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Intervention Summary

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Self-Help in Eliminating Life-Threatening Diseases (SHIELD)

Self-Help in Eliminating Life-Threatening Diseases (SHIELD) is a training program for adult men and women who are current or former drug users with or without HIV. SHIELD trainees become peer educators on risky behaviors for HIV infection, serving as indigenous outreach workers for others in their immediate social network (i.e., sex and drug partners, family members, friends) and/or community network. SHIELD aims to motivate peer educators to reduce or eliminate their own injection drug use and needle sharing and to increase condom use during sex, as well as to encourage others to practice similar behaviors.

SHIELD is delivered in groups of 4-12 trainees by community facilitators certified in HIV testing and counseling. Facilitators use a highly scripted manual and interactive sessions to train peer educators in leadership, communication, conflict resolution, and ways to overcome barriers to effective outreach. Teaching approaches include group problem solving, use of HIV risk reduction ladders, condom and safer drug injection demonstrations and practice, games, and role-playing of real-life situations. Peer educators are provided with materials--informational brochures, kits for cleaning needles, and condoms--to distribute to outreach contacts. Between sessions, peer educators discuss their outreach efforts with the facilitators, who provide feedback. The version of SHIELD currently available is delivered over 3 weeks in 6 sessions of 90-120 minutes; the version used in the study reviewed for this summary consisted of 10 90-minute sessions delivered over a 5-week period.

Descriptive Information

Areas of Interest Substance abuse treatment
Outcomes Review Date: April 2011
1: Injection drug use
2: HIV sexual risk behaviors
3: HIV outreach
Outcome Categories Drugs
Ages 26-55 (Adult)
Genders Male
Female
Races/Ethnicities Black or African American
Race/ethnicity unspecified
Settings Other community settings
Geographic Locations Urban
Implementation History SHIELD was first evaluated in a research study conducted with 250 participants in Baltimore, Maryland, between 1997 and 2003. The intervention has been implemented in two community-based agencies in Baltimore as well as in India, Kyrgyzstan, Russia, Thailand, Ukraine, and Vietnam. As of June 2010, 45 agencies had received training in SHIELD and 1,200 individuals had received the intervention.
NIH Funding/CER Studies Partially/fully funded by National Institutes of Health: Yes
Evaluated in comparative effectiveness research studies: Yes
Adaptations SHIELD has been adapted for use with active injection drug users and heterosexual women in Baltimore, Maryland, and translated and adapted for drug users in several international settings.
Adverse Effects No adverse effects, concerns, or unintended consequences were identified by the developer.
IOM Prevention Categories IOM prevention categories are not applicable.

Quality of Research
Review Date: April 2011

Documents Reviewed

The documents below were reviewed for Quality of Research. The research point of contact can provide information regarding the studies reviewed and the availability of additional materials, including those from more recent studies that may have been conducted.

Study 1

Latkin, C. A., Sherman, S., & Knowlton, A. (2003). HIV prevention among drug users: Outcome of a network-oriented peer outreach intervention. Health Psychology, 22(4), 332-339.  Pub Med icon

Supplementary Materials

Dickson-Gomez, J. B., Knowlton, A., & Latkin, C. (2004). Values and identity: The meaning of work for injection drug users involved in volunteer HIV prevention outreach. Substance Use and Misuse, 39(8), 1259-1286.  Pub Med icon

Latkin, C. A., Hua, W., & Davey, M. A. (2004). Factors associated with peer HIV prevention outreach in drug-using communities. AIDS Education and Prevention, 16(6), 499-508.  Pub Med icon

Latkin, C., Mandell, W., Vlahov, D., Oziemkowska, M., & Celentano, D. (1996). People and places: Behavioral settings and personal network characteristics as correlates of needle sharing. Journal of Acquired Immune Deficiency Syndromes and Human Retrovirology, 13(3), 273-280.  Pub Med icon

