Mary Jane Rotheram-Borus

Evolution of China's response to HIV/AIDS

Summary Four factors have driven Chinas response to the HIV/AIDS pandemic: (1) existing government structures and networks of relationships; (2) increasing scientific information; (3) external influences that underscored the potential consequences of an HIV/AIDS pandemic and thus accelerated strategic planning; and (4) increasing political commitment at the highest levels. Chinas response culminated in legislation to control HIV/AIDS—the AIDS Prevention and Control Regulations. Three major initiatives are being scaled up concurrently. First, the government has prioritised interventions to control the epidemic in injection drug users, sex workers, men who have sex with men, and plasma donors. Second, routine HIV testing is being implemented in populations at high risk of infection. Third, the government is providing treatment for infected individuals. These bold programmes have emerged from a process of gradual and prolonged dialogue and collaboration between officials at every level of government, researchers, service providers, policymakers, and politicians, and have led to decisive action.

Scaling up mHealth: where is the evidence?

Mark Tomlinson and colleagues question whether there is sufficient evidence on implementation and effectiveness to match the wide enthusiasm for mHealth interventions, and propose a global strategy to determine needed evidence to support mHealth scale-up.

HIV prevention among sex workers in India

Summary: To test the efficacy of a sustainable community-level HIV intervention among sex workers, the Sonagachi Project was replicated, including community organizing and advocacy, peer education, condom social marketing, and establishment of a health clinic. Sex workers were randomly selected in 2 small urban communities in northeastern India (n = 100 each) and assessed every 5–6 months over 15 months (85% retention). Overall condom use increased significantly in the intervention community (39%) compared with the control community (11%), and the proportion of consistent condom users increased 25% in the intervention community compared with a 16% decrease in the control community. This study supports the efficacy of the Sonagachi model intervention in increasing condom use and maintaining low HIV prevalence among sex workers.

Suicidal Behavior and Gay-Related Stress among Gay and Bisexual Male Adolescents

Adolescents are increasingly at risk for attempting suicide, particularly among those subgroups experiencing high stress. Typically, adolescentfemales are atfar greater risk (10.3% attempt suicide) as compared to males (6.2% attempt suicide). In contrast to rates among adolescents in community-based studies, attempted suicide was reported by 39% of a consecutive series of 138 self-identified gay and bisexual males, ages 14 through 19 years, presenting at a social service agency for lesbian and gay adolescents in New York City. More than one-half ofattempters had tried to kill themselves more than once, and suicide attempters were more likely to have dropped out of school, to be ejected from their homes, and to have friends or relatives who attempted suicide. Gay-related stressors were significantly more common among suicide attempters as compared to nonattempters, but general life stress was not higher Thesefindings imply that gay youths are at increased risk for attempting suicide. Clinicians and staff in community-based agencies need to enhance their awareness of the possibilities of suicide attempts among gay and bisexual male youths, increasing screening for risk and actively seeking to reduce gay-related stress.

Theory-Guided, Empirically Supported Avenues for Intervention on HIV Medication Nonadherence: Findings from the Healthy Living Project

OBJECTIVES Adherence to antiretroviral therapy (ART) remains a challenge in efforts to maximize HIV treatment benefits. Previous studies of antiretroviral adherence are limited by low statistical power, homogeneous samples, and biased assessment methods. Based on Social Action Theory and using a large, diverse sample of men and women living with HIV, the objectives of the current study are to clarify correlates of nonadherence to ART and to provide theory-guided, empirically supported direction for intervening on ART nonadherence. DESIGN Cross-sectional interview study utilizing a computerized interview. SETTING Recruited from clinics, agencies, and via media ads in four U.S. cities from June 2000 to January 2002. PARTICIPANTS Two thousand seven hundred and sixty-five HIV-positive adults taking ART. MAIN OUTCOME MEASURE Computer-assessed self-reported antiretroviral adherence. RESULTS Thirty-two percent reported less than 90% adherence to ART in the prior 3 days. A number of factors were related to nonadherence in univariate analysis. Multivariate analyses identified that being African American, being in a primary relationship, and a history of injection drug use or homelessness in the past year were associated with greater likelihood of nonadherence. Furthermore, adherence self-efficacy, and being able to manage side effects and fit medications into daily routines were protective against nonadherence. Being tired of taking medications was associated with poorer adherence whereas a belief that nonadherence can make the virus stronger was associated with better adherence. CONCLUSIONS Results support the need for multifocused interventions to improve medication adherence that address logistical barriers, substance use, attitudes and expectancies, as well as skills building and self-efficacy enhancement. Further exploration of issues related to adherence for African Americans and men in primary relationships is warranted.

Stigma, social support, and depression among people living with HIV in Thailand

Abstract Background. People living with HIV/AIDS (PLWHA) in Thailand face tremendous challenges, including HIV-related stigma, lack of social support, and mental health issues such as depression. This study aims to examine complex relationships among demographics, HIV-related stigma, and social support and their impact on depression among PLWHA in Thailand. Methods. This study uses data collected in northern and northeastern Thailand. A total of 408 PLWHA were recruited and interviewed in 2007. HIV-related stigma was measured by two subscales: “Internalized Shame” and “Perceived Stigma.” Based on correlation analyses, hierarchical multiple regression models were used to examine the predictors of depression, social support, and HIV-related stigma, controlling for demographic characteristics. Results. Correlational analysis revealed that depression was significantly associated with both dimensions of stigma: internalized shame and perceived stigma. Self-reported emotional social support was negatively associated with depression. We found that internalized shame and emotional social support were significant predictors of depression after controlling for gender, age, income, and education. Conclusions. HIV-related stigma has a negative impact on psychological wellbeing of PLWHA in Thailand, and emotional social support remains a protective factor against depression. Intervention developers and clinicians working with PLWHA may find it useful to incorporate the association between stigma and depression into their programs and treatments, and to address social support as a protective effect for the mental health of PLWHA.

