Ann O’Leary

Effects on sexual risk behavior and STD rate of brief HIV/STD prevention interventions for African American women in primary care settings.

OBJECTIVES We tested the efficacy of brief HIV/sexually transmitted disease (STD) risk-reduction interventions for African American women in primary care settings. METHODS In a randomized controlled trial, 564 African American women recruited at a Newark, NJ, inner-city womens health clinic were assigned to a 20-minute one-on-one HIV/STD behavioral skill-building intervention, 200-minute group HIV/STD behavioral skill-building intervention, 20-minute one-on-one HIV/STD information intervention, 200-minute group HIV/STD information intervention, or 200-minute health intervention control group. Primary outcomes were self-reported sexual behaviors in the previous 3 months; secondary outcome was STD incidence. RESULTS At 12-month follow-up, participants in the skill-building interventions reported less unprotected sexual intercourse than did participants in the information interventions (Cohens d [d]=0.23, P=.02), reported a greater proportion of protected sexual intercourse than did information intervention participants (d=0.21, P=.05) and control participants (d=0.24, P=.03), and were less likely to test positive for an STD than were control participants (d=0.20, P=.03). CONCLUSIONS This study suggests that brief single-session, one-on-one or group skill-building interventions may reduce HIV/STD risk behaviors and STD morbidity among inner-city African American women in primary care settings.

Correlates of Risk Patterns and Race/Ethnicity among HIV-Positive Men who have Sex with Men

Behaviors related to HIV infection vary by race, with African American and Latino men who have sex with men (MSM) more likely to report sex with women than are European–American MSM. The epidemic among African Americans, in particular, is growing rapidly among both men and women. Some have hypothesized that bisexually active men may be contributing to the epidemic among women. However, little is known about risk patterns among men of different races who are already infected. In this study of 456 HIV-seropositive MSM we found that, like HIV-negative MSM, African American MSM who are HIV-positive were less likely than European American men to identify as gay, more likely to report sex with women, and less comfortable discussing their MSM behavior with close friends and acquaintances. African American participants also exhibited higher levels of internalized homophobia, as well as lower self-efficacy for disclosing their HIV status to sex partners. Implications for interventions for this population are discussed.

Risk Perception and sexual risk behaviors among HIV-positive men on antiretroviral therapy.

There are reports of increased sexual risk behavior among people on highly active antiretroviral therapy (HAART) due to beliefs about risk of HIV transmission when on HAART. In a cross-sectional study (Seropositive Urban Men’s Study), we examined the relationship between risk perception and sexual risk behavior among sexually active, culturally diverse HIV positive men who have sex with men (N = 456). Less than twenty-five percent engaged in unprotected anal sex (either with an HIV negative, or unknown-status partner, or an HIV positive partner) within the past 3 months. Most men believed there was significant health risk (to partner or self) associated with unprotected sex when on HAART. There was no increased risk behavior associated with being on HAART, although the perception of negative health consequences, including HIV transmission, when on HAART was significantly lower for the relatively small subset of men who reported unprotected sex. Prevention strategies need to be tailored to address risk perception associated with HAART.

Beliefs about Personal and Partner Responsibility among HIV-Seropositive Men Who Have Sex with Men: Measurement and Association with Transmission Risk Behavior

Beliefs of people living with HIV about their own responsibility for preventing HIV transmission (personal responsibility) and their sex partners’ responsibility for protecting themselves (partner responsibility) are poorly understood. A sample of 1163 HIV-seropositive men who have sex with men (MSM; 55% men of color) completed an A-CASI assessment of sexual behavior and psychosocial measures. A two-dimensional model that represents four orientations toward responsibility was tested: (1) self—high personal and low partner responsibility, (2) other—low personal and high partner responsibility, (3) shared—high personal and high partner responsibility, and (4) diminished—low personal and low partner responsibility. As predicted, the self-responsibility group demonstrated the lowest risk of HIV transmission; the other responsibility group had the highest risk. Intermediate risk was observed in the shared and diminished responsibility groups. Implications for future research and HIV prevention efforts are discussed.

Cognitive-behavioural health-promotion intervention increases fruit and vegetable consumption and physical activity among South African adolescents: a cluster-randomised controlled trial.