Latkin, C. A., Mandell, W., Vlahov, D., Oziemkowska, M., & Celentano, D. D. (1996). The long-term outcome of a personal network-oriented HIV prevention intervention for injection drug users: The SAFE study. American Journal of Community Psychology, 24(3), 341-364.  Pub Med icon

McElrath, K., Chitwood, D. D., Griffin, D. K., & Comerford, M. (1994). The consistency of self-reported HIV risk behavior among injection drug users. American Journal of Public Health, 84(12), 1965-1970.  Pub Med icon

National Institute of Mental Health (NIMH) Multisite HIV Prevention Trial Group. (1997). Quality control and quality assurance in HIV prevention research: Model from a multisite HIV prevention trial. AIDS, 11(Suppl. 2), S49-S53.

National Institute of Mental Health (NIMH) Multisite HIV Prevention Trial Group. (1998). The NIMH Multisite HIV Prevention Trial: Reducing HIV sexual risk behavior. Science, 280(5371), 1889-1894.  Pub Med icon

Vlahov, D., Anthony, J. C., Munoz, A., Margolick, J., Nelson, K. E., Celentano, D. D., et al. (1991). The ALIVE study, a longitudinal study of HIV-1 infection in intravenous drug users: Description of methods and characteristics of participants. In P. Hartsock & S. G. Genser (Eds.), Longitudinal studies of HIV infection in intravenous drug users: Methodological issues in natural history research. NIDA Research Monograph, Number 109 (DHHS Publication No. 91-1786, pp. 75-100). Washington, D.C.: U.S. Government Printing Office.

Outcomes

Outcome 1: Injection drug use
Description of Measures Injection drug use was measured by asking participants to report on the following injection drug use behaviors in the past 6 months:

  • Frequency of injection drug use. Participants were asked about the frequency of injecting cocaine, heroin, and "speedball" (i.e., cocaine and heroin combined) on an 8-point scale ranging from "never" to "more than five times a day." Reports of frequency were recoded as a change score from baseline to 6-month postintervention follow-up by assigning "1" for reduced frequency or "0" for increased or unchanged frequency.
  • Frequency of sharing used needles. Participants were asked about the frequency of using a needle or tools (i.e., injection equipment) immediately after another person without cleaning them first with bleach. They responded using an 8-point scale ranging from "never" to "more than once a day." Reports of frequency were recoded as a change score from baseline to 6-month follow-up by assigning "1" for reduced frequency or "0" for increased or unchanged frequency.
  • Stopping drug injection for the past 6 months. Stopping drug injection was measured as a dichotomous "yes" or "no" answer to the question, "In the past six months, have you injected drugs?" Reports of stopping drug injection were recoded as a change score from baseline to 6-month follow-up by assigning a "1" for not injecting any drugs or a "0" for increased or unchanged drug injection frequency.
The change scores for the three behaviors were summed for a composite change score from baseline to 6-month follow-up. The score ranged from 0 to 3, with a higher score indicating a greater reduction in injection drug use behavior.
Key Findings In a randomized clinical trial, individuals willing to conduct outreach HIV education were randomly assigned to the SHIELD intervention to be trained as peer educators or to an attention control condition. The control condition was designed to duplicate SHIELD's number of sessions, duration, and interest to participants; it included basic HIV prevention education and a videotape presentation and group discussions targeting addiction and family psychodynamics. At the 6-month follow-up:

