Margaret R. Weeks

A Little Thing Called Love: Condom Use in High‐Risk Primary Heterosexual Relationships

CONTEXT Condoms are less likely to be used in primary relationships than in other relationship types. An understanding of what women and men expect when entering into these relationships, as well as how they make decisions about condom use and other prevention behaviors, is essential to efforts to curb the spread of HIV. METHODS Qualitative in-depth interviews were conducted with 25 high-risk heterosexual couples, including HIV-serodiscordant couples, participating in a trial of the female condom in Hartford in 2004-2007. Data were coded and analyzed in an iterative inductive and deductive process. RESULTS Participants described nonuse of condoms as a strategy to fi nd and maintain a primary relationship, establish trust and increase intimacy. Many had unprotected intercourse while recognizing their risk of HIV and other STDs, placing their love for their partner and other emotional needs over concerns about their health. Several couples reduced their STD risk by practicing negotiated safety (i.e., using condoms until their serostatus had been determined) or similar strategies, including sharing sexual or drug use history, disclosing HIV test results and using condoms until they decided that their relationship would be monogamous. CONCLUSIONS HIV prevention approaches must recognize the importance of love and the needs that primary relationships satisfy if they are to be considered relevant by those at greatest risk. Negotiated safety and similar strategies may be an important risk reduction tool for heterosexuals, particularly those in HIV-affected relationships, but their potential effectiveness may vary.

A dynamic social systems model for considering structural factors in HIV prevention and detection

We present a model for HIV-related behaviors that emphasizes the dynamic and social nature of the structural factors that influence HIV prevention and detection. Key structural dimensions of the model include resources, science and technology, formal social control, informal social influences and control, social interconnectedness, and settings. These six dimensions can be conceptualized on macro, meso, and micro levels. Given the inherent complexity of structural factors and their interrelatedness, HIV prevention interventions may focus on different levels and dimensions. We employ a systems perspective to describe the interconnected and dynamic processes of change among social systems and their components. The topics of HIV testing and safer injection facilities (SIFs) are analyzed using this structural framework. Finally, we discuss methodological issues in the development and evaluation of structural interventions for HIV prevention and detection.

High Risk Drug Use Sites, Meaning and Practice: Implications for AidS Prevention

A study of drug use locations in Hartford, CT, Is designed to understand the environmental and social conditions within “high risk sites” where drug users inject drugs or smoke crack, In order to develop AIDS prevention models that build upon the physical and social organization of these locations. The study assesses high-risk sites characterized on the basis of type of location or structure, presence and strength of gatekeepers, and presence and strength of HIV prevention opportunities and pressures. A combination of ethnographic, epidemiological, and social network methods are used to document the characteristics, social organization, natural history, and dynamics of these sites, the network relations of site users, and the various opportunities for, or barriers to, on-site social-level HIV prevention intervention. This paper provides an overview of the study and presents preliminary findings, Including the degree to which drug injectors and crack smokers use specific types of sites in Hartford. The paper also discusses the ways these findings Inform development of on-site, type-specific and peer-led or structural HIV-prevention Interventions.

Microbicide Acceptability Among High-Risk Urban U.S. Women: Experiences and Perceptions of Sexually Transmitted HIV Prevention

Objectives: The objectives of this study were to measure microbicide acceptability among high-risk women in Hartford, Connecticut, and contextual factors likely to affect acceptability and use. Goal: The goal of this study was to assess usefulness of microbicides for HIV/sexually transmitted infection (STI) prevention for high-risk women. Study: Ethnographic interviews (n = 75) and a survey (n = 471) explored women’s perspectives on HIV/STI prevention, vaginal contraceptives similar to microbicides, and microbicide acceptability. Participants (n = 94) in a 2-week behavioral trial used an over-the-counter vaginal moisturizer to simulate microbicide use during sex with primary, casual, and/or paying partners. Results: Findings showed limited experience with vaginal contraceptives, but high interest in microbicides as an alternative to condoms, indicated by an acceptability index score of 2.73 (standard deviation, 0.49; scale of 1–4) in the overall sample. General microbicide acceptability varied by ethnicity, prior contraceptive and violence/abuse experiences, relationship power, and other attitudinal factors. The simulation trial indicated significant willingness to use the product in various locations and with all types of partners. Conclusions: Vaginal microbicides may improve prevention outcomes for high-risk inner-city women.

