Robert M. Malow - US grants

The major objective of the proposed investigation is to evaluate: 1) the mediating variables associated with changing HIV risk behavior; and 2) the impact of psychoeducational (PE) HIV Risk Reduction training added to a drug abuse treatment program, compared to that of a conventional didactic procedure. To accomplish this goal, selected drug dependent patients admitted to the Miami Veterans Affairs Medical Center Drug Dependence Treatment Program will be randomly assigned to (a) an Information (INFO) condition in which subjects receive brochures describing HIV transmission and risk reduction, or (b) a Psychoeducational (PE) condition modeled after Heitzman, Sorensen, et al. (1988). Subjects in the PE condition will receive brochures and will also participate in group sessions in which HIV risk reduction instruction is provided, incorporating optimal behavioral change strategies. Self reports of risk behavior and behavioral demonstrations of lower risk behaviors such as condom use and needle cleaning will be measured prior to intervention and at 3, 6, and 12 months following intervention. A second objective is to administer a stronger version of PE than previous studies which have produced HIV risk behavior reductions among drug addicts. A third objective is to measure the influence of extratherapeutic factors, including the quality and quantity of drug abuse treatment received and life context variables (e.g., social support, resources, and stressors). Additional objectives are to: (a) monitor patients' involvement in various components of the HIV prevention intervention and to relate level of involvement to proximal and ultimate outcome variables; (b) control for the effect of information on intervention outcome; (c) evaluate immediate and enduring effects of intervention by assessing outcome over one year; and (d) include objective measures of drug treatment outcome (e.g., drug testing, compliance with aftercare) and staff verification of patients' self-report data.

AIMS: Our major objectives are to evaluate: 1) a theoretical model regarding the mechanisms and processes associated with changing HIV risk behavior; 2) the impact of an Enhanced Psychoeducational (PE-E) HIV Risk Reduction training added to a drug abuse treatment program, compared to that of a conventional informational (INFO) HIV prevention procedure; and 3) to measure the influence of life events/social context variables (e.g., social support, resources, and stressors). Given the heuristic value of a theoretical model in developing effective prevention procedures, our study will be guided by the AIDS Risk Reduction Model (ARRM; Catania et al., 1990, 1994). The proposed project will be among the first to evaluate a psychoeducation intervention for our target population of socioeconomically disadvantaged, "crack" cocaine abusing, pregnant and postpartum, African American women at high risk for HIV that includes their male primary sex partners (PSPs). HYPOTHESES: Hypotheses are that: 1) greater levels of intervention implementation will predict greater positive change in post-treatment and follow-up levels of the ARRM mediating and HIV risk reduction outcome variables; 2) greater positive change in the ARRM mediating variables will predict greater change in HIV risk reduction outcome variables; 3) because our target sample is indigent, "disempowered", substance abusing women, social context variables will be significantly related to HIV risk reduction outcome; 4) PE-E will produce greater positive changes in ARRM and social context mediating variables than INFO; and 5) PE-E will be most effective for subjects showing the greatest initial problems in ARRM and social context mediating variables. METHOD: Our target sample of women in substance abuse treatment (n=160) will be assigned using a random block design to a) the INFO condition in which subjects receive two session of didactic HIV transmission and risk reduction information, or b) the PE-E condition in which subjects participate in multiple HIV risk reduction sessions with their primary sex partner. Adherence to experimental end control conditions will be monitored and carefully documented. Risk behavior, drug use, HIV serostatus, and other clinically significant phenomena will be measured at pre- and post-intervention and at 3, 6, and 12 months. ANALYSES: To ensure that data are reliable and valid, correlational techniques will be used to assess levels of agreement between self-report and other converging information sources. Data analyses will involve a 2- way (intervention condition x time) factorial design (e.g., MANCOVA or ANCOVA). Analyses will include survival curves, multivariate logistic regression and factor analyses to reduce the number of variables. Step- wise multiple linear regression analyses will be used to evaluate the ARRM constructs and to identify baseline variables that predict a successful response for each treatment condition.