Rates of chronic diseases are high among Black South Africans but few studies have tested cognitive-behavioural health-promotion interventions to reduce this problem. We tested the efficacy of such an intervention among adolescents in a cluster-randomised controlled trial. We randomly selected 9 of 17 matched pairs of schools and randomised one school in each pair to the cognitive-behavioural health-promotion intervention designed to encourage health-related behaviours and the other to a human immunodeficiency virus (HIV)/sexually transmitted disease (STD) risk-reduction intervention that served as the control. Interventions were based on social cognitive theory, the theory of planned behaviour and qualitative data from the target population. Data collectors, blind to participants’ intervention, administered confidential assessments at baseline and 3, 6 and 12 months post-intervention. Primary outcomes were fruit and vegetable consumption and physical activity. Participants were 1057 grade 6 learners (mean age = 12.4 years), with 96.7% retained at 12-month follow-up. Generalised estimating equations revealed that averaged over the follow-ups, a greater percentage of health-promotion intervention participants than HIV/STD control participants met 5-a-Day fruit and vegetable and physical activity guidelines. The intervention also increased health-promotion knowledge, attitude and intention, but did not decrease substance use or substance-use attitude and intention. The findings suggest that theory based and contextually appropriate interventions may increase health behaviours among young adolescents in sub-Saharan Africa.

Optimism and Education Buffer the Effects of Syndemic Conditions on HIV Status Among African American Men Who Have Sex with Men

The present study sought to replicate effects of the number of syndemic psychosocial health conditions on sexual risk behavior and HIV infection among a sample of high-risk African American men who have sex with men (MSM) and to identify resilience factors that may buffer these effects. We used baseline data from an HIV risk-reduction trial to examine whether a higher number of syndemic conditions was associated with higher rates of self-reported sexual risk behavior and HIV infection. Using logistic regression models, we tested for interactions between number of syndemic conditions and several potential resilience factors to identify buffering effects. Replicating previous studies, we found significant associations between numbers of syndemic conditions and higher rates of sexual risk behavior and HIV infection. Surprisingly, we also replicated a previous finding (Stall et al., Am J Public Health, 93(6):939–942, 2003) that the effects of syndemic burden on HIV status fell off at the highest levels of syndemic conditions. Among a variety of potential resilience factors, two—optimism and education—buffered the syndemic effect on HIV prevalence. This is, to our knowledge, the first paper to identify resilience factors buffering against syndemic effects among MSM. It also constitutes a significant contribution to the literature regarding prevention among black MSM. These results point to the need to identify HIV-positive black MSM and provide effective treatment for them and to develop interventions addressing both syndemic and resilience factors.

Moderation and mediation of an effective HIV risk-reduction intervention for South African adolescents.

Background“Let Us Protect Our Future” is a sexual risk-reduction intervention for sixth-grade adolescents in South Africa. Tested in a cluster-randomized controlled trial, the intervention significantly reduced self-reported intercourse and unprotected intercourse during a 12-month follow-up period.PurposeThe present analyses were conducted to identify moderators of the intervention’s efficacy as well as, which theory-based variables mediated the intervention’s effects.MethodsIntervention efficacy over the 3-, 6-, and 12-month follow-up was tested using generalized estimating equation models.ResultsLiving with their father in the home, parental strictness, and religiosity moderated the efficacy of the intervention in reducing unprotected intercourse. Self-efficacy to avoid risky situations and expected parental disapproval of their having intercourse, derived from Social Cognitive Theory, significantly mediated the intervention’s effect on abstinence.ConclusionsThis is the first study to demonstrate that Social Cognitive variables mediate the efficacy of a sexual risk-reduction intervention among South African adolescents.

