Catalina Ramirez

Policies and politics that promote HIV infection in the Southern United States.

The United States is characterized by geographic disparities in health, including HIV infection. These disparities are greatest with respect to the South, a heterogeneous region that comprises 17 states and Washington, DC, and is home to 37% of the nation’s population [1]. The South’s worse health outcomes are not restricted to HIV infection. The region has the highest rates of chlamydia, gonorrhea, and syphilis [2]; obesity [3], age-adjusted all-cause mortality [4], and mortality due to heart disease, diabetes and cancer [3]. A number of key social, structural, and policy factors drive the poorer health and HIV status of Southerners [5,6]. The South is the poorest of the nation’s four regions, with the highest percentage of people living in poverty areas and the lowest median household incomes [7]. Southerners are less likely to have health insurance [8] – a reality that heightens the salience of the current debate concerning increases in healthcare coverage through Medicaid expansion and implementation of The Affordable Care Act. This article reviews the epidemiology of HIV infection in the South and key laws and policies that contribute to its HIV patterns.

Preventing HIV infection in women.

Abstract:Although the number of new infections has declined recently, women still constitute almost half of the worlds 34 million people with HIV infection, and HIV remains the leading cause of death among women of reproductive age. Prevention research has made considerable progress during the past few years in addressing the biological, behavioral, and social factors that influence womens vulnerability to HIV infection. Nevertheless, substantial work still must be performed to implement scientific advancements and to resolve many questions that remain. This article highlights some of the recent advances and persistent gaps in HIV prevention research for women and outlines key research and policy priorities.

Acceptability of male circumcision for prevention of HIV infection among men and women in Uganda

In the last decade, three randomized controlled trials in Kenya, South Africa, and Uganda have shown that medical male circumcision (MMC) reduces the sexual transmission of HIV from women to men. Objectives of this assessment were to measure acceptability of adult MMC and circumcision of children to inform policies regarding whether and how to promote MMC as an HIV prevention strategy. This mixed-method study, conducted across four Ugandan districts, included a two-stage household survey of 833 adult males and 842 adult females, focus group discussions, and a health provider survey. Respondents’ acceptability of MMC was positive and substantial after being informed about the results of recent randomized trials. In uncircumcised men, between 40% and 62% across the districts would consider getting circumcised. Across the four districts between 60% and 86% of fathers and 49% and 95% of mothers were supportive of MMC for sons. Widespread support exists among men and women in this study for promoting MMC as part of Ugandas current ‘ABC + ’ HIV prevention strategy.

Reducing Concurrent Sexual Partnerships Among Blacks in the Rural Southeastern United States: Development of Narrative Messages for a Radio Campaign

In the United States, heterosexual transmission of HIV infection is dramatically higher among Blacks than among Whites. Overlapping (concurrent) sexual partnerships promote HIV transmission. The authors describe their process for developing a radio campaign (Escape the Web) to raise awareness among 18–34-year-old Black adults of the effect of concurrency on HIV transmission in the rural South. Radio is a powerful channel for the delivery of narrative-style health messages. Through six focus groups (n = 51) and 42 intercept interviews, the authors explored attitudes toward concurrency and solicited feedback on sample messages. Men were advised to (a) end concurrent partnerships and not to begin new ones; (b) use condoms consistently with all partners; and (c) tell others about the risks of concurrency and benefits of ending concurrent partnerships. The narrative portrayed risky behaviors that trigger initiation of casual partnerships. Women were advised to (a) end partnerships in which they are not their partners only partner; (b) use condoms consistently with all partners; and (c) tell others about the risks of concurrency and benefits of ending concurrent partnerships. Messages for all advised better modeling for children.

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.

Neighborhood Health Care Access and Sexually Transmitted Infections among Women in the Southern United States: A Cross-Sectional Multilevel Analysis

Introduction The United States has experienced an increase in reportable sexually transmitted infections (STIs) while simultaneously experiencing a decline in safety net services for STI testing and treatment. This multilevel study assessed relationships between neighborhood-level access to health care and STIs among a predominantly Human Immunodeficiency Virus (HIV)-seropositive cohort of women living in the south. Methods This cross-sectional multilevel analysis included baseline data from HIV-seropositive and HIV-seronegative women enrolled in the Women’s Interagency HIV Study sites in Alabama, Florida, Georgia, Mississippi, and North Carolina between 2013 and 2015 (N = 666). Administrative data (eg, United States Census) described health care access (eg, percentage of residents with a primary care provider, percentage of residents with health insurance) in the census tracts where women lived. Sexually transmitted infections (chlamydia, gonorrhea, trichomoniasis, or early syphilis) were diagnosed using laboratory testing. Generalized estimating equations were used to determine relationships between tract-level characteristics and STIs. Analyses were conducted using SAS 9.4. Results Seventy percent of participants were HIV-seropositive. Eleven percent of participants had an STI. A 4-unit increase in the percentage of residents with a primary care provider was associated with 39% lower STI risk (risk ratio, 0.61, 95% confidence interval, 0.38–0.99). The percentage of tract residents with health insurance was not associated with STIs (risk ratio, 0.98, 95% confidence interval, 0.91–1.05). Relationships did not vary by HIV status. Conclusions Greater neighborhood health care access was associated with fewer STIs. Research should establish the causality of this relationship and pathways through which neighborhood health care access influences STIs. Structural interventions and programs increasing linkage to care may reduce STIs.