Empowering sex workers in India to reduce vulnerability to HIV and sexually transmitted diseases

The Sonagachi Project was initiated in Kolkata, India in 1992 as a STD/HIV intervention for sex workers. The project evolved to adopt strategies common to womens empowerment programs globally (i.e., community mobilization, rights-based framing, advocacy, micro-finance) to address common factors that support effective, evidence-based HIV/STD prevention. The Sonagachi model is now a broadly diffused evidence-based empowerment program. We previously demonstrated significant condom use increases among female sex workers in a 16 month replication trial of the Sonagachi empowerment intervention (n=110) compared to a control community (n=106) receiving standard care of STD clinic, condom promotion, and peer education in two randomly assigned rural towns in West Bengal, India (Basu et al., 2004). This article examines the interventions impacts on 21 measured variables reflecting five common factors of effective HIV/STD prevention programs to estimate the impact of empowerment strategies on HIV/STD prevention program goals. The intervention which was conducted in 2000-2001 significantly: 1) improved knowledge of STDs and condom protection from STD and HIV, and maintained STD/HIV risk perceptions despite treatment; 2) provided a frame to motivate change based on reframing sex work as valid work, increasing disclosure of profession, and instilling a hopeful future orientation reflected in desire for more education or training; 3) improved skills in sexual and workplace negotiations reflected in increased refusal, condom decision-making, and ability to change work contract, but not ability to take leave; 4) built social support by increasing social interactions outside work, social function participation, and helping other sex workers; and 5) addressed environmental barriers of economic vulnerabilities by increasing savings and alternative income, but not working in other locations, nor reduced loan taking, and did not increase voting to build social capital. This studys results demonstrate that, compared to narrowcast clinical and prevention services alone, empowerment strategies can significantly impact a broader range of factors to reduce vulnerability to HIV/STDs.

Common elements in self-management of HIV and other chronic illnesses: an integrative framework

Abstract HIV/AIDS is widely recognized as a chronic illness within HIV care, but is often excluded from chronic disease lists outside the field. Similar to other chronic diseases, HIV requires lifetime changes in physical health, psychological functioning, social relations, and adoption of disease-specific regimens. The shift from acute to chronic illness requires a self-management model in which patients assume an active and informed role in healthcare decision making to change behaviors and social relations to optimize health and proactively address predictable challenges of chronic diseases generally and HIV specifically. This article reviews literature on chronic disease self-management to identify factors common across chronic diseases, highlight HIV-specific challenges, and review recent developments in self-management interventions for people living with HIV (PLH) and other chronic diseases. An integrated framework of common elements or tasks in chronic disease self-management is presented that outlines 14 elements in three broad categories: physical health; psychological functioning; and social relationships. Common elements for physical health include: a framework for understanding illness and wellness; health promoting behaviors; treatment adherence; self-monitoring of physical status; accessing appropriate treatment and services; and preventing transmission. Elements related to psychological functioning include: self-efficacy and empowerment; cognitive skills; reducing negative emotional states; and managing identity shifts. Social relationship elements include: collaborative relationships with healthcare providers; social support; disclosure and stigma management; and positive social and family relationships. There is a global need to scale up chronic disease self-management services, including for HIV, but there are significant challenges related to healthcare system and provider capacities, and stigma is a significant barrier to HIV-identified service utilization. Recognizing that self-management of HIV has more in common with all chronic diseases than differences suggests that the design and delivery of HIV support services can be incorporated into combined or integrated prevention and wellness services.

The Past, Present, and Future of HIV Prevention: Integrating Behavioral, Biomedical, and Structural Intervention Strategies for the Next Generation of HIV Prevention

In the past 25 years, the field of HIV prevention research has been transformed repeatedly. Today, effective HIV prevention requires a combination of behavioral, biomedical, and structural intervention strategies. Risk of transmitting or acquiring HIV is reduced by consistent male- and female-condom use, reductions in concurrent and/or sequential sexual and needle-sharing partners, male circumcision, and treatment with antiretroviral medications. At least 144 behavioral prevention programs have been found effective in reducing HIV transmission acts; however, scale up of these programs has not occurred outside of the United States. A series of recent failures of HIV-prevention efficacy trials for biomedical innovations such as HIV vaccines, treating herpes simplex 2 and other sexually transmitted infections, and diaphragm and microbicide barriers highlights the need for behavioral strategies to accompany biomedical strategies. This challenges prevention researchers to reconceptualize how cost-effective, useful, realistic, and sustainable prevention programs will be designed, delivered, tested, and diffused. The next generation of HIV prevention science must draw from the successes of existing evidence-based interventions and the expertise of the market sector to integrate preventive innovations and behaviors into everyday routines.

Gay-related stress and its correlates among gay and bisexual male adolescents of predominantly Black and Hispanic background

The relationships among gay-related and non-gay-related stressful life events, self-esteem, emotional distress, and multiple problem behaviors (conduct problems, alcohol use, drug use, and sexual risk acts) were examined among 136 gay and bisexual male youths, predominantly Hispanic and Black, seeking social and recreational services at a gay-identified community-based agency in New York City. Increasing levels of gay-related stressful life events were associated moderately with emotional distress and the multiple problem behaviors. In addition, high self-esteem was related to low levels of emotional distress. However, self-esteem did not buffer the relationships between gay-related stressful life events and emotional distress or between these life events and the multiple problem behaviors. In addition, only one chance ethnic difference emerged in emotional distress or multiple problem behaviors. Future research should examine the chronic impact of gay-related stressful life events on gay and bisexual youths and identify the resources that allow the youths to cope with this stress.