Anna Rubtsova

Comparative Effectiveness of a Faith-Based HIV Intervention for African American Women: Importance of Enhancing Religious Social Capital

OBJECTIVES We assessed the effectiveness of P4 for Women, a faith-based HIV intervention. METHODS We used a 2-arm comparative effectiveness trial involving 134 African American women aged 18 to 34 years to compare the effectiveness of the Centers for Disease Control and Prevention-defined evidence-based Sisters Informing Sisters about Topics on AIDS (SISTA) HIV intervention with P4 for Women, an adapted faith-based version of SISTA. Participants were recruited from a large black church in Atlanta, Georgia, and completed assessments at baseline and follow-up. RESULTS Both SISTA and P4 for Women had statistically significant effects on this studys primary outcome-consistent condom use in the past 90 days-as well as other sexual behaviors. However, P4 for Women also had statistically significant effects on the number of weeks women were abstinent, on all psychosocial mediators, and most noteworthy, on all measures of religious social capital. Results were achieved by enhancing structural social capital through ministry participation, religious values and norms, linking trust and by reducing negative religious coping. High intervention attendance may indicate the feasibility of conducting faith-based HIV prevention research for African American women. CONCLUSIONS P4 for Women enhanced abstinence and safer sex practices as well as religious social capital, and was more acceptable than SISTA. Such efforts may assist faith leaders in responding to the HIV epidemic in African American women.

Racial Differences and Correlates of Potential Adoption of Pre-exposure Prophylaxis (PrEP): Results of a National Survey

Objective:To examine the association between sociodemographic factors, sexual behaviors, and social factors on potential uptake of preexposure prophylaxis (PrEP) among African American and White adult women in the United States. Methods:Participants were recruited through a nationally representative, random-digit dial telephone household survey. Participants comprised a nationally representative, random sample of unmarried African American (N = 1042) and White women (N = 411) aged 20–44 years. Interviews were conducted using computer-assisted telephone interviewing technology. Bivariate and multivariate analyses examined the relationship between sociodemographics, sexual behaviors, and social influences on womens potential uptake of PrEP. Results:In multivariate analyses, women with lower educational status, greater lifetime sexual partners, provider recommendations supportive of PrEP, and peer norms supportive of PrEP use were more likely to report potential PrEP uptake. Racial analyses revealed that compared with White women, African American women were significantly more likely to report potential use of PrEP [adjusted odds ratio (aOR) = 1.76, P ⩽ 0.001], more likely to report use of PrEP if recommended by a health-care provider (aOR = 1.65, P ⩽ 0.001), less likely to report that they would be embarrassed to ask a health-care provider for PrEP (aOR = 0.59, P ⩽ 0.05), and more likely to report use of PrEP if their female friends also used PrEP (aOR = 2.2, P ⩽ 0.001). The potential cost for PrEP was identified as a barrier to adoption by both African American and White women. Conclusions:Findings suggest that women at increased risk for HIV, including those with less education and greater number of sexual partners, may be more likely to use PrEP, although cost may serve as a barrier.

Young adult women and correlates of potential adoption of pre-exposure prophylaxis (PrEP): results of a national survey.

We examine potential use of pre-exposure prophylaxis (PrEP) among young adult women, based on nationally representative random-digit dial telephone household survey of 1,453 US African-American and white women. The hypotheses were generated based on Health Belief Model. Our analyses showed that, as compared to women of 30-45 years old, young women of 20-29 years old experienced stronger social influences on PrEP uptake. However, as compared to older women, young women did not report higher potential PrEP uptake or adherence, despite their greater risk of HIV. For PrEP to be an effective method of prevention for young adult women, interventions are needed to increase HIV risk awareness.

