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Comment & Response
August 2015

The Broad Approach of a Structural Intervention Study and the Lack of Effect Detection—Reply

Author Affiliations
  • 1All Children’s Hospital Johns Hopkins Medicine, St Petersburg, Florida
  • 2Westat, Rockville, Maryland
JAMA Pediatr. 2015;169(8):790-791. doi:10.1001/jamapediatrics.2015.1375

In Reply In general, we agree with the comments made by Woods et al1 regarding our study on structural interventions. However, we take issue with their interpretation of the value and intent of our efforts. We feel that important information was obtained and several lessons learned were worth sharing with the research community.

The Connect to Protect program, which is the focus of our study, was fundamentally different from the intervention that Woods et al1 describe in their letter. We feel that there is a need and a space for both types of interventions in reducing the spread of human immunodeficiency virus (HIV). In contrast to the statement that our study focused on structural interventions aimed at reducing risk in a population at relatively low risk, we have previously demonstrated substantial HIV prevalence of more than 15% in these Connect to Protect communities from which young men who have sex with men represent a main risk group driving the national HIV epidemic.2 However, community venues more frequently congregated by young men who have sex with men are not necessarily the same as those for other at-risk youth populations. Therefore, the causal chains involved in the HIV epidemic among youth are particularly complex. The Connect to Protect project team felt that it would be neither appropriate nor effective to impose a particular intervention or suite of interventions on a community. The team consciously rejected a top-down approach to policy change in favor of an approach that also prioritized the process by which communities could mobilize to discuss, adopt, and disseminate change. This broad approach was entirely intentional. While we could have selected a single structural change to implement and evaluate, there was no evidence to suggest that a single structural change existed that would be acceptable and relevant to the diverse communities who participated in our nationwide program.

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