  • SHIELD participants were more than 3 times as likely as control group participants to report reducing the sharing of used needles (p < .05) and stopping injection drug use (p < .05), after controlling for age, gender, race, education, arrest history, HIV serostatus, and mood at baseline. These group differences were associated with medium effect sizes (adjusted odds ratios = 3.27 and 3.65 for reducing the sharing of used needles and stopping injection drug use, respectively).
  • SHIELD participants were almost 3 times as likely as control group participants to report reductions in overall injection drug use behaviors (composite change score, p < .05), after controlling for age, gender, race, employment, arrest history, HIV serostatus, and mood at baseline. This group difference was associated with a medium effect size (adjusted odds ratio = 2.83).
Studies Measuring Outcome Study 1
Study Designs Experimental
Quality of Research Rating 3.0 (0.0-4.0 scale)
Outcome 2: HIV sexual risk behaviors
Description of Measures HIV sexual risk behaviors were measured by asking participants to report on the frequency of their condom use during vaginal, oral, and anal sex with main and casual partners in the past 90 days. The main partner was defined as "someone who you have had an ongoing relationship with and who you have sex with often, like a spouse, lover, boyfriend, or girlfriend." A casual partner was defined as "someone you have sex with occasionally." For each type of sex with each type of partner, study participants rated the frequency of condom use on a 5-point scale that ranged from 0 (never) to 4 (all the time).

For each type of sex with each type of partner, the reported frequency of condom use was recoded as a change score from baseline to the 6-month postintervention follow-up by assigning "1" for increased frequency or "0" for decreased or unchanged frequency. For each type of partner, the change score for each of the three types of sex--oral (0 or 1), anal (0 or 1), and vaginal (0 or 1)--were summed for a total ranging from 0 to 3. The summed change score for each type of sex partner was dichotomized to create a composite score, coded "1" for increased frequency (i.e., a summed change score greater than 0) or "0" for decreased or unchanged frequency (i.e., a summed change score equal to 0).
Key Findings In a randomized clinical trial, individuals willing to conduct outreach HIV education were randomly assigned to the SHIELD intervention to be trained as peer educators or to an attention control condition. The control condition was designed to duplicate SHIELD's number of sessions, duration, and interest to participants; it included basic HIV prevention education and a videotape presentation and group discussions targeting addiction and family psychodynamics. From baseline to the 6-month follow-up:

  • A larger percentage of SHIELD participants than control group participants had an increase in condom use during vaginal sex with casual partners (16% vs. 4%, p < .05).
  • SHIELD participants were more than 7 times as likely as control group participants to have an increase in condom use with casual partners (composite change score, p < .01), after controlling for age, gender, race, education, arrests, HIV serostatus, and mood at baseline. This group difference was associated with a large effect size (adjusted odds ratio = 7.13).
Studies Measuring Outcome Study 1
Study Designs Experimental
Quality of Research Rating 3.1 (0.0-4.0 scale)
Outcome 3: HIV outreach
Description of Measures HIV outreach was measured by a self-report survey at the 6-month postintervention follow-up. Survey items asked whether participants had talked to each of the following types of individuals about HIV prevention in the past month: family members, sex partners, non-drug users, drug users, and "drug buddies" (i.e., individuals who worked with the participant to acquire drugs or money). Participants were also asked to indicate the number of their network members, if any, to which they provided each of the following outreach services: talked to about high-risk drug behavior, talked to about using condoms, provided with condoms, and provided with bleach to disinfect syringes.
Key Findings In a randomized clinical trial, individuals willing to conduct outreach HIV education were randomly assigned to the SHIELD intervention to be trained as peer educators or to an attention control condition. The control condition was designed to duplicate SHIELD's number of sessions, duration, and interest to participants; it included basic HIV prevention education and a videotape presentation and group discussions targeting addiction and family psychodynamics. At the 6-month follow-up:

  • A higher percentage of SHIELD participants than control group participants reported talking about HIV prevention in the past month with family members (35% vs. 19%, p < .05), sex partners (34% vs. 18%, p < .05), non-drug users (35% vs. 22%, p < .05), and drug users (39% vs. 23%, p < .05).
  • Compared with control group participants, SHIELD participants reported talking to more members in their social network about using condoms (0.91 vs. 1.48, p = .028) and distributing condoms to more members in their social network (0.59 vs. 1.10, p = .014).
Studies Measuring Outcome Study 1
Study Designs Experimental
Quality of Research Rating 3.1 (0.0-4.0 scale)

Study Populations

The following populations were identified in the studies reviewed for Quality of Research.