Effects of Antiretroviral Therapy and Depressive Symptoms on All-Cause Mortality among HIV-Infected Women

Depression affects up to 30% of human immunodeficiency virus (HIV)-infected individuals. We estimated joint effects of antiretroviral therapy (ART) initiation and depressive symptoms on time to death using a joint marginal structural model and data from a cohort of HIV-infected women from the Womens Interagency HIV Study (conducted in the United States) from 1998-2011. Among 848 women contributing 6,721 years of follow-up, 194 participants died during follow-up, resulting in a crude mortality rate of 2.9 per 100 women-years. Cumulative mortality curves indicated greatest mortality for women who reported depressive symptoms and had not initiated ART. The hazard ratio for depressive symptoms was 3.38 (95% confidence interval (CI): 2.15, 5.33) and for ART was 0.47 (95% CI: 0.31, 0.70). Using a reference category of women without depressive symptoms who had initiated ART, the hazard ratio for women with depressive symptoms who had initiated ART was 3.60 (95% CI: 2.02, 6.43). For women without depressive symptoms who had not started ART, the hazard ratio was 2.36 (95% CI: 1.16, 4.81). Among women reporting depressive symptoms who had not started ART, the hazard ratio was 7.47 (95% CI: 3.91, 14.3). We found a protective effect of ART initiation on mortality, as well as a harmful effect of depressive symptoms, in a cohort of HIV-infected women.

A New Paradigm for Optimizing HIV Intervention Synergy: The Role of Interdependence in Integrating HIV Prevention Interventions

There is emerging consensus regarding the need to optimize the efficacy of HIV interventions by integrating evidence-based social, behavioral and biomedical interventions to produce a population-level impact on the HIV/AIDS epidemic. Unfortunately, there is limited discussion specifying how interventions can be integrated to yield maximal prevention impact. Of importance to program planners is the need to specify which combination of interventions to integrate and how interventions should be sequenced to achieve the prevention synergy needed to reduce the risk of HIV acquisition and transmission among diverse at-risk populations. In this Supplement Vermund et al. explore biomedical HIV interventions that have shown efficacy in reducing HIV incidence, while Wingood, DiClemente and Blank, respectively, discuss combination interventions to reduce concurrency, technological interventions to reduce intervention decay, and intervention cascades to enhance medication adherence. Novel intervention settings within which to conduct HIV prevention research is highlighted by Rich’s collaborations with correctional facilities, Latkin’s research on social networks and DiClemente’s research in county health departments. Rhodes and colleagues discuss the use of community-based participatory research (CBPR) to access at-risk Latino men who have sex with men (MSMs) and Sullivan, Grey and Rosser highlight emerging technologies to access MSM to reduce HIV-related disparities. Additionally, this supplement addresses implementation science approaches to sustaining HIV interventions. Glasgow and colleagues advance the Evidence Integration Triangle, Brown and co-investigators discuss computational linguistics and system science and Wingood presents adaptation of evidence-based behavioral intervention as a strategy to enhance implementation. A social ecological perspective1 provides a framework for examining how the interaction of multiple interventions (e.g., pre-exposure prophylaxis (PrEP), male circumcision, antiretroviral therapy (ART), behavioral) and techniques (e.g., CBPR, technology) implemented in key venues (e.g., correctional facilities, health departments, social networks) when targeted at different levels of influence (Table 1) create HIV prevention synergy for specific at-risk populations (e.g., MSM, women, serodiscordant couples). The central principle of the social ecological perspective is that the risk of acquiring and/or transmitting HIV arises from a complex interaction of multiple determinants (or factors) corresponding to different “levels of influence,” often depicted as nested concentric circles (Figure 1). The circles represent contextual layers of increasing scope: intrapersonal, interpersonal, organizational, community, and macro/policy level determinants.2 This manuscript uses the social ecological framework to conceptualize how integrating HIV biomedical and behavioral interventions at these five levels can produce complementary or synergistic effects2. Without such a comprehensive framework, program planners may combine interventions that produce scattered, redundant or mutually opposing effects2. This perspective also provides a compelling approach for the scale-up of combination interventions integrated across different levels of influence to facilitate their reach and sustainability. Figure 1 Levels of Influence nested within the socio-ecological model Table 1 Patient and provider intervention strategies across different levels of influence The ecological perspective emphasizes interdependence among levels of influence. Thus, interventions at one level may influence interventions at another level. Hence, interdependence emerges as a central mechanism for integrating interventions at multiple levels. Below we examine three forms of interdependence – pooled interdependence, sequential interdependence and reciprocal interdependence3 – as applied to PrEP adherence interventions and other HIV prevention interventions. Pooled Interdependence The concept of pooled interdependence is derived from organization theory. This concept emphasizes that social organizations are complex systems composed of many interdependent parts, such as teams, departments, units, or subsidiaries3. Under pooled interdependence, organizational components are independent in terms of their everyday functioning, tasks, and routine processes; yet these components are interdependent in that they all contribute to organizational efficiency. If any component malfunctions, organizational efficiency is jeopardized3. Similarly, pooled interdependence of integrated HIV interventions occurs when interventions at different levels of influence work independently of each other to provide HIV prevention services to a target population. For example, research shows that although many providers know about PrEP, few actually prescribe it in their clinical practice4. To increase prescribing practices providers need to successfully identify appropriate candidates, individuals at highest risk of HIV who may benefit most from PrEP, such as seronegative partners in HIV serodiscordant relationships5, MSM6,7, or heterosexual men and women engaging in risky sexual practices5. This, however, is not an easy task due to provider and patient discomfort with discussions involving sexual orientation, risky sexual practices, or drug use.4 An organizational-level (structural) intervention, designed to evaluate new procedures to facilitate providers’ identifying appropriate PrEP candidates, can work independently from an intrapersonal-level (behavioral) intervention to increase PrEP adherence among seronegative partners in HIV serodiscordant relationships. However, both contribute to the broader prevention goal of decreasing HIV transmission, demonstrating pooled interdependence (Figure 2). Figure 2 Pooled Interdependence Model (applied to enhancing PrEP adherence) In general, biomedical interventions operate independently from behavioral interventions which, in turn, operate independently from structural interventions. Each intervention makes a discrete contribution to enhance PrEP adherence, without being dependent on each other. The efficacy of PrEP adherence is the sum, or the accumulation, of the intervention contributions at different levels. While deployed at different levels of influence, the interventions target the same outcome (PrEP adherence) and converge. Importantly, differential exposure to interventions across levels may produce scattered and noncumulative effects.

