Agatha N. Eke

A profile of U.S.-based trials of behavioral and social interventions for HIV risk reduction.

Summary: We describe 99 (experimental and certain quasi‐experimental) U.S.‐based trials, reported or published since 1988, of behavioral and social interventions that measured prespecified behavioral and biologic outcomes and aimed to reduce risk for HIV infection. Studies identified through June 1998 by the HIV/AIDS Prevention Research Synthesis project were grouped into 4 risk behavior areas: drug‐related (k [number of studies] = 48), heterosexual youth (k = 24), heterosexual adult (k = 17), and same‐sex (k = 10). We compared the studies in the 4 areas by variables key to the development, evaluation, and transfer of interventions. Participants comprised injection drug users (43% of studies), drug users out of treatment (29%), African Americans (18%), clinic patients (18%), youth in schools (10%), and drug users in treatment (10%). Most studies were randomized (85%), provided another intervention to the control or comparison groups (71%), and evaluated behavioral interventions (92%). On average, interventions were conducted in 5 sessions (total, 8 hours) during 3 months. The theoretical basis of the intervention was not noted in 57% of the reports. At least one variable from each of the 3 outcome classifications was measured in 8% of the studies: behavioral, biologic, and psychosocial. Distinct profiles exist for the 4 risk areas. Addressing gaps in research and reporting would be helpful for analytical and program activities. This sizable portfolio of evaluated interventions contributes to effectiveness reviews and to considerations of transfer to program practice.

Correlates of HIV-Related Risk Behaviors in African American Adolescents from Substance-Using Families: Patterns of Adolescent-Level Factors Associated with Sexual Experience and Substance Use

PURPOSE To examine adolescent-level correlates of HIV-related risk behaviors among urban African American adolescents whose mothers use crack cocaine. METHODS Interviews were conducted with 208 African American adolescents (aged 12-17 years) to assess psychosocial, behavioral, and perceived environment correlates of HIV-related risk behavior. Adolescents were children of community-recruited African American women not currently in drug treatment who reported crack cocaine use (in last 6 months). Bivariate and multivariate regression models were used to evaluate associations among adolescent-level factors, sexual experience, and substance use. RESULTS Of the adolescents, 30% reported being sexually experienced, and 23% reported alcohol or drug use in the past month. Older age and lower school satisfaction were associated with both sexual experience and substance use, but no other factors were associated with both risk behaviors. Male gender, current substance use, high HIV/AIDS knowledge, and high risk perception were associated with being sexual experienced. Sexual experience and lower expectations for future life outcomes were associated with substance use. A general pattern of protective factors related to attitudes about future goals, help-seeking behavior, and positive feelings about school emerged for substance use. CONCLUSIONS These results suggest that the patterns of adolescent-level risk and protective factors for sexual experience and substance use may be unique in African American adolescents from substance-abusing families. Instead of an increase in problem behaviors associated with using substances, protective factors were evident, suggesting these adolescents may have resiliency for dealing with environmental stressors related to substance use. Implications for HIV prevention programs involving mentoring and goal development are discussed.

Social oppression, psychological vulnerability, and unprotected intercourse among young Black men who have sex with men.

OBJECTIVE Young Black men who have sex with men (YBMSM) are at extraordinarily high risk for HIV infection. Given their dual minority identity, they experience multiple forms of social oppression-racism, homophobia, and poverty. This study tested a model for how these forces contribute to their sexual risk behavior. METHOD YBMSM (n = 1,289) from 2 Texas cities completed a 1-time assessment of sexual behaviors and psychosocial variables. Structural equation modeling was used to characterize relationships among variables. RESULTS Experiences of racism, homophobia, and socioeconomic distress were all associated with unprotected anal intercourse (UAI) either directly or indirectly in a manner largely consistent with Díazs (1997, 1998) model of the effects of social oppression. Racism, homophobia, and socioeconomic distress were each associated with specific psychological vulnerabilities, which were in turn associated with participation in difficult sexual situations (e.g., in a public setting), and then UAI. The effects of racism were largely mediated by depressive symptoms and participation in difficult sexual situations. Homophobia was mediated by depressive symptoms, social support, and internalized homophobia. The effects of socioeconomic distress were partially mediated by decreased social support and greater participation in difficult sexual situations. Socioeconomic distress also had a significant direct effect on UAI not explained by the proposed mediators. CONCLUSIONS Social oppression contributes to YBMSMs psychological vulnerabilities, participation in difficult sexual situations, and their UAI. Interventions to reduce sexual risk in YBMSM should address socioeconomic disadvantage, homophobia, and racism, as well as the psychological challenges that social oppression creates for them.

