Jianghong Li

Changing Drug Users’ Risk Environments: Peer Health Advocates as Multi-level Community Change Agents

Peer delivered, social oriented HIV prevention intervention designs are increasingly popular for addressing broader contexts of health risk beyond a focus on individual factors. Such interventions have the potential to affect multiple social levels of risk and change, including at the individual, network, and community levels, and reflect social ecological principles of interaction across social levels over time. The iterative and feedback dynamic generated by this multi-level effect increases the likelihood for sustained health improvement initiated by those trained to deliver the peer intervention. The Risk Avoidance Partnership (RAP), conducted with heroin and cocaine/crack users in Hartford, Connecticut, exemplified this intervention design and illustrated the multi-level effect on drug users’ risk and harm reduction at the individual level, the social network level, and the larger community level. Implications of the RAP program for designing effective prevention programs and for analyzing long-term change to reduce HIV transmission among high-risk groups are discussed from this ecological and multi-level intervention perspective.

Challenges, strategies, and lessons learned from a participatory community intervention study to promote female condoms among rural sex workers in Southern China

China faces a rapidly emerging HIV epidemic and nationwide resurgence of sexually transmitted infections associated with a growing sex industry. Community empowerment and capacity building through community-based participatory research partnerships show promise for developing, testing, and refining multilevel interventions suited to the local context that are effective and appropriate to address these concerns. However, such efforts are fraught with challenges, both for community collaborators and for researchers. We have built an international team of scientists from Beijing and the United States and collaborating health policy makers, health educators, and care providers from Hainan and Guangxi Province Centers for Disease Prevention and Control and the local counties and towns where we are conducting our study. This team is in the process of testing a community-wide, multilevel intervention to promote female condoms and other HIV prevention within sex-work establishments. This article presents lessons learned from our experiences in the first two study sites of this intervention trial.

Multilevel Social Influences on Female Condom Use and Adoption Among Women in the Urban United States

Heterosexually transmitted HIV remains of critical concern in the United States and around the world, especially among vulnerable and disadvantaged women, complicated by socioeconomic circumstances, gender power, addiction, and experiences of abuse, among other conditions. Effective woman-initiated HIV prevention options, such as the female condom (FC), are needed that women can use in different sexual relationship contexts. We conducted a behavioral and attitudinal survey with 461 primarily African American and Latina (especially Puerto Rican) women in Hartford, Connecticut, to measure factors on the individual, partner relationship, peer, and community levels influencing their initial and continued use of FC (using the prototype FC1) for disease prevention. We used multivariate analyses and structural equation modeling to assess effects of multiple level factors on FC use and unprotected sex with primary, casual, and paying partners. Initial, recent, and continued FC use was associated with factors on the individual level (education, marital status, drug use, child abuse experiences, HIV status), partner level (number of sex partners, paying sex partner, relationship power), and peer level (more or influential peers saying positive things about FC). Community level factors of availability and support were consistently poor across all sectors, which limited overall FC use. Patterns differed between African American and Latina women in stages and contexts of FC use and unprotected sex. FC can make a valuable contribution to reducing heterosexually transmitted HIV among women in many circumstances. The greatest barrier to increased FC use is the lack of a supportive community environment for its promotion and use.

A Social Network Approach to Demonstrate the Diffusion and Change Process of Intervention From Peer Health Advocates to the Drug Using Community

Project RAP (Risk Avoidance Partnership) trained 112 active drug users to become peer health advocates (PHAs). Six months after baseline survey (Nbl = 522), 91.6% of PHAs and 56.6% of community drug users adopted the RAP innovation of giving peer intervention, and 59.5% of all participants (N6m = 367) were exposed to RAP innovation. Sociometric network analysis shows that adoption of and exposure to RAP innovation was associated with proximity to a PHA or a highly active interventionist (HAI), being directly linked to multiple PHAs/HAIs, and being located in a network sector where multiple PHAs/HAIs were clustered. RAP innovation has diffused into the Hartford drug-using community.

Altruism and Peer-Led HIV Prevention Targeting Heroin and Cocaine Users

Peer-delivered HIV prevention and intervention programs play an important role in halting the spread of HIV. Rigorous scientific analysis of the aforementioned programs has focused on the immediate reduction of risk-related behaviors among the target populations. In our longitudinal study of the Risk Avoidance Partnership Peer Intervention for HIV, we assessed the long-term behavioral effects of a peer-led HIV intervention project with active drug users. Initial analysis of the qualitative data highlights the role of altruism as a motivator in sustaining peer educators beyond the immediate goals of the project. We contend that altruism found in volunteers is an important factor in maintaining long-term participation in HIV intervention programs and initiatives using peer educators.