Healthy Aging in Older Women Living with HIV Infection: a Systematic Review of Psychosocial Factors

Due to life-enhancing effects of antiretroviral therapy, HIV-positive persons have the potential for long life comparable to their uninfected peers. Older women (age 50+) living with HIV (OWLH) are often an under-recognized aging group. We conducted a systematic review to examine psychosocial factors that impact how OWLH live, cope, and age with HIV. Initial key word search yielded 1527 records, and 21 studies met our inclusion criteria of original quantitative or qualitative research published between 2013 and 2016 with results specific to OWLH. These focused on health care and self-management, sexual health and risk, stigma, loneliness, mental health (depression, substance use), and protective factors (coping, social support, well-being). Due to the scarcity of studies on each topic and inconclusive findings, no clear patterns of results emerged. As the number of OWLH continues to grow, more research, including longitudinal studies, is needed to fully characterize the psychosocial factors that impact aging with HIV.

HIV and Aging Research in Women: An Overview

This paper reviews some background issues as a foundation to place the ensuing supplement papers of this special issue section in context. The articles in this special supplement issue deepen and expand our understanding of biomedical, neurocognitive, and psychosocial aspects involved in human immunodeficiency virus (HIV) of older women, primarily through the use of the Women’s Interagency HIV Study (WIHS) prospective cohort study. As it relates to research on the intersection between HIV and aging in women, we discuss (i) epidemiology as introduction, (ii) the cohort study design featuring the WIHS, (iii) definitions, (iv) models, and (v) section articles.

Associations Between Neighborhood Characteristics, Social Cohesion, and Perceived Sex Partner Risk and Non-Monogamy Among HIV-Seropositive and HIV-Seronegative Women in the Southern U.S.