Acquisition and review of non-U.S.-based HIV risk reduction intervention studies.

Summary: In response to the HIV/AIDS epidemic, many governments and nongovernmental organizations have supported numerous HIV prevention intervention studies in both the United States and in other countries. To understand which intervention approaches have worked outside the United States, the Centers for Disease Control and Prevention extended the scope of its HIV/AIDS Prevention Research Synthesis (PRS) project to include non‐U.S.‐based studies. We describe briefly the PRS experience with the challenges of acquiring and reviewing those studies, and some of the specialized efforts to find them. The ultimate goals of the PRS project related to international prevention research are to include all available reports of non‐U.S.‐based studies in the PRS database and to provide comprehensive reviews of those studies. The findings of the reviews would not only highlight common themes of effectiveness or research gaps in the international arena but could also be useful for improving prevention research and programs in the United States.

Shifting Resources and Focus to Meet the Goals of the National HIV/AIDS Strategy: The Enhanced Comprehensive HIV Prevention Planning Project, 2010–2013

In September 2010, CDC launched the Enhanced Comprehensive HIV Prevention Planning (ECHPP) project to shift HIV-related activities to meet goals of the 2010 National HIV/AIDS Strategy (NHAS). Twelve health departments in cities with high AIDS burden participated. These 12 grantees submitted plans detailing jurisdiction-level goals, strategies, and objectives for HIV prevention and care activities. We reviewed plans to identify themes in the planning process and initial implementation. Planning themes included data integration, broad engagement of partners, and resource allocation modeling. Implementation themes included organizational change, building partnerships, enhancing data use, developing protocols and policies, and providing training and technical assistance for new and expanded activities. Pilot programs also allowed grantees to assess the feasibility of large-scale implementation. These findings indicate that health departments in areas hardest hit by HIV are shifting their HIV prevention and care programs to increase local impact. Examples from ECHPP will be of interest to other health departments as they work toward meeting the NHAS goals.

Addressing Poverty and HIV Using Microenterprise: Findings from Qualitative Research to Reduce Risk among Unemployed or Underemployed African American Women

Introduction. Microenterprise programs are widely used to improve health outcomes among women internationally. However, there is little information on applicability to American women living in poverty. We conducted formative research to identify activities that are viable and attractive, that may produce income to address some proportion of economic need and could be incorporated in the development of a micro-enterprise HIV-prevention intervention to reduce HIV/STD transmission among unemployed or underemployed African American women at risk for HIV. Methods. Focus groups were convened with young African American women and community leaders in two southern states. Interviews with women participating in the focus groups were also convened. Results. Findings suggest an intervention should incorporate activities to increase self-esteem, enhance employability and job sustainability to decrease financial dependence. This research serves as the foundation for developing a novel approach to HIV prevention in the U.S. that may directly address poverty as a social determinant of health.

Dyadic, Small Group, and Community-Level Behavioral Interventions for STD/HIV Prevention

105 STD/HIV prevention efforts, including education, information, and counseling, have frequently been used to motivate individuals to reduce their risk behaviors. Many of these prevention approaches are drawn from theories that link risk behavior to individual psychological processes such as cognition, beliefs, attitudes, self-efficacy, and perception of risk (1). Although these approaches can help individuals initiate risk-reduction steps and make short-term changes in their risk behaviors, most individual beliefs, attitudes, and, ultimately, behaviors are influenced by the larger environmental and community contexts within which they reside (2). Therefore, long-lasting maintenance of protective behaviors is likely only when peer group social norms, relationships, the environment, and public health policies support personal behavior change effort (2,3). Thus, prevention may also target the community, or special groups of individuals at higher risk for, or more vulnerable to STD/HIV (4). This chapter will focus on and provide examples of STD/HIV interventions that target couples, small groups, and communities.