Study Age Gender Race/Ethnicity
Study 1 26-55 (Adult) 61% Male
39% Female
94% Black or African American
6% Race/ethnicity unspecified

Quality of Research Ratings by Criteria (0.0-4.0 scale)

External reviewers independently evaluate the Quality of Research for an intervention's reported results using six criteria:

  1. Reliability of measures
  2. Validity of measures
  3. Intervention fidelity
  4. Missing data and attrition
  5. Potential confounding variables
  6. Appropriateness of analysis

For more information about these criteria and the meaning of the ratings, see Quality of Research.

Outcome Reliability
of Measures
Validity
of Measures
Fidelity Missing
Data/Attrition
Confounding
Variables
Data
Analysis
Overall
Rating
1: Injection drug use 2.2 3.7 2.8 2.5 3.0 3.7 3.0
2: HIV sexual risk behaviors 3.1 3.6 2.8 2.5 3.0 3.7 3.1
3: HIV outreach 2.6 3.8 2.8 2.5 3.0 3.7 3.1

Study Strengths

All the outcome measures have acceptable psychometric properties based on use in the field. The intervention included a manual with session scripts that were piloted extensively before the start of the study. Intervention sessions were audiotaped, with at least 10% reviewed by a supervisor who both rated the session for the level of participant/group interest and compared the session script to the audiotaped session to note omissions by facilitators. Intervention group participants also rated the quality of each session. The study used experienced, indigenous paraprofessionals as the facilitators. Separate interviewers blind to study condition conducted the outcome assessments, which were randomly audiotaped, with 10% reviewed by a supervisor to assess fidelity. The 6-month follow-up rate was high at 92% (229 of the 250 randomized participants). The study used a randomized design with an equal-attention control condition designed to be equivalent to the intervention in number of sessions, duration, and interest to participants, and the average number of sessions attended did not differ between the intervention and control group, all of which controlled for many confounds. Confounds were further minimized by including the between-group differences in baseline demographics and risk behavior in the statistical modeling of the outcomes. The study used an intent-to-treat approach, and the statistical modeling of the outcome data was sophisticated, appropriate for the sample size, and consistent with the study hypotheses.

Study Weaknesses

For all outcome measures, no test-retest reliability data were presented for the study sample, and no concurrent validity measures (e.g., urine screen, presence of visible needle marks, collateral reports of condom use or outreach efforts) were used. No tested fidelity instrument was used in the study. The attrition between screening and study completion was extreme, with 1,495 potential individuals screened for 250 individuals randomized and 229 individuals assessed at the 6-month follow-up. There was no measure or tracking of other interventions or services received by study participants that might have contributed to the outcomes, and it is unclear how the financial compensation for session attendance might have confounded retention and consequently the outcome findings in both conditions.

Readiness for Dissemination
Review Date: April 2011

Materials Reviewed

The materials below were reviewed for Readiness for Dissemination. The implementation point of contact can provide information regarding implementation of the intervention and the availability of additional, updated, or new materials.

Centers for Disease Control and Prevention. (n.d.). Self-Help in Eliminating Life-Threatening Diseases (SHIELD). In Compendium of evidence-based HIV behavioral interventions. Atlanta, GA: U.S. Department of Health and Human Services, Centers for Disease Control and Prevention. Accessed at http://www.cdc.gov/hiv/topics/research/prs/resources/factsheets/SHIELD.htm

Latkin, C., Tobin, K., & Davey-Rothwell, M. (n.d.). SHIELD: Facilitator's guide. Baltimore, MD: Author.

Latkin, C., Tobin, K., & Davey-Rothwell, M. (n.d.). SHIELD: Monitoring and evaluation plan. Baltimore, MD: Author.

Latkin, C., Tobin, K., & Davey-Rothwell, M. (n.d.). SHIELD: Project manager's guide. Baltimore, MD: Author.

