extent of African American MSM

living with HIV in Los Angeles County, we refer to the CDC (2015), which states “In terms of

risk for transmission, Los Angeles County’s HIV epidemic is similar to that of California and

other western states. Men who have sex with men (MSM) account for more than three-quarters

(77.7%) of all people living with HIV”. Participants will be chosen by the cluster sampling
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method, a probability-based sampling technique, in locations where African American

population is high throughout Los Angeles County. Calculating the sample size of this

population is important for the program as it requires a sample that is large enough to show

statistical significance, as well as a sample size that is small enough to satisfy all criteria. A 0.8

power test, 0.2 for P1, and a 0.05 significance level for alpha will be used to determine Type 1

and Type 2 error. A minimum sample size of 250 participants each will be needed for the non-

comparison group and experimental group, with a total of 500 participants. To account for the

estimated percentages of individuals who cannot be or drop out during the program, and for

those individuals who refuse to participate, 20% (100 participants) will be added for posttest, for

a total sample size population of 600 participants. From the 600 participants, 300 participants

will be the experimental group and another 300 participants will make up the comparison group

(similar to control group).

b) Design of Experimental Methodology

The evaluation design in which HIV Treatment Program will be using is the non-

equivalent comparison group. The reason for choosing non-equivalent comparison group is

because it is structured like a pre-test post-test randomized experiment, but it lacks the main

feature of the randomized designs (randomized equal characteristics). Disadvantages include not

being able to find cause and effect relationships, cannot manipulate predictor variables, and the

methods of study are often correlated to case studies.

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Brooks, R. A., Allen, V. C., Regan, R., Mutchler, M. G., Cervantes-Tadeo, R., & Lee, S. (2017).

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