Lowering HIV risk among ethnic minority drug users: comparing culturally targeted intervention to a standard intervention.

To test the efficacy of culturally targeted acquired immunodeficiency syndrome (AIDS) prevention programs on ethnic minority street drug users, 669 African-American and Puerto Rican drug users were assigned to receive either the National Institute on Drug Abuse (NIDA) standard intervention or a culturally competent enhanced intervention in a quasi-experimental study. The standard intervention was a two-session educational program, while both the African-American and Puerto Rican enhanced interventions provided additional AIDS information in a culturally appropriate fashion. Although human immunodeficiency virus (HIV) risk behaviors, as measured by Bells risk indices, decreased, there were no meaningful significant differences between interventions. However, participants who went into drug treatment programs showed greater reduction in HIV risk behavior. Cultural interventions may provide better outcome if they concentrate on getting participants into drug treatment.

Changing the environment of aids risk: Findings on syringe exchange and pharmacy sales of syringes in Hartford, CT

This paper reports findings from a National Institute on Drug Abuse-funded study designed to test the hypothesis that environmental changes, such as the enactment of laws to increase the accessibility of sterile syringes, including syringe exchange and pharmacy sale of syringes without a prescription, will lower the frequency of HIV risk and the prevalence of HIV among street drug users. Project COPE, a study of AIDS risk and risk prevention, collected longitudinal data on drug use, HIV risk, serostatus, and source of syringes in a sample of 710 out-of-treatment injection drug users in Hartford, CT. Findings support the hypothesis and the growing research-based conclusion that syringe exchange is an effective AIDS risk reduction modality.

If I Didn’t Have HIV, I’d Be Dead Now: Illness Narratives of Drug Users Living With HIV/AIDS

The purpose of this study is to illuminate the experiences of lower income, urban, HIV-positive drug users. The authors asked 60 participants about HIV risk behaviors, the impact of HIV on their lives, religious beliefs, life plans, relationships, and work-related issues both prior to and since diagnosis. They developed a theoretical framework based on illness narratives and ambiguous loss theories. Themes pertaining to both physical and emotional or spiritual dimensions were located within Benefit, Loss, or Status Quo orientations. The findings contribute to researchers’ understanding of the HIV/AIDS illness experiences among the very marginalized and have important implications for physical and mental health care professionals working with HIV-positive drug users.

Times and Places: Process Evaluation of a Peer-Led HIV Prevention Intervention

Here we present results from a process evaluation of a peer-led HIV prevention intervention. The Risk Avoidance Partnership, conducted from 2001 to 2005, trained active drug users to be peer health advocates (PHAs) to provide harm reduction materials and information to their peers. Results indicate that PHAs actively conducted harm reduction outreach both when partnered with staff and on their own time. Although PHAs conducted most of their outreach in public locations, they also provided drug users with harm reduction materials at critical moments in places where HIV risky behaviors were likely to occur. PHAs were credible and trusted sources of information to their drug-using peers who sought PHAs out for HIV prevention materials. Process evaluations of successful HIV prevention interventions are necessary to understand how and why such interventions work for further intervention refinement.

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.

The Relationship Between Housing Status and HIV Risk Among Active Drug Users: A Qualitative Analysis

This paper examines the relationship between housing status and HIV risk using longitudinal, qualitative data collected in 2004–2005, from a purposeful sample of 65 active drug users in a variety of housed and homeless situations in Hartford, Connecticut. These data were supplemented with observations and in-depth interviews regarding drug use behavior collected in 2001–2005 to evaluate a peer-led HIV prevention intervention. Data reveal differences in social context within and among different housing statuses that affect HIV risk or protective behaviors including the ability to carry drug paraphernalia and HIV prevention materials, the amount of drugs in the immediate environment, access to subsidized and supportive housing, and relationships with those with whom drug users live. Policy implications of the findings, limitations to the data, and future research are discussed.