Neighborhood social and physical factors shape sexual network characteristics in HIV-seronegative adults in the U.S. This multilevel analysis evaluated whether these relationships also exist in a predominantly HIV-seropositive cohort of women. This cross-sectional multilevel analysis included data from 734 women enrolled in the Women’s Interagency HIV Study’s sites in the U.S. South. Census tract-level contextual data captured socioeconomic disadvantage (e.g., tract poverty), number of alcohol outlets, and number of non-profits in the census tracts where women lived; participant-level data, including perceived neighborhood cohesion, were gathered via survey. We used hierarchical generalized linear models to evaluate relationships between tract characteristics and two outcomes: perceived main sex partner risk level (e.g., partner substance use) and perceived main sex partner non-monogamy. We tested whether these relationships varied by women’s HIV status. Greater tract-level socioeconomic disadvantage was associated with greater sex partner risk (OR 1.29, 95% CI 1.06–1.58) among HIV-seropositive women and less partner non-monogamy among HIV-seronegative women (OR 0.69, 95% CI 0.51–0.92). Perceived neighborhood trust and cohesion was associated with lower partner risk (OR 0.83, 95% CI 0.69–1.00) for HIV-seropositive and HIV-seronegative women. The tract-level number of alcohol outlets and non-profits were not associated with partner risk characteristics. Neighborhood characteristics are associated with perceived sex partner risk and non-monogamy among women in the South; these relationships vary by HIV status. Future studies should examine causal relationships and explore the pathways through which neighborhoods influence partner selection and risk characteristics.

Relationships between neighbourhood characteristics and current STI status among HIV-infected and HIV-uninfected women living in the Southern USA: A cross-sectional multilevel analysis

Objectives Neighbourhood characteristics (eg, high poverty rates) are associated with STIs among HIV-uninfected women in the USA. However, no multilevel analyses investigating the associations between neighbourhood exposures and STIs have explored these relationships among women living with HIV infection. The objectives of this study were to: (1) examine relationships between neighbourhood characteristics and current STI status and (2) investigate whether the magnitudes and directions of these relationships varied by HIV status in a predominantly HIV-infected cohort of women living in the Southern USA. Methods This cross-sectional multilevel analysis tests relationships between census tract characteristics and current STI status using data from 737 women enrolled at the Womens Interagency HIV Studys southern sites (530 HIV-infected and 207 HIV-uninfected women). Administrative data (eg, US Census) described the census tract-level social disorder (eg, violent crime rate) and social disadvantage (eg, alcohol outlet density) where women lived. Participant-level data were gathered via survey. Testing positive for a current STI was defined as a laboratory-confirmed diagnosis of chlamydia, gonorrhoea, trichomoniasis or syphilis. Hierarchical generalised linear models were used to determine relationships between tract-level characteristics and current STI status, and to test whether these relationships varied by HIV status. Results Eleven per cent of participants tested positive for at least one current STI. Greater tract-level social disorder (OR=1.34, 95% CI 0.99 to 1.87) and social disadvantage (OR=1.34, 95% CI 0.96 to 1.86) were associated with having a current STI. There was no evidence of additive or multiplicative interaction between tract-level characteristics and HIV status. Conclusions Findings suggest that neighbourhood characteristics may be associated with current STIs among women living in the South, and that relationships do not vary by HIV status. Future research should establish the temporality of these relationships and explore pathways through which neighbourhoods create vulnerability to STIs. Trial registration number NCT00000797; results.

Utilization of Alcohol Treatment Among HIV-Positive Women with Hazardous Drinking

Hazardous alcohol consumption has been frequently reported among women with HIV infection and is associated with a variety of negative health consequences. Treatments to reduce alcohol use may bring in health benefits. However, little is known regarding the utilization of alcohol treatment services among HIV+ women with hazardous drinking. Using data from the Womens Interagency HIV Study (WIHS), this study assessed utilization of any alcohol treatment in the past 6 months and performed multivariable logistic regression to determine correlates of receipt of any alcohol treatment. Among 474 HIV+ women reporting recent hazardous drinking, less than one in five (19%) reported recent utilization of any alcohol treatment. Alcoholics Anonymous (AA) was the most commonly reported (12.9%), followed by inpatient detoxification (9.9%) and outpatient alcohol treatment program (7.0%). Half (51%) receiving any alcohol treatment reported utilization of multiple treatments. Multivariable analyses found alcohol treatment was more often utilized by those who had social support (odds ratio [OR]=1.68, 95% confidence interval [CI]=1.00 to 2.83), fewer economic resources (income ≤