Inclusion of the female condom in a male condom-only intervention in the sex industry in China: A cross-sectional analysis of pre- and post-intervention surveys in three study sites

OBJECTIVES To describe female condom (FC) use, male condom (MC) use and overall levels of protected sex before, during and after FC education and promotion (using the original prototype FC) combined with MC promotion among female sex workers in three rural or small urban settings in southern China. STUDY DESIGN The 1-year FC intervention was conducted by local health workers through outreach to establishments where sex work is conducted. Three serial cross-sectional surveys were conducted in each study town before, during and after the intervention along with process documentation throughout the intervention period. METHODS Cross-sectional data from pre-intervention (baseline) and 6-month and 12-month post-intervention surveys from three study sites are used in a descriptive comparison of the context of the sex industry, outreach in two phases of intervention, and FC adoption after the intensive intervention phase in each site. RESULTS Approximately 75-80% of eligible women working in sex establishments, varying from 74 to 155 participants for each survey, were recruited from three study sites. After introduction and promotion of the FC along with the MC during the community public health intervention, between one-fifth and one-half of the study participants had tried the FC in the three study sites by the time of the 6-month and 12-month cross-sectional surveys. Among them, 10-30% had used the FC more than once. FC awareness increased following the intervention with much less variation across the three study sites. At baseline, 31-54% of participants across the three sites reported 100% protected sex in the last 30 days with all types of partners. At one of the sites with relatively low MC use before the intervention, the proportion of women reporting 100% protected sex in the last 30 days increased by 15%, and the proportion reporting nil protected sex in the last 30 days decreased by 13% between baseline and 12-month post-intervention surveys. More complex profiles of FC and MC use and protected sex were shown at the other two study sites, where a higher level of protection had been reached before the project started. CONCLUSIONS Different levels of FC adoption were identified after the 1-year FC promotion intervention through outreach to sex establishments. The input, output and outcomes of the intervention may be associated with womens demographic and risk characteristics, the local capacities of intervention staff, and other contextual factors. Further analysis of these factors will help establish the role of the FC in increasing protected sex, and provide insight into how to achieve greater FC use.

Female condom use in the rural sex industry in China: Analysis of users and non-users at post-intervention surveys

Abstract Changes in sexual attitudes and behaviors and resurgence of the sex industry in China have increased concerns about HIV/AIDS and sexually transmitted infections (STI) epidemics. Little attention has been paid to the significant and growing sex industry in rural China. Promotion of barrier protection in this context is most effective to prevent STIs and pregnancy. The female condom (FC) is a barrier method that gives women more autonomy in its application, and has other advantages, but has been little promoted and tested in high risk contexts in China. The China/US Womens Health Project was designed to promote FC use in addition to male condoms (MC) through outreach intervention conducted in sex work establishments in rural and small urban towns in southern China, using the original prototype FC1. The study used quantitative and qualitative methods to document the pre-intervention context, intervention delivery process, and post-intervention outcomes of FC use. In this paper we compare post-intervention FC users and non-users in the first study sites, two rural towns in a single county in Hainan Province. Examination of cross-sectional six-month and 12-month surveys indicated that, despite relatively high MC use, about one-third of the women in sex work establishments in these rural towns had adopted FC at each post-intervention survey. Compared with non-users, FC users were more likely to be freelance women in boarding houses, more sexually experienced, married with children, more sexually active in the prior month, and more exposed to the intervention. The rural context hampered intervention implementation, particularly the significant limits in health and human resources available to manage prevention of HIV/STIs among women in the sex industry. These challenges highlight the need to better understand the context of the rural sex industry and capacity of local resources for better prevention efforts and the benefits that new prevention technologies like FC can offer.

Initial and sustained female condom use among low-income urban U.S. women.