APPLICANT'S ABSTRACT: This proposed 5-year study compares the long-term effects of an Enhanced-Cognitive-Behavioral (E-CB) Intervention to a Standard Care (SC) comparison condition in reducing the risk of HIV transmission risk behaviors among a culturally diverse, lower-SES, sexually-active, recovering Alcohol or Other Drugs (AODs) abusing population of 320 Severely Mental Ill (SMI) women and men. The study is a randomized (by cohort), two-group design with repeated measures over time (6 and 12 month follow-up) comparing the efficacy of E-CB with SC in psychiatric treatment. Although there have been a few randomized HIV prevention outcome studies in the SMI population, these studies did not focus on reducing AOD use and other putative psychiatric mediators of HIV transmission risk behavior. This study is significant because it addresses the urgent need to develop an effective intervention to reduce HIV transmission risk and AOD use in a growing population of SMI patients in treatment and it focuses on overcoming several neglected issues of practical significance. Of importance, this study employs a standardized psychosocial E-CB intervention that has been specifically gender-tailored for the target population and attempts to reduce risky behavior in an SMI group that includes HIV + individuals. Using multivariate methods, we will assess whether: 1) E-CB reduces HIV risk behaviors to a greater extent than SC; 2) E-CB reduces AOD use and other psychiatric symptoms' indices to a greater extent than SC; 3) AODs use, other psychiatric symptoms, and HIV-specific risk variables (e.g., self-efficacy, condom skills) are mediators of outcome; and 4) key variables (e.g., tramatic abuse history, neuropsychological functioning, gender) are moderators of outcome. Secondary analyses (Hierarchical Linear Modeling, Structural Equations) will explore cause models of how important variables (e.g., psychiatric diagnosis and symptoms, AOD and HIV attitudes, beliefs, skills) may interact to predict HIV transmission risk behavior. If successful, this research will provide important new intervention strategies that can be practically implemented with recovering AOD abusing SMI psychiatric outpatients. The proposed project will contribute new and unique information about the effects of gender, serostatus, neuropsychological functioning, AOD abuse, psychiatric symptoms and other putative mediators/moderates of HIV transmission risk outcome among SMI patients.

DESCRIPTION: (Applicant's Abstract) The primary aim of this proposed 4 year study compares the effects of an Enhanced Cognitive-Behavioral (E-CB) Intervention to a "Standard Care" Information Condition in reducing HIV risk among culturally diverse, poor minority male adolescent offenders (N=440). Since the E-CB intervention is offered in the context of court-mandated treatment, it provides a unique opportunity to reach an extremely high risk group that might otherwise be impossible to engage in an intense and specialized HIV risk reduction intervention. Although some of the drug treatment program activities share common components to the E-CB, these activities do not a) incorporate the motivationally, enhanced E-CB format of encouraging participants to actively assist in developing their own risk-reduction strategic to best suit their circumstances; b) include HIV risk specific mixed gender groups with facilitated interactions focused on rehearsing strategies to reduce risk; and c) emphasis on cognitive-behavioral strategies to cope with the transition from in-patient status to community living. AIM 2 is to evaluate if E-CB reduces drug use to a greater extent than SC. AIM 3 is to evaluate if drug abuse (particularly crack cocaine) may mediate the relationships between our interventions and HIV risk outcome. AIM 4 is to evaluate if key variables mediate the relationships between our interventions and HIV risk and drug abuse outcome. AIM 5 is to evaluate if key variables may moderate the relationships between our interventions and our HIV risk and drug abuse outcome. An EXPLORATORY AIM is to evaluate if E-CB produces greater positive therapeutic impact than SC on HIV testing behavior and results. Risk behavior, drug use, HIV and STD status, HIV testing acceptance, drug and other clinically significant phenomena will be measured at pre- and at 6 months post- intervention.. Multiple methods (in-depth interviewing, STD and drug urine analyses) will be used to corroborate and supplement self reports. Repeated measures MANOVA and regression analyses will be used to analyze the effects of E-CB on HIV risk mediating and outcome variables and to explore the relationships between mediating, moderating and outcome variables.