On the Battlefield: The Black Church, Public Health, and the Fight against HIV among African American Gay and Bisexual Men

HIV affects African American gay and bisexual men (AAGBM) more disproportionately than any other group in the USA. The Black Church, which has been a historic mainstay for African American empowerment and well-being, has the potential to be a public health partner for HIV prevention with AAGBM. Public health partnerships with the Black Church can strengthen HIV prevention efforts with AAGBM by [1] adapting church-based prevention strategies developed for other African American subgroups [2], providing prevention and referral services [3], considering how scripture supports prevention efforts, and [4] emphasizing the tenets of liberation theology. Public health should consider how thoughtful engagement, research, and interventions can support these approaches. Developing partnerships with the Black Church and African American clergy can promote effective HIV prevention efforts for AAGBM.

The Role of the Primary Romantic Relationship in HIV Care Engagement Outcomes Among Young HIV-Positive Black Men Who Have Sex with Men

The primary romantic relationship plays a fundamental role in health maintenance, but little is known about its role in HIV care engagement among young Black men who have sex with men (MSM) living with HIV. We examined how HIV care engagement outcomes (i.e., having a primary healthcare provider, receiving HIV treatment, taking antiretroviral medication, and medication adherence) vary by partnership status (single vs. concordant-positive vs. discordant) in a sample of young Black MSM living with HIV. Results showed mixed findings. Partnership status was significantly associated with HIV care engagement, even after adjusting for individual, social, and structural factors. While partnered men were consistently more likely than their single counterparts to have a regular healthcare provider, to receive recent treatment, and to have ever taken antiretroviral medication, they were less likely to report currently receiving antiretroviral therapy. Moreover, men with a discordant partner reported better adherence compared to men with a concordant or no partner. The association between partnership status and HIV care engagement outcomes was not consistent across the stages of the HIV Care Continuum, highlighting the complexity in how and why young Black men living with HIV engage in HIV healthcare. Given the social context of HIV disease management, more research is needed to explicate underlying mechanisms involved in HIV care and treatment that differ by relational factors for young Black MSM living with HIV.

Spirituality/religiosity, substance use, and HIV testing among young black men who have sex with men

BACKGROUND Spirituality and religiosity may serve as both a resource and a barrier to HIV prevention with young black men who have sex with men (YBMSM). We examined indices of spirituality/religiosity as correlates of binge drinking, stimulant use, and recent HIV testing in a sample of YBMSM. METHODS From 2011-2013, annual venue-based surveys of sexually active YBMSM ages 18-29 were conducted in Dallas and Houston, Texas. Binge drinking and stimulant use were assessed in the past two months. Participants recently tested for HIV (i.e., within the past six months) were compared to those without recent HIV testing (i.e., never tested or tested more than six months ago). RESULTS Among the 1565 HIV-negative or HIV-unknown YBMSM enrolled, more engagement in spiritual and religious activities was associated with greater odds of reporting stimulant use (Adjusted Odds Ratio [AOR]=1.20; 95% CI=1.04-1.40) while higher spiritual coping was associated with lower odds of reporting stimulant use (AOR=0.66; 95% CI=0.56-0.78). Binge drinking was independently associated with 29% lower odds of recent HIV testing (AOR=0.71; 95% CI=0.55-0.92), but lower odds of binge drinking did not mediate the association of engagement in spiritual and religious activities with 27% greater odds of recent HIV testing (AOR=1.27; 95% CI=1.11-1.46). CONCLUSIONS Among YBMSM, culturally tailored approaches addressing spirituality/religiosity could support prevention of stimulant use and increase HIV testing. In particular, expanded efforts are needed to promote HIV testing in binge drinkers.