Rhonda Rosenberg

The HIV/AIDS epidemic in the Dominican Republic: key contributing factors.

This article reviews HIV/AIDS epidemiological data and recent research conducted in the Dominican Republic, with a focus on explaining the variability in estimated seroincidence and prevalence within the country. HIV seroprevalence estimates range from 1.0% (in the general population) to 11.0% among men who have sex with men (MSM). Some have indicated that the highest HIV seroprevalence occurs in Haitian enclaves called bateyes (US Agency for International Development [USAID], 2008), which are migrant worker shantytowns primarily serving the sugar industry in the Dominican Republic. Others report higher or comparable rates to the bateyes in areas related to the tourism and sex industries. As in other Caribbean and Latin American countries, reported HIV transmission in the Dominican Republic is predominantly due to unprotected heterosexual sex and the infection rate has been increasing disproportionally among women. The Dominican Republic represents two thirds of the Hispaniola island; the western one third is occupied by Haiti, the nation with the highest HIV prevalence in the western hemisphere. Although data is limited, it shows important differences in seroprevalence and incidence between these two countries, but commonalities such as poverty, gender inequalities, and stigma appear to be pivotal factors driving the epidemic. This article will discuss these and other factors that may contribute to the HIV epidemic in the Dominican Republic, as well as highlight the gaps in the literature and provide recommendations to guide further work in this area, particularly in the role of governance in sustainable HIV prevention.

The Relationship Between HIV/Sexually Transmitted Infection Risk and Alcohol Use During Commercial Sex Episodes: Results From the Study of Female Commercial Sex Workers in the Philippines

The HIV_Sexually Transmitted Infection (STI) risk associated with alcohol use between female commercial sex workers (FCSWs) and their customers has been understudied. We examined this relationship for 1,114 FCSWs aged 15–54 with data collected during the baseline study period (1994 to 1998) in four southern provinces of the Philippines. Two alcohol-related risk situations during commercial sex episodes were examined: prior alcohol use by an FCSW and perceived intoxication in a customer. The influence of sociodemographic variables on sexual risk behaviors was also studied. Multiple sexual risk behaviors were observed with more frequency for FCSWs if alcohol was used before commercial sex or if the episode involved a customer perceived to be intoxicated. Forty-two percent of FCSWs who had sex with an intoxicated customer were STI positive, significantly more than FCSWs who did not have sex with an intoxicated customer (28%, p <. 01). Similar significant differences were found for FCSWs who did not consume alcohol before having sex and were STI positive (29%) versus FCSW who did consume alcohol before sex and were STI positive (33%, p <. 01). Our analyses reinforce accumulating evidence in the field that sexual risk reduction interventions need to go beyond the behaviors of individual FCSWs to meet the layering of risks such as observed in this study. Multilevel strategies targeting customer substance use and other situational and structural factors have proven to be pivotal mediators in our other research with this population. These experiences and the limitations of this study are discussed.

Depression, Substance Abuse and Other Contextual Predictors of Adherence to Antiretroviral Therapy (ART) Among Haitians

Haiti has the highest number of individuals living with HIV in the Caribbean. Due to Haiti’s resource-poor environment and inadequate mental health and substance abuse services, adherence to antiretroviral therapy (ART) may be especially difficult. This study examined associations among demographics, maladaptive coping, partner conflict, alcohol problems, depression, and negative attitudes about medications and their impact on adherence among 194 HIV-positive Haitians. In a mediated directional structural equation model, depression and negative attitudes about ART directly predicted poorer adherence. Greater partner conflict, maladaptive coping and alcohol problems predicted more depression. Maladaptive coping predicted a negative attitude about ART. Alcohol problems predicted partner conflict and maladaptive coping. Significant indirect effects on adherence mediated through both depression and negative attitudes about ART include negative effects of female gender, alcohol problems and maladaptive coping. Results highlight the importance of integrated care for depression, alcohol use and other psychosocial problems to increase ART adherence.ResumenHaití tiene el número más alto de personas que viven con el VIH en el Caribe. Debido a la escases de recursos y servicios de salud mental y tratamiento del abuso de sustancias psicoactivas en el entorno Haitiano, la adherencia a la terapia antirretroviral (TARV) se puede volver especialmente difícil. Este estudio examinó asociaciones entre características demográficas, métodos inadaptados de lidiar, conflicto con la pareja, problemas relacionados al consumo del alcohol, la depresión, y las actitudes negativas sobre los medicamentos, y el impacto de dichas variables en la adherencia en 194 haitianos VIH-positivos. En un modelo de ecuación estructural, la depresión y las actitudes negativas sobre la TARV directamente predecían una adherencia inferior. Niveles más altos de conflicto con la pareja, métodos inadaptados de lidiar y problemas relacionados al consumo del alcohol predecían más depresión. Los métodos inadaptados de lidiar predecían una actitud negativa frente a la TARV. Problemas con el consumo del alcohol predecían conflicto con la pareja y métodos inadaptados de lidiar. Efectos indirectos significativos que afectan la adherencia mediados por ambas la depresión y las actitudes negativas sobre la TARV incluyen los efectos negativos del sexo femenino, problemas relacionados al consumo del alcohol y los métodos inadaptados de lidiar. Estos hallazgos recalcan la necesidad de una atención integral para la depresión, el consumo de alcohol y los problemas psicosociales para aumentar la adherencia a la TARV.