DESCRIPTION (adapted from the Abstract): In this proposed 5-year study the researchers will compare the effects of an Enhanced Cognitive-Behavioral (E-CB) Intervention to a Standard Care Information (SC-INFO) Condition in reducing the risk of HIV transmission (e.g., proportion of protected sexual acts, number of sex partners, use of alcohol or other drugs [ADD] proximal to sex activity) among a culturally diverse, inner city, ADD- abusing population of 440 HIV-negative adolescent offenders and 50 HIV- positive adolescent offenders. Their specific aims are to evaluate: (1) if E-CB reduces HIV risk behaviors to a greater extent than SC-INFO; (2) if E-CB reduces AOD use to a greater extent than SC-INFO; (3) if AOD abuse may mediate the relationship between our interventions and HIV risk behaviors outcomes, (4) if key variables mediate the relationships between these interventions and HIV risk behaviors and AOD-abuse interventions and the HIV-risk behavior and AOD-abuse outcome. The exploratory aim is to evaluate effects of HIV serostatus on outcome variables. The study is significant because it addresses the urgent need to develop an effective intervention to reduce HIV risk and AOD use in a growing population of adolescent offenders court ordered into treatment. The needs of these offenders have not been addressed adequately by traditional AOD-abuse treatment programs as indicated by an extremely high rate of relapse to unsafe sex and alcohol/drug abuse. Specific features of this project that increase the probability that it will produce definitive and innovative information include: (a) the use of a standardized, psychosocial E-CB intervention which has been specifically tailored for the target population; (b) the employment of a randomized experimental design that compares subjects assigned to E-CB with those assigned to a standard care condition; (c) the timing of the intervention to occur prior to the stressful transition from inpatient to outpatient status; and (d) the inclusion of HIV-positive youths in the study and validation of an intervention that attempts to reduce risky sex and AOD-using behaviors in mixed serostatus groups.

DESCRIPTION: (Applicant's Abstract) Cognitive Behavioral Stress Management (CBSM) is an intervention developed by our project team during over a decade of NIH-funded research to address the unique primary and secondary prevention issues of the HIV+ population. This proposed 5-year study is designed to evaluate the effects of an adapted version of this intervention, CBSM-RDA, aimed at the unique needs of HIV+ recovering drug abusers (RDAs) and the ethnic/cultural factors that may mediate outcome. In particular, this study heeds the national priority on translational research and adaptation of proven interventions to benefit minority HIV+ subgroups, who are culturally different, less affluent, and who bear the added burden of a history of drug abuse and the special needs of recovery. Because this is a grossly understudied population, especially with regard to CART adherence (Combination Antiretroviral Therapy), a key aim of this study is to focus CBSM-RDA on improving medication adherence and on understand the trajectories of success due to our intervention. We propose a randomized clinical trial to test relative effects of CBSM-RDA and a Health Promotion Comparison (HPQ condition, designed to be structurally equivalent in time, attention, and interest value. Employing a 2 (CBSM-RDA vs. HPQ) x 5 (pre-, post-intervention, 4, 8, and 12-month follow-up assessments) design, we will provide the intervention to a culturally diverse, predominantly minority population of HIV+ RDA men (N= 160) and women (N= 160) and comparatively assess the therapeutic effects of CBSM-RDA and HPC on key endpoints: distress and quality of life, drug abuse relapse, unsafe sex, CART adherence, and health status. Another key motivation of this research is to specify the mediators and moderators of these endpoints to address issues of mechanism of action and generalizability, respectively. Hierarchical Linear & Structural Equations Modeling will be used to explore how study variables interrelate to predict outcome. If successful, this research will provide important new intervention strategies that can be practically implemented with HIV+ drug abusers.

This is a revision of an application that responded to a RFA (HD- 98-015, REPLICATION OF COMMUNITY-BASED HIV INTERVENTIONS FOR YOUTH) which called for proposals to replicate effective adolescent community-based behavioral HIV prevention interventions. In this application, we propose to replicate a Cognitive-Behavioral HIV transmission risk reduction (CB-HIV-TRR) intervention entitled "Becoming A Responsible Teen" (BART) that has been shown to be highly effective with African American adolescents in Mississippi. During the first 3 months of the proposed project, we will continue our work of culturally tailoring the BART intervention to our target population of high- risk 14-17 year old Haitian American (H-A) youths. Then, we will evaluate the effects of the adapted BART intervention in H-A male (N=160) and female (N=160) high risk adolescents. Employing a 2 (BART vs. Control) x 7 (pre-, post-intervention, 3, 6, 9,12,15- month follow-up assessments) design, we will evaluate the extent to which the BART intervention produces greater HIV transmission risk reduction than a time matched Health Promotion Comparison (HPC) control group. We propose a 15-month follow-up period to provide a better assessment of the effectiveness of the intervention to sustain behavior change that is essential since changes in risk behaviors must be enduring if they are to be meaningful. We shall also attempt to specify the mediators and moderators of these endpoints to address issues of mechanism of action and generalizability, respectively. Using Hierarchical Linear and Structural Equations Modeling, we will explore causal models of how important variables (for example self-efficacy, behavioral intentions, social network factors, acculturation) may interrelate to predict HIV transmission risk behavior. If successful, this research will provide important new intervention strategies that can be practically implemented with high-risk H-A adolescents.

