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The Guidance Definitions
Reconciling Differences between Guidance Definitions and Local Terminology
Reporting Non-HIV Risk Behavior Populations
This chapter:
- Reviews the Guidance definitions for interventions and populations;
- Presents strategies for reconciling differences between the Guidance definitions and local terminology; and
- Discuses strategies for reporting populations that are not defined by HIV risk behaviors.
The Guidance Definitions
The Guidance establishes definitions for HIV prevention interventions and the behavioral risk populations they serve. The Guidance distinguishes between interventions that do and do not include skills-building activities because the development of HIV risk-reduction skills is an important part of interventions that lead to behavior change. With the exception of "Mother with/at risk for HIV" and "General Population," the Guidance uses HIV behavioral risk population categories because interventions are supposed to influence behaviors that transmit HIV disease.
These intervention and population definitions are used for reporting intervention plan and process monitoring data. By establishing definitions for use by all jurisdictions, the Guidance facilitates uniform reporting of evaluation data to CDC and can improve the clarity of communications within a jurisdiction.
"Probably one the biggest things that came to light with the Guidance definitions was that people weren't calling the interventions by the same name, both internally with our health department staff, as well as with our contractors, even though we had definitions and standards in place." Health Department Staff Member
Each aggregate intervention plan and process monitoring data report consists of descriptive data for one of seven interventions provided for a specific population in a jurisdiction. The interventions and populations and their definitions are presented below.
| Intervention Definitions |
| Intervention |
Definition |
Excludes |
| Individual-Level Intervention (ILI) |
Health education and risk-reduction counseling provided to one individual at a time. ILI assists clients in making plans for individual behavior change and ongoing appraisals of their own behavior and includes skills building activities. These interventions also facilitate linkages to services in both clinic and community settings (e.g., substance abuse treatment settings) in support of behaviors and practices that prevent transmission of HIV, and they help clients make plans to obtain these services. |
Outreach and prevention case management. Each intervention constitutes its own category. Also excludes HIV counseling and testing which is reported in a separate category using the standard bubble sheets. |
| Group-Level Intervention (GLI) |
Health education and risk-reduction counseling (see above) that shifts the delivery of service from the individual to groups of varying sizes. GLI uses peer and non-peer models involving a wide range of skills, information, education, and support. |
Any group education that lacks a skills component (e.g., information only education such as "one-shot" presentations). These types of interventions should be included in the HC/PI category. |
| Outreach |
HIV/AIDS educational interventions generally conducted by peer or paraprofessional educators face-to-face with high-risk individuals in the neighborhoods or other areas where they typically congregate. Outreach usually includes distribution of condoms, bleach, sexual responsibility kits, and educational materials. Includes peer opinion leader models. |
Condom drop offs, materials distribution, and other outreach activities that lack face-to-face contact with a client. |
| Prevention Case Management (PCM) |
Client-centered HIV prevention activity with the fundamental goal of promoting the adoption of HIV risk-reduction behaviors by clients with multiple, complex problems and risk-reduction needs; a hybrid of HIV risk-reduction counseling and traditional case management that provides intensive, ongoing, and individualized prevention counseling, support, and service brokerage. |
One-to-one counseling that lacks ongoing and individualized prevention counseling, support, and service brokerage. |
| Partner Counseling and Referral Services (PCRS) |
A systematic approach to notifying sex and needle-sharing partners of HIV-infected persons of their possible exposure to HIV so they can avoid infection or, if already infected, can prevent transmission to others. PCRS helps partners gain earlier access to individualized counseling, HIV testing, medical evaluation, treatment, and other prevention services. |
HIV counseling and testing which is reported in a separate category using the standard bubble sheets. |
| Health Communication/Public Information (HC/PI) |
The delivery of planned HIV/AIDS prevention messages through one or more channels to target audiences to build general support for safe behavior, support personal risk-reduction efforts, and/or inform persons at risk for infection how to obtain specific services.
Electronic Media: Means by which information is electronically conveyed to large groups of people; includes radio, television, public service announcements, news broadcasts, infomercials, etc., which reach a large-scale (e.g., city-, region-, or statewide) audience.
Print Media: These formats also reach a large-scale or nationwide audience and includes any printed material, such as newspapers, magazines, pamphlets, and "environmental media" such as billboards and transportation signage.
Hotline: Telephone service (local or toll-free) offering up-to-date information and referral to local services (e.g., counseling/testing and support groups).