OBJECTIVES The female condom (FC), an effective barrier method for HIV/sexually transmitted infection (STI) prevention, continues to be absent from most community settings, including reproductive health and treatment clinics. Reducing or eliminating basic barriers, including lack of awareness, knowledge of proper use, and access to free samples, may significantly increase use among those who want or need them. METHODS A prospective cohort of 461 women in Hartford, Connecticut (2005-2008), was interviewed at baseline, 1 month, and 10 months about FC use and other personal, partner, peer, and community factors. All participants received brief demonstration of FC use and four free FC1 at baseline. Pairwise longitudinal tests and structural equation modeling were used to test predictors of initial (1 month) and sustained (10 month) FC use. RESULTS Although only 29% of the sample reported ever having used FC at baseline, 73% of never users (51% of the returned 1-month sample) had initiated FC use by 1 month after receiving the brief intervention. Additionally, 24% of the returned 10-month sample (30% of 10-month FC users) reported sustained use, measured as having used FC at baseline or 1 month and also in the prior 30 days. General latent variable modeling indicated that FC knowledge and attitudes predicted initiating FC use; male condom use, FC knowledge and attitudes, and network exposure to FC information predicted sustained use. CONCLUSIONS Findings indicated that many women will potentially initiate and continue using FC when basic barriers are removed. Brief FC education with free trial samples should be built into standard clinical practice and public health programs.

Multilevel Dynamic Systems Affecting Introduction of HIV/STI Prevention Innovations Among Chinese Women in Sex Work Establishments

Social and public health scientists are increasingly interested in applying system dynamics theory to improve understanding and to harness the forces of change within complex, multilevel systems that affect community intervention implementation, effects, and sustainability. Building a system dynamics model based on ethnographic case study has the advantage of using empirically documented contextual factors and processes of change in a real-world and real-time setting that can then be tested in the same and other settings. System dynamics modeling offers great promise for addressing persistent problems like HIV and other sexually transmitted epidemics, particularly in complex rapidly developing countries such as China. We generated a system dynamics model of a multilevel intervention we conducted to promote female condoms for HIV/sexually transmitted infection (STI) prevention among Chinese women in sex work establishments. The model reflects factors and forces affecting the study’s intervention, implementation, and effects. To build this conceptual model, we drew on our experiences and findings from this intensive, longitudinal mixed-ethnographic and quantitative four-town comparative case study (2007-2012) of the sex work establishments, the intervention conducted in them, and factors likely to explain variation in process and outcomes in the four towns. Multiple feedback loops in the sex work establishments, women’s social networks, and the health organization responsible for implementing HIV/STI interventions in each town and at the town level directly or indirectly influenced the female condom intervention. We present the conceptual system dynamics model and discuss how further testing in this and other settings can inform future community interventions to reduce HIV and STIs.

Overlooked Threats to Respondent Driven Sampling Estimators: Peer Recruitment Reality, Degree Measures, and Random Selection Assumption

Intensive sociometric network data were collected from a typical respondent driven sample (RDS) of 528 people who inject drugs residing in Hartford, Connecticut in 2012–2013. This rich dataset enabled us to analyze a large number of unobserved network nodes and ties for the purpose of assessing common assumptions underlying RDS estimators. Results show that several assumptions central to RDS estimators, such as random selection, enrollment probability proportional to degree, and recruitment occurring over recruiter’s network ties, were violated. These problems stem from an overly simplistic conceptualization of peer recruitment processes and dynamics. We found nearly half of participants were recruited via coupon redistribution on the street. Non-uniform patterns occurred in multiple recruitment stages related to both recruiter behavior (choosing and reaching alters, passing coupons, etc.) and recruit behavior (accepting/rejecting coupons, failing to enter study, passing coupons to others). Some factors associated with these patterns were also associated with HIV risk.ResumenSe colectaron datos de redes socio métricas intensivas a partir de un tópico (MDE) Muestreo Dirigido por los Entrevistados de unas 528 personas que se inyectaban drogas que residen en xxx en2012–2013. Este conjunto de datos nos permitió analizar un gran número de nodos y arcos de red no observados. Y los vínculos con el fin de evaluar los supuestos comunes subyacentes MDE estimadores. Los resultados muestran que se han violado varios supuestos centrales para los estimadores MDE, como la selección aleatoria, la probabilidad de matriculación y el reclutamiento que ocurren sobre los lazos de red del reclutador. Estos problemas surgen de una conceptualización excesivamente simplista los procesos y las dinámicas de reclutamiento en pares. Se encontró que casi la mitad de los participantes fueron reclutados a través de la distribución de cupones. Los patrones no uniformes ocurrieron en etapas múltiples del reclutamiento relacionadas con el comportamiento del reclutador (pasando los cupones, etc.) Y el comportamiento de reclutamiento (aceptar/rechazar el cupón, no entrar en el estudio, pasar cupones a otros). Factores asociados con estos patrones también se asociaron con el riesgo de VIH.