Latkin, C., Tobin, K., & Davey-Rothwell, M. (n.d.). SHIELD: Starter kit and implementation plan. Baltimore, MD: Author.

Latkin, C., Tobin, K., & Davey-Rothwell, M. (n.d.). SHIELD: Technical assistance guide. Baltimore, MD: Author.

Program page on the Diffusion of Effective Behavioral Interventions (DEBI) project Web site, http://www.effectiveinterventions.org/en/Interventions/SHIELD.aspx

Other implementation materials:

  • Blank risk ladder
  • HIV Drug Splitting Risk ladder
  • HIV drug splitting risk ladder behavior cards
  • HIV Injection Risk ladder
  • HIV injection risk ladder behavior cards
  • Lube cards
  • Sex Risk ladder
  • Sex risk ladder behavior cards
  • SHIELD Fact Sheet
  • SHIELD Handouts for Participants Folder
  • SHIELD Intervention Package Orientation

Readiness for Dissemination Ratings by Criteria (0.0-4.0 scale)

External reviewers independently evaluate the intervention's Readiness for Dissemination using three criteria:

  1. Availability of implementation materials
  2. Availability of training and support resources
  3. Availability of quality assurance procedures

For more information about these criteria and the meaning of the ratings, see Readiness for Dissemination.

Implementation
Materials
Training and Support
Resources
Quality Assurance
Procedures
Overall
Rating
3.5 3.5 3.5 3.5

Dissemination Strengths

Program materials are comprehensive and address organizational readiness, stakeholder buy-in, staffing requirements, job responsibilities, required resources, and budget. The facilitator training includes direct instruction and opportunities to practice new skills. Ongoing technical assistance and consultation are available to implementation sites through the program developers and the Centers for Disease Control and Prevention (CDC). An array of materials is available to support fidelity monitoring and the development and implementation of a program evaluation plan.

Dissemination Weaknesses

While opportunities exist for peer educators to discuss their outreach efforts with and receive feedback from facilitators, no specific guidance is provided to facilitators on how to debrief or counsel peer educators who may have difficulty with the sensitive issues related to drug use or sexual behaviors that may arise during training sessions and outreach. No fidelity monitoring tools are available to support the quality assurance of outreach efforts.

Costs

The cost information below was provided by the developer. Although this cost information may have been updated by the developer since the time of review, it may not reflect the current costs or availability of items (including newly developed or discontinued items). The implementation point of contact can provide current information and discuss implementation requirements.

Item Description Cost Required by Developer
Intervention package (includes Facilitator's Guide, Project Manager's Guide, Technical Assistance Guide, and Monitoring and Evaluation Plan) Free Yes
2.5-day, off-site facilitator training by CDC Capacity Building Assistance (CBA) Provider, held monthly at various locations Free for up to 20 participants Yes, one training option required
2.5-day, on-site facilitator training by program developers $3,000 for up to 8 participants, plus travel expenses Yes, one training option required
2.5-day, off-site facilitator training by program developers, held in Baltimore, MD $3,000 for up to 8 participants Yes, one training option required
On-site technical assistance from CDC CBA Provider Free for agencies that attended the CDC training, plus cost of travel expenses No
Phone or email technical assistance from CDC CBA Provider Free for agencies that attended the CDC training No
Phone or email technical assistance from program developers $100 per hour No

Additional Information

The intervention package can be downloaded from the program Web site.

Contact Information

To learn more about implementation, contact:
Melissa A. Davey-Rothwell, Ph.D., M.P.H., CHES
(410) 614-5854
mdavey@jhsph.edu

Karin Tobin, Ph.D.
(410) 502-5368
ktobin@jhsph.edu

To learn more about research, contact:
Carl A. Latkin, Ph.D.
(410) 955-3972
clatkin@jhsph.edu

Melissa A. Davey-Rothwell, Ph.D., M.P.H., CHES
(410) 614-5854
mdavey@jhsph.edu

Consider these Questions to Ask (PDF, 54KB) as you explore the possible use of this intervention.

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