Clearinghouse: Interactive electronic outreach systems using telephones, mail, and the Internet/Worldwide Web to provide a responsive information service to the general public as well as high-risk populations
Presentations/Lectures: These are information-only activities conducted in group settings; often called "one-shot" education interventions. |
Group interventions with a skills-building component, which constitutes a separate intervention category. |
| Other |
Category to be used for those interventions funded with CDC Program Announcement 99004 funds that cannot be described by the definitions provided for the other six types of interventions. This category includes community-level intervention (CLI).
CLI are interventions that seek to improve the risk conditions and behaviors in a community through a focus on the community as a whole, rather than by intervening with individuals or small groups. This is often done by attempting to alter social norms, policies, or characteristics of the environment. Examples of CLI include community mobilizations, social marketing campaigns, community-wide events, policy interventions, and structural interventions. |
Any intervention that can be described by one of the existing categories. |
| Population Definitions |
| Population |
Definition |
Exposure Route and Risk Behaviors |
| MSM |
HIV prevention needs of men who report sexual contact with other men or with both men and women. |
Unprotected sex between men that results in exposure to semen or blood. |
| MSM / IDU |
HIV prevention needs of men who report both sexual contact with other men and injection drug use. |
Risks through both unprotected sex with other men and injection drug use that results in exposure to semen or blood. |
| IDU |
HIV prevention needs of people who are at risk for HIV infection through the use of equipment to inject drugs (e.g., syringes, needles, cookers, spoons). |
Use of needles, syringes, or preparation materials by two or more people that results in exposure to blood. |
| Heterosexual sex with someone at risk for or infected with HIV |
HIV prevention needs of persons who report specific heterosexual contact with a person with, or at increased risk for, HIV infection (e.g., sex with an IDU, a bisexual male, or a person known to be HIV-positive or to have AIDS). |
Unprotected vaginal, anal, or oral sex between a man and woman that results in exposure to semen, vaginal fluids, or blood. |
| Women who are at risk for or infected with HIV who are pregnant |
HIV prevention needs of women who have HIV or are at risk of becoming infected and who are pregnant or at risk of becoming pregnant and, thus, at risk of transmitting HIV to their infant. |
Transmission to the baby prenatally, during delivery, or through breast-feeding. |
| General population |
Intervention will not be targeted to any specific groups whose behavior puts them at high risk for HIV infection. |
No specific risk for HIV, but often the target of broad prevention or education efforts to increase awareness or change community norms. |
Reconciling Differences between Guidance Definitions and Local Terminology
Some jurisdictions defined their populations and interventions prior to the release of the Guidance, consequently, these definitions may differ from those found within the Guidance. Examples of locally defined populations include youth, women, crack users, African Americans, homeless persons, incarcerated persons, people living with HIV, and other groups not explicitly defined by a behavior that increases one's risk for HIV exposure or transmission to others. In the absence of a specified HIV-risk behavior, these populations do not match the Guidance definitions for populations. Similarly, local intervention definitions and Guidance definitions may differ (e.g., contractors may consider a "home party" to be a GLI even if it does not include a skills-building component).
Differences between Guidance definitions and local terms may cause health department staff and contractors to feel that some populations and interventions have been excluded from the Guidance. It is important to emphasize that the Guidance does not require health departments to replace local terms that have already been established in the jurisdiction. However, health departments must be able to translate local terms to match the Guidance definitions for reporting to CDC so that a national standardized data set can be created and maintained.
Reconciling differences between local terminology and Guidance definitions is an important step in developing a system for gathering and reporting Guidance data. Health departments commonly use three different strategies for reconciling these differences:
- Contractors use local terms,
- Contractors use Guidance definitions, and
- Contractors use both Guidance definitions and local terms.
Contractors Use Local Terms
Health departments allow their contractors to continue to use local population and intervention terms and to report data to them using this language. These data are then recoded by the health department to match the Guidance definitions for reporting to CDC.
| Example: |
A target population might be reported to the health department as "crack users" and then recoded and reported by the health department to CDC as targeting "heterosexuals", if that is the predominant HIV risk behavior exhibited by this population. Likewise, a series of "home parties" with a skills-building component may be recoded as a GLI. |
Health departments are encouraged to work closely with their contractors to understand how local definitions are used and to develop a systematic way to recode data consistent with Guidance definitions. Recoding of local population and intervention data can be done manually or can be facilitated by data management software. Software can be programmed to allow data entry using local terms and then automatically recode the data according to how the health department has decided to report these populations and interventions to CDC.