Measuring Concurrency Attitudes: Development and Validation of a Vignette-Based Scale.

Background Concurrent sexual partnerships (partnerships that overlap in time) may contribute to higher rates of HIV transmission in African Americans. Attitudes toward a behavior constitute an important component of most models of health-related behavior and behavioral change. We have developed a scale, employing realistic vignettes that appear to reliably measure attitudes about concurrency in young African American adults. Methods Vignette-based items to assess attitudes about concurrency were developed following focus groups and cognitive testing of items adapted from existing scales assessing psychosocial constructs surrounding related sexual behaviors. The new items were included in a telephone survey of African American adults (18–34 years old) in Eastern North Carolina immediately before and after a radio campaign designed to discourage concurrency. We performed an exploratory factor analysis on each sample (pre- and post-campaign) to cross-validate results. We retained factors with a primary loading of ≥0.50 and no secondary loading >0.30. Cronbach’s coefficient alpha was used to evaluate internal reliability. Associations in the predicted direction between the mean responses to items on the final factor and known correlates of concurrency validated the scale. Results Factor analysis in a random pre-campaign subsample yielded a one-factor 6-item scale with acceptable internal consistency (Cronbach’s α = 0.79). As expected, the attitude factor was positively associated with participation in concurrent partnerships, whether assessed by self-report (r = 0.298, p<0.0001) or deduced from dates of recent sexual partnerships (r = 0.298, p<0.0001). The factor was also positively associated with alcohol (r = 0.216, p<0.0001) and drug use (r = 0.225, p<0.0001) and negatively associated with increasing age (r = -0.088, p- = 0.02) and female gender (r = -0.232, p<0.0001). Factor analyses repeated in the second random pre-campaign subsample and post-campaign sample confirmed these results. Conclusion A vignette-based scale may be an effective measure of key attitudes related to concurrency and potentially a useful tool to evaluate interventions addressing this network pattern.

Black Pastors’ Views on preaching about sex: barriers, facilitators, and opportunities for HIV prevention messaging

ABSTRACT Objectives: Despite the disproportionately high rates of heterosexually transmitted HIV infection among US Blacks and ongoing need for effective inexpensive behavioral interventions, the use of sermons as an HIV prevention tool in Black churches has received little research attention. The Black church plays an important role in Black communities and is a potential ally in development and delivery of sexual risk prevention messages. The objective of this study was to examine Black pastors’ thoughts about whether sermons should address issues related to heterosexual relationships – and the barriers and facilitators to discussing these topics in a sermon setting. Design: We conducted in-depth semi-structured, individual interviews among 39 pastors of Black churches in North Carolina and analyzed the interview data using thematic analysis strategies based on grounded theory. Results: Pastors expressed widely ranging opinions, especially about discussion of condom use, but generally agreed that sermons should discuss marriage, abstinence, monogamy, dating, and infidelity – behaviors that impact sexual networks and HIV transmission. The major barriers to incorporation of these subjects into sermons include the extent to which a concept undermines their religious beliefs and uncertainty about how to incorporate it. However, scriptural support for a prevention message and the pastor’s perception that the message is relevant to the congregation facilitate incorporation of related topics into sermons. Conclusions: These findings have implications for the potential utility of sermons as an HIV prevention tool and suggest that it is possible for public health professionals and pastors of Black churches to form partnerships to develop messages that are consonant with pastors’ religious convictions as well as public health recommendations.

Changing Attitudes About Concurrency Among Young African Americans: Results of a Radio Campaign

We created and evaluated an 8-month campaign of provocative radio ads to change attitudes about concurrent (overlapping) sexual partnerships among young African Americans. We created a concurrency attitude scale and compared its score distributions in independent samples of African Americans, ages 18-34 years, interviewed by telephone before (n = 678) and after (n = 479) the campaign. Pre- and post-campaign samples reflected similar response rates (pre: 32.6%; post: 31.8%) and distributions of personal characteristics. Reported exposure to concurrency messages was greater after the campaign (pre: 6.3%, post: 30.9%), and mean scores indicated less acceptance of concurrency (pre: 3.40 [95% CI 3.23, 3.57]; post: 2.62 [2.46, 2.78]). Score differences were not a function of differences in composition of the samples (adjusted means: pre: 3.37 [3.21, 3.53]; post: 2.62 [2.47, 2.76]). Findings demonstrate that a carefully targeted, intensive mass media campaign can change attitudes about concurrency, which should facilitate behavior change.