DESCRIPTION: (provided by applicant) This proposed study targeting drug abusing adolescents is a 5-year randomized controlled trial of an Enhanced-Cognitive Behavioral HIV prevention intervention, augmented by components focused on Social Influence (Soc-Influence) and Psychiatric/Psychological (Psych) Symptoms. The primary aim is to compare the effects of E-CB on primary outcomes (HIV risk behaviors) with a Health Promotion Comparison (HPC) condition, matched for attention, time, and attention value, when administered under conditions approaching ecologically valid "real life" community circumstances. E-CB is considered an enhancement over existing CB approaches because it integrates key components derived from "effective" CB adolescent-specific HIV interventions, as appraised in the CDC's Compendium of HIV Prevention Interventions, and adds components to address Soc-Influence (parental monitoring and parent-child communication) and Psych factors (drug abuse & psychiatric symptom severity). The proposed sample of 160 male and 160 female adolescents will be drawn from a target population of predominantly minority, low income, culturally diverse, sexually active, alcohol and other drug (AOD) abusing youth-a group most disproportionately affected by HIV and other health disparities. We propose to examine how intervention effects are 1) mediated by Attitude-Motivation-Skill variables, Social Influence, and Psychiatric Variables and moderated by 4 key factors: age, gender, cognitive functioning, and traumatic abuse history. HLM and SEM procedures will be used to explore how study variables interrelate to predict outcome. This project is significant in its response to the NIH priority on translational research, in which HIV prevention is refocused on the adaptation of "effective" interventions to reach new populations. The proposed project further responds to the NIH priority on bridging clinical research and practice, the emphasis is to bring interventions developed during efficacy trials in a rigorous academic setting, into communities in a manner adaptable to "real world" conditions by community based providers. If successful, this research will delineate important HIV risk factors and new intervention strategies that can be practically implemented with high-risk adolescents within their communities.

DESCRIPTION (provided by applicant): The proposed study addresses the persistent disconnect between HIV prevention science and community practice as urgently identified by the Institute of Medicine (1998,2000) and the NIH (2000,2001). Of noted priority is the need to transfer effective HIV prevention interventions targeting adolescents to community-based settings that directly serve the highest risk groups. This study's primary aim is to assess the effectiveness of a Cognitive Behavioral (CB) HIV adolescent prevention intervention in an adapted design (CB-A) for implementation in Community-Based Organizations (CBOs) by CBO staff. The CB-A will be compared to a time and attention matched Standard Care condition (SC) in a randomized clinical trial, in which delivery of both is by well-established CBOs and staff. Similar to our originally developed CB that has shown great promise in a research-based efficacy clinical trial, CB-A incorporates the same innovative mix of behavioral skills training, motivational enhancement, and relapse prevention components of interventions previously demonstrated to be effective and identified in the CDC's (1999) Compendium of HIV Prevention Interventions with Evidence of Effectiveness. In designing the randomized clinical trial and the CB-A intervention for optimal translation and technology transfer, our academic university medical center research team has formed a close partnership and collaboration with a network of CBOs, well-integrated as HIV prevention and treatment providers serving the surrounding, socioeconomically disadvantaged racial/ethnic minority communities of Miami-Dade County, Florida. This county carries the greatest HIV/AIDS burden and is the most densely multicultural and urban area within the state. Using youth-serving CBOs as recruitment sites, the proposed sample of 160 male and 160 female adolescents will be predominantly minority, low income, culturally diverse, sexually active youths with recent histories of Alcohol and Other Drug (AOD) abuse. The scondary aims of this proposed study are to evaluate if key variables mediate and moderate relationships between the intervention and HIV risk behavior outcomes. This study is significant because it addresses the urgent need to develop an effective, highly targeted intervention that is usable by CBO practitioners to reduce HIV transmission behaviors in this extremely vulnerable and risky population subgroup, in an area of the country that is disproportionately affected by HIV and the pervasive national problem of racial/ethnic health disparities.

DESCRIPTION (provided by applicant): The proposed study is a gender-and-culturally specific adaptation and randomized trial of a group-formatted Motivational-Enhanced, Brief Behavioral Skills Intervention (BBSI-A) for reducing HIV risk among 320 predominantly Hispanic and African American women, representing a target population of the AOD abusing, seriously mentally ill (SMI) population in community treatment in the HIV epicenter of Miami. A key focus is how group processes (e.g., group alliance, engagement, cohesion, and climate), which have been rarely studied in HIV prevention research, may mediate change. The intervention to be adapted and evaluated is derived from Information-Motivation-Behavior (IMB) theory, and is evidence-based and archived by scientific consensus for dissemination. The adaptation, BBSI-A, will be compared to a time-matched, video-based "Treatment as Usual" Educational (EDUC) condition. Hierarchical Linear & Structural Equations Modeling will be used to explore HIV risk outcomes as well as how intervention effects are mediated by Group Processes (e.g., group engagement, alliance, cohesion and climate), IMB variables, AOD use and Psychiatric variables. These analytical techniques will also be used to explore how HIV risk outcomes are moderated by 2 key factors: cognitive functioning, and traumatic abuse history. Understanding causal mechanisms by which interventions exert their effects, including the mediating influences of theoretically important group process factors, should contribute to subsequent efforts to apply effective interventions in other clinical settings. The proposed project responds to the NIH priority on bridging clinical research and practice, in which the emphasis is on adapting effective research-based intervention strategies for the "real world" conditions faced by community based providers. If successful, this research will present an HIV intervention strategy that can be practically implemented for high-risk AOD abusing SMI women within their communities.

[unreadable] DESCRIPTION (provided by applicant): The proposed study, targeting Pregnant Drug Abusers in treatment, is a randomized trial of Enhanced- Behavioral Skills Training (E-BST) compared to a time- and attention-matched Health Promotion Comparison (HPC) condition. E-BST is an adaptation of the original BST intervention (Eldridge, St. Lawrence et al. 1997), designed to strengthen relationship-based social competency skills of the original BST were crucial in sustaining adherence to protective behavior. The E-BST emphasizes negotiation/communication skills with sexual partners/significant others and social ecological skills of help- seeking and service utilization. Such ecological enhancements at multiple interactive levels-pointed to in the original BST trial as potentially facilitative of refusal skills-may provide continued reinforcement of behavioral change even after the intervention has ended. BST is one of the only effective behavioral interventions for women in drug treatment; however, only modest, short-term gains were demonstrated. Growing evidence indicates that impacts will continue to be minimal until interventions go beyond the individual to address contextual factors that can empower women in their actual life situations and address the difficulty of adopting and sustaining protective behavior. Participants will be 320 culturally diverse (30% Hispanic, 60% African American) pregnant drug abusers in treatment with random assignment to the E-BST and HPC. We will use HIM to explore how intervention effects are mediated by theoretically relevant Individual Cognitive-Behavioral (e.g., Information-Motivation-Behavior; Fisher and Fisher, 1992) and Contextual (e.g., Drug Abuse, Service and Social Support Utilization) factors and moderated by key background factors: cognitive functioning and traumatic abuse history. The proposed project responds to the NIH priority on translational research to adapt effective research-based intervention strategies to "real world" conditions. If successful, this research will offer a realizable HIV intervention strategy, bridging research and practice, that can be implemented for pregnant drug abusers within their communities. [unreadable] [unreadable] [unreadable] [unreadable]

DESCRIPTION (provided by applicant): The proposed randomized controlled study will attempt to reduce HIV sexual transmission risk and substance use, increase the utilization of primary HIV care services, and improve psychosocial health among a sample of 320 alcohol abusing, HIV+ individuals. The experimental intervention will include an adaptation of the Holistic Health Recovery Program (HHRP;Margolin et al., 2003) that is the only evidence-based, HIV+ intervention for improving sexual risk and adherence outcomes for an addicted population. For this study, the intervention will be adapted for use in a culturally diverse, alcohol abusing sample. HHRP will be compared to a Health Promotion Comparison (HPC) condition, which addresses common health problems, including personal hygiene and healthy living. Specific aims include: 1) comparing the adapted HHRP to the HPC condition to evaluate if HHRP reduces HIV sexual transmission risk, alcohol and other drug use, and improves the utilization of primary HIV care services and psychosocial health;2) evaluating how Information, Motivation, Behavioral Skills mediate intervention effects on safe sex outcome;and 3) evaluating how key neuropsychological and molecular-genetic factors moderate the effect of the intervention on HIV transmission risk outcomes. Recruitment sites are primarily located in densely populated, multicultural, low income, urban areas of Miami with high rates of AOD abuse, HIV, violence and poverty, with the vast majority of the population being uninsured and suffering from multiple health disparities. The study is a prospective, randomized by cohort two-group design. The scheduled sequence of procedures will be: a) informed consent, screening, and baseline assessment;b) a 120 minute group session of HHRP or HPC sessions administered once a week for 12 consecutive weeks;and c) a post- intervention assessment. Follow-up assessment protocols will be administered at 3, 6, and 12 months post-intervention. Neuropsychological and blood tests for molecular/genetic typing will also be conducted to assist in identifying factors which may influence the impact of the intervention study. The proposed study will attempt to reduce HIV sexual transmission risk and substance use among a sample of alcohol abusing, HIV+ individuals. In studying the memory, information processing, executive functioning as well as genetic factors of the individuals of this study, researchers will be better able to discern those factors which may have an impact on treatment effects. This study therefore has the potential to identify individual characteristics that may contribute to specific reductions in risky behaviors in this sample.

[unreadable] DESCRIPTION (provided by applicant): The proposed study is an adaptation and randomized trial of a Cognitive-Behavioral Stress Management (CBSM) intervention for simultaneously enhancing safer sex practices, adherence to ARV medication, and reducing alcohol or other drugs (AOD) use, in a predominantly poor urban population in Haiti. With our on- site clinical research partner, the GHESKIO Centers, a key focus will be how HIV intervention outcomes are influenced by Environmental and PsychoSocial (Env-Psy-Soc) factors. Performing this study in Haiti with GHESKIO presents a unique opportunity to contribute an EnvPsySoc dimension to the HIV/AIDS prevention and treatment scale-up that is ongoing there and in the region. GHESKIO is unique and unparalleled in Haiti and the region as a socially trusted infectious disease control institution that has been there since the discovery of the HIV virus and that has successfully adapted an academically disciplined HIV/AIDS clinical research and training model into the urban and rural communities of Haiti. GHESKIO operates using an integrated care model similar to a typical U.S. VA center, and serves a population reflective of the fault lines of the epidemic in resource-constrained countries: poverty and disempowerment, the trauma and violence of chaotic urbanization and frequent civil disorder and inadequate rule of law. Using the vehicle of CBSM, a potentially efficacious prevention intervention for reducing HIV transmission risk among People Living with HIV (PLWH) in this clinical venue enhances the probability of success. CBSM-A, the adapted intervention to be evaluated, is based on an NIH pilot study in Haiti that was guided by Information-Motivation-Behavior (IMB) theory. It is a small-group design for HIV+ AOD using populations, which also addresses their cognitive/self management and coping barriers that may impede sustainable outcomes, particularly in resource-constrained settings as Haiti. HLM/SEM analyses will be used to explore adherence to safer sex and ARV medication guidelines as well as how intervention effects are influenced by traditional IMB variables, AOD use, and EnvPsySoc factors. The proposed project responds to the NIH priority on integrating environmental-psychosocial research and on bridging clinical research and practice, by adapting and translating effective research-based intervention strategies for the "real world" conditions faced by community based providers. If successful, this research will present an HIV intervention strategy that can be practically implemented for HIV+ adults with high risk behaviors (alcohol use and unsafe sexual practices) in Haiti and other resource-constrained settings, while advancing the knowledge base of how to tailor interventions for such settings. [unreadable] PUBLIC HEALTH RELEVANCE: The proposed study is an adaptation and randomized trial of a Cognitive-Behavioral Stress Management (CBSM) intervention that will enhance safer sex practices, adherence to ARV medication, and reduce alcohol or other drugs (AOD) use in People Living with HIV (PLWH) in a high risk, poor, urban center in Haiti. A key focus of the study will be how HIV intervention outcomes are influenced by a set of alcohol-related Environmental and PsychoSocial (Env-Psy-Soc) factors. If successful, this research will present an HIV intervention strategy that can be practically implemented for HIV+ adults with high risk behaviors, including alcohol use, in Haiti and other resource-constrained settings, while advancing the knowledge base of how to tailor interventions for such settings. [unreadable] [unreadable] [unreadable]