HIV is a major threat to the health and psychosocial well-being of infected people, particularly in low-resource countries that have had limited access to antiretroviral treatment (ART). South Africa (SA) has one of the highest HIV prevalence rates in the world. Recently, a national plan was initiated to make ART widely available in SA which will result in a growing population of people living with HIV who survive and must live with HIV disease as a chronic, stigmatizing, and transmittable illness, with the potential for significant public health consequences. The goal of this application is to adapt and pilot test a counselor- and multimedia-driven social support intervention to promote optimal medical care adherence for adult patients accessing ART in SA community based clinics. The original intervention (SMART Couples) was developed and tested in the US with HIV+ adults and their serodiscordant partners. This curriculum will be modified in two primary ways: (1) we will modify the approach so that it can be used with all adult patients on ART, allowing them to include any member of their social network (not just a serodiscordant partner); and (2) we will translate the intervention into a multimedia computer-based format so that it can be used effectively by lay counselors, with minimal training, supervision, and cost. In Phase 1, we will adapt the SMART curriculum for SA adult men and women using a Social Action Theory (SAT) model of behavioral health. We will use community-based participatory research methods (CBPR) to modify the existing curriculum and to specify procedures for intervention and assessment delivery. A series of consumer consultant meetings with health care staff (e.g., nurses, physicians, psychologists, and HIV counselors) and patients accessing HIV services will focus on adapting the intervention for the local setting. Content from the existing SMART manual and newly developed media will be reviewed by theses key stakeholders and the research team. We will examine intervention implementation issues, with attention not only to logistics, but also to attitudes about psychosocial interventions, HIV stigma, and provider roles, particularly those of nurses and adherence counselors. Through the use of CBPR, we will build consensus about which components of the existing SMART intervention are relevant to the SA context and add local techniques that are deemed more relevant, but that also allow us to retain fidelity to core intervention components and our theoretical framework. In Phase 2, 66 HIV+ adult patients at three clinics in the South Peninsula District of the Western Cape (False Bay, Victoria Hospital, and Retreat Clinic) will participate in a pilot randomized controlled trial of the intervention. They will be randomized either to the active intervention or to """"""""standard of care."""""""" Participants will be assessed at three time-points (pre- and post-test intervention and 3-month follow-up) on adherence and other behavioral health outcomes, social support processes, and other self-regulation and contextual variables - guided by the SAT model. Process variables, including barriers and facilitators of feasibility and acceptability will be collected from patients and clinic staff. The findings can be used to inform larger-scale effectiveness studies in similar settings. ? ? ?