DISPROPORTIONATE RATES OF INCARCERATION CONTRIBUTE TO HEALTH DISPARITIES

The theme of the October 2005 issue of the Journal was the public health consequences of imprisonment. This issue illuminated the wide-ranging health care needs of the more than 2.2 million men—most of whom are African American—who are incarcerated in the United States. Persistent health disparities characterize impoverished communities with large numbers of men who are locked away with limited access to quality health care and treatment,1 and these disparities are fueled by cycles of recidivism. Each year more than a half million offenders move back and forth between their communities and prison.2 The 1990s prison boom was associated with increased wage inequality for young, poorly educated African American men with prison records.3 The high rates of incarceration of young African American men result in racial and ethnic wage disparities (low wages, unemployment, family instability, recidivism, and restrictions on political and social rights)4 that exacerbate their lack of access to health care, treatment, and prevention. These are the people for whom the mission of public health is intended. Jails and prisons are gateways for public health professionals, whose research and practice help ensure conditions in which all people can be healthy.5 Burgeoning HIV infection rates among African American men, many of whom have been incarcerated, make this disease the most potent symbol of health disparity in the United States. Furthermore, disparities in incarceration rates for African American men lower the ratio of men to women in African American communities. This situation promotes partner concurrency, which is a known risk factor for the transmission of HIV and other sexually transmitted diseases.6 Incarcerated populations, therefore, constitute the new public health mission field for evidence-based interventions and comprehensive case management. Fortunately, collaborations between correctional health and community organizations, including faith-based programs, are producing promising prevention and prisoner reentry programs.7(p1682),8 A nationwide conversation must begin to challenge correctional practices and legal policies that exacerbate health disparities. Broad questions must be asked about the relationships between causes of crime, sentencing policies, and health care delivery in correctional settings and about the aggregate influence of these factors on the health of African American communities. Answers to these compelling questions are possible if we make a national commitment to public health and to correctional policies that protect the most vulnerable people among us.

Cluster-randomized controlled trial of an HIV/sexually transmitted infection risk-reduction intervention for South African men.

OBJECTIVES We tested the efficacy of a sexual risk-reduction intervention for men in South Africa, where heterosexual exposure is the main mode of HIV transmission. METHODS Matched-pairs of neighborhoods in Eastern Cape Province, South Africa, were randomly selected and within pairs randomized to 1 of 2 interventions based on social cognitive theory and qualitative research: HIV/sexually transmitted infection (STI) risk-reduction, targeting condom use, or attention-matched control, targeting health issues unrelated to sexual risks. Sexually active men aged 18 to 45 years were eligible. The primary outcome was consistent condom use in the past 3 months. RESULTS Of 1181 participants, 1106 (93.6%) completed the 12-month follow-up. HIV and STI risk-reduction participants had higher odds of reporting consistent condom use (odds ratio [OR] = 1.32; 95% confidence interval [CI] = 1.03, 1.71) and condom use at last vaginal intercourse (OR = 1.40; 95% CI = 1.08, 1.82) than did attention-control participants, adjusting for baseline prevalence. No differences were observed on unprotected intercourse or multiple partnerships. Findings did not differ for sex with steady as opposed to casual partners. CONCLUSIONS Behavioral interventions specifically targeting men can contribute to efforts to reduce sexual risk behaviors in South Africa.

Drinking motives as prospective predictors of outcome in an intervention trial with heavily drinking HIV patients

BACKGROUND Heavy alcohol consumption in HIV patients is an increasing health concern. Applying the drinking motivational model to HIV primary care patients, drinking motives (drinking to cope with negative affect, for social facilitation, and in response to social pressure) were associated with alcohol consumption at a baseline interview. However, whether these motives predict continued heavy drinking or alcohol dependence in this population is unknown. METHODS Participants were 254 heavy-drinking urban HIV primary care patients (78.0% male; 94.5% African American or Hispanic) participating in a randomized trial of brief drinking-reduction interventions. Drinking motive scales, as well as measures of alcohol consumption and alcohol dependence, were administered at baseline. Consumption and dependence measures were re-administered at the end of treatment two months later. Regression analyses tested whether baseline drinking motive scale scores predicted continued heavy drinking and alcohol dependence status at the end of treatment, and whether motives interacted with treatment condition. RESULTS Baseline drinking to cope with negative affect predicted continued heavy drinking (p<0.05) and alcohol dependence, the latter in both in the full sample (adjusted odds ratio [AOR]=2.14) and among those with baseline dependence (AOR=2.52). Motives did not interact with treatment condition in predicting alcohol outcomes. CONCLUSIONS Drinking to cope with negative affect may identify HIV patients needing targeted intervention to reduce drinking, and may inform development of more effective interventions addressing ways other than heavy drinking to cope with negative affect.