Alcohol use severity and HIV sexual risk among juvenile offenders.

Guided by the Information Motivation Behavioral Skills (IMB) model, we examine the alcohol severity/sexual risk relationship for juvenile offenders who are at extreme risk for HIV/AIDS due to situational vulnerabilities, substance abuse, and personality factors. Sexual risk behavior was analyzed by levels of alcohol use among 634 ethnically diverse adolescents in Miami between 1998 and 2002. Adolescents with the highest levels of alcohol use reported significantly higher levels of total and unprotected sexual activity and sex acts proximate to drinking. Alcohol use related problems require more attention by HIV interventionists. Alcohol severity may reduce the effectiveness of HIV interventions that do not address concurrent substance use.

Cultural adaptation in translational research: field experiences.

The incrasse in the incidence of HIV/AIDS among minorities in the United States and in certain developing nations has prompted new intervention priorities, stressing the adaptation of efficacious interventions for diverse and marginalized groups. The experiences of Florida International University’s AIDS Prevention Program in translating HIV primary and secondary prevention interventions among these multicultural populations provide insight into the process of cultural adaptations and address the new scientific emphasis on ecological validity. An iterative process involvcing forward and backward translation, a cultural linguistic committee, focus group discussions, documentation of project procedures, and consultations with other researchers in the field was used to modify interventions. This article presents strategies used to ensure fidelity in implementing the efficacious core components of evidencebased interventions for reducing HIV transmission and drug use behaviors and the challenges posed by making cultural adaptation for participants with low literacy. This experience demonstrates the importance of integrating culturally relevant material in the translation process with intense focus on language and nuance. The process must ensure that the level of intervention is appropriate for the educational level of participants. Furthermore, the rights of participants must be protected during consenting procedures by instituting policies that recognize the socioeconomic, educational, and systemic pressures to participate in research.

The Impact of Disaster on HIV in Haiti and Priority Areas Related to the Haitian Crisis

In recognition of the public health crisis in Haiti, the Journal of the Association of Nurses in AIDS Care (JANAC) plans to publish a themed issue on natural disaster, trauma, and HIV in Haiti. The issue will be published in early 2011. Haiti’s current crisis is exacerbated by a history of poverty and political instability and some effort is warranted to contextualize the crisis and to focus on priorities for HIV prevention and care. This commentary provides background information and a discussion of areas that affect HIV-infected Haitians in the present environment. ment of Health Promotion & Disease Prevention and AIDS Prevention Program, Robert Stempel College of Public Health & Social Work, Florida International University, Background Biscayne Bay Campus, North Miami. Bronwen Lichtenstein, PhD, is an associate professor, Department of Criminal Justice, The University of Alabama, Tuscaloosa, research fellow, Rural Center of AIDS/STD Prevention, Indiana University, Bloomington. Jessy G. D evieux, PhD, is an associate professor, Department of Health Promotion & Disease Prevention, and a co-director of the AIDS Prevention Program, Robert Stempel College of Public Health & Social Work, Florida International University, Biscayne Bay Campus, North Miami. The authors report no real or perceived vested interests that relate to this article (including relationships with pharmaceutical companies, biomedical device manufacturers, grantors, or other entities whose products or services are related to topics covered in this manuscript) that could be construed as a conflict of interest. This study was funded in part by Grant R01AA018084 from the National Institute on Alcohol Abuse and Alcoholism to Dr. Malow. The HIV prevention community is largely familiar with Haiti’s history of high prevalence of HIV. However, health workers and others might not be aware of Haiti’s robust scientific and clinical response to the epidemic or the particular character of the Haitian epidemic, which is complicated by high rates of co-infection with malaria, tuberculosis (TB), and several neglected tropical diseases (NTDs; Beau de Rochars et al. 2004; Hotez, Bottazzi, Franco-Paredes, Ault, & Periago, 2008; Pape, 2004; Streit & Lafontant, 2008). These infections compound the challenge of HIV prevention and treatment in ways rarely seen by researchers and practitioners in developed countries.

Effects of a Culturally Adapted HIV Prevention Intervention in Haitian Youth

&NA; This study assessed the impact of an 8‐week community‐based translation of Becoming a Responsible Teen (BART), an HIV intervention that has been shown to be effective in other at‐risk adolescent populations. A sample of Haitian adolescents living in the Miami area was randomized to a general health education control group (n = 101) or the BART intervention (n = 145), which was based on the information‐motivation‐behavior (IMB) model. Improvement in various IMB components (i.e., attitudinal, knowledge, and behavioral skills variables) related to condom use was assessed 1 month after the intervention. Longitudinal structural equation models using a mixture of latent and measured multi‐item variables indicated that the intervention significantly and positively impacted all IMB variables tested in the model. These BART intervention‐linked changes reflected greater knowledge, greater intentions to use condoms in the future, higher safer sex self‐efficacy, an improved attitude about condom use, and an enhanced ability to use condoms after the 8‐week intervention.

A Strategy for Improving Community Effectiveness of HIV/AIDS Intervention Design: The Community Readiness Model in the Caribbean

The Community Readiness Model (CR) offers a