"We tried asking people to conform to the Guidance definitions and we know that didn't work. Now we're going to use their own terminology and use the computer to do all of that work internally to translate the data to the Guidance terms. So when we program our data entry system that's how we'll set it up." Health Department Staff Member
Contractors Use Guidance Definitions
Health departments expect their contractors to adopt the Guidance definitions and to use these terms exclusively. Health departments often collaborate initially with their contractors to clarify the relationship between the Guidance definitions and local population and intervention terms.
| Example: |
A jurisdiction may decide that interventions targeting "youth" will be reported as reaching two Guidance populations: "heterosexual" and "MSM." Similarly, the activities of a speakers' bureau formerly reported by contractors as "risk-reduction sessions" may now be reported as "HC/PI." |
Once the relationship between local terms and the Guidance definitions has been clarified, the health department may need to provide ongoing assistance to contractors during the transition to using the new definitions. Population and intervention definitions can be incorporated into paper data collection forms and data entry screens to reinforce proper use of the definitions and to facilitate accurate reporting.
Contractors Use Both Guidance Definitions and Local Terms
Health departments expect their contractors to adopt the Guidance definitions but also allow them to use local population and intervention terms. For populations, contractors report data using the Guidance definitions and also select one or more locally defined terms to further describe the population (e.g., heterosexual homeless person living with HIV).
Likewise, intervention data can be reported using Guidance definitions paired with local intervention terms (e.g. GLI risk reduction party). The simultaneous use of local and Guidance terms can be facilitated by data management software. Data entry screens can display local terms linked to data entry fields that prompt reporting using the Guidance definitions.
Summary
Health departments are encouraged to consider the advantages and limitations of these three strategies as they develop systems for collecting and reporting Guidance data in their jurisdiction. Contractors' exclusive use of locally defined population and intervention terms avoids the challenges of establishing a new set of definitions and may retain consistency with language already used by local planning and service delivery groups (e.g., HIV prevention community planning groups). This strategy, however, may be vulnerable to errors when data are recoded for reporting to CDC and may not address the problem of differences in how populations and interventions are defined within and across jurisdictions.
Although it can initially be challenging for a jurisdiction to adopt new definitions for populations and interventions, this approach can lead to long-term improvements in the accuracy and consistency of data collection and reporting and can improve the clarity of communications among contractors within and across jurisdictions.
While the combination of these two strategies, using both Guidance definitions and local terms, still requires the adoption of new definitions, it enables consistent and accurate reporting to CDC, facilitates clear communication among contractors within and across jurisdictions, and retains population and intervention terms relevant within the jurisdiction (e.g., "HIV-positive" and "home parties") that can be used for local data analysis and reporting purposes.
It is important to note that these three strategies are not mutually exclusive. Health departments may clarify the relationship between some local terms and the Guidance definitions and, for these terms, expect contractors to use the Guidance definitions for reporting purposes. In the same jurisdiction, other local terms that do not fit within the Guidance definitions may be retained and used by contractors as distinct reporting categories. The use of these strategies may also change over time as jurisdictions' reporting systems evolve to ensure greater uniformity and quality of data.
Reporting Non-HIV Risk Behavior Populations
Although the Guidance defines populations by their HIV risk behaviors (except for "Mother with/at risk for HIV" and "General Population"), many jurisdictions previously defined populations in a way that does not specify HIV risk behaviors. These populations include, but are not limited to: youth, women, crack users, African Americans, homeless persons, incarcerated persons, and people living with HIV. The situational, behavioral, and demographic characteristics used to define these populations provide important contextual information that should be considered when designing an intervention. For example, HIV positive MSM may have very different prevention needs than HIV positive IDUs. Likewise, an intervention targeting heterosexual crack users may be designed differently from one reaching heterosexuals who do not use crack. These examples clarify why the Guidance does not preclude the use of these characteristics to describe populations as long as an HIV risk behavior is also specified. Again, jurisdictions are welcome to use non-HIV risk behavior characteristics to define their populations; only the Guidance terms are required for reporting to CDC.
Jurisdictions with population definitions that do not specify an HIV risk behavior should consider which HIV risk behavior is exhibited by the population. In some cases, more than one HIV risk behavior may be present. The population "youth" may be comprised of two sub-populations, one engaging in heterosexual risk behavior, the other in MSM risk behavior. In this case, two distinct populations, based on risk behavior, may be considered when developing interventions and when collecting and reporting Guidance data.
"I appreciated that CDC forced us into the population definitions the way it did. Many of our contractors asked us why are you forcing us to think about how the population got HIV. There are lots of things you can say about people that are true but for a moment let's think about why they are at risk for HIV. It is a good discipline." Health Department Staff Member
When the specific HIV risk behaviors are not known, health departments should avoid the temptation to report the population as General Population. Rather, needs assessment may be required to learn more about the population's prevention needs as a prelude to defining the population and designing effective interventions. General Population, according to the Guidance, should be reserved only for those interventions that do not target a specific risk for HIV (e.g., a city-wide media campaign to raise awareness of HIV/AIDS).
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