New CHIP Principal Investigator Lisa Eaton, an assistant research professor of psychology in the College of Liberal Arts and Sciences, recently won a five-year National Institute of Mental Health grant to conduct a large-scale, randomized clinical trial of an HIV prevention intervention she successfully piloted in Atlanta.

The trial of Eaton’s Think Twice intervention will involve 670 HIV-negative, young, black men who have sex with men.

Think Twice is designed to teach men who have sex with men the risks associated with an HIV prevention strategy known as “serosorting” and to empower them to make educated choices about their sexual behaviors and to effectively manage the scenarios in which HIV transmission is most likely to occur.

Serosorting – limiting sexual partners to those who are of the same HIV status – has emerged as an alternative to condom use, but actually has been shown to increase, rather than decrease, HIV risk for a variety of reasons, Eaton says.

“This grant is a sign of the state of the epidemic in the U.S. in regard to young, gay, black men. Their rates of HIV rival any third world country we would consider hardest hit by the epidemic,” she says. “It is totally out of control, particularly in places like Atlanta. Data from the CDC are startling. It’s a crisis.”

According to a report released by the U.S. Centers for Disease Control and Prevention (CDC) in August, new HIV cases nationwide rose by nearly 50 percent between 2006 and 2009 among young, black, gay men.

Compounding the crisis, Eaton says, community-based prevention programs targeting men who have sex with men have dwindled during the past decade, and only three evidence-based interventions designed specifically for this group are disseminated by the CDC, none of which are individual-level or brief interventions.

Think Twice is a brief (40 minutes), single-session intervention delivered by a peer counselor: it is designed to be implemented in a cost-effective manner in public health settings.

The intervention has two critical components: a focus on informed personal decision-making around partner selection; and the creation of a teachable moment – a time period and emotional state in which people are more open to changing their behavior.

Think Twice is delivered through a graphic novel created to convey messages about serosorting in an interactive, informative, and non-intimidating manner. The comic book depicts a fictitious (but evidence-based) gay man who tests HIV negative, uses serosorting as an HIV prevention strategy, and then tests positive at the end of the story.

The peer counselor and study participant use the story as a springboard for a discussion about how the main character could have become infected (his partner could be acutely HIV infected which would result in an HIV negative test; they may not have explicitly discussed HIV status; the partner could have misrepresented his HIV status; or the partner may be relying on outdated test results), and then the counselor and participant work together to identify ways the character could have reduced his HIV risk.

The next piece of the intervention, which creates the teachable moment, involves showing participants a visual diagram of the character’s sexual partners and acts, asking the study participant to create a diagram of his own sexual partners and acts, and then asking the participant to compare the two diagrams.

“Through this activity, participants readily reflected on instances in which they potentially exposed themselves to HIV, thus creating a teachable moment,” Eaton wrote in an article about the Think Twice pilot study published in the American Journal of Public Health in the spring.

Finally, a peer counselor helps each participant develop an individual risk-reduction plan he considers reasonable.

The findings of Eaton’s pilot project include:

• Men in the serosorting intervention arm of the pilot reported fewer sexual partners than did men in the control arm.
• Those in the serosorting intervention condition also reported increased condom-use self-efficacy and increased perceptions of risk for HIV transmission.

The Think Twice pilot involved 149 at-risk gay men living in Atlanta, 80 percent of whom were African American, and it took place in a community-based setting.

“We’re working with the right people, at the right time, in the right place – and the intervention is very practical,” Eaton says. “We’re in a position to make a major impact, given the infrastructure we already have in Atlanta.”

Eaton, who earned her Ph.D. in psychology from UConn in 2009, has worked as part of CHIP PI Seth Kalichman’s Southeastern HIV/AIDS Research Evaluation (SHARE) Project for the past eight years.

Through Kalichman’s continuously-funded National Institutes of Health projects, SHARE has worked with people living with HIV in Atlanta for the past 15 years. Kalichman estimates the SHARE Project has engaged more than 4,500 people living with HIV during that time.

Eaton credits her success in securing funding for a large-scale clinical trial so early in her career in part to Kalichman’s mentorship (Kalichman is a co-investigator on the grant), and also credits Trace Kershaw at Yale School of Public Health for providing frequent guidance in grantsmanship.

Other members of SHARE Project working on Eaton’s R01 trial include Daniel Driffin, Kevin English, and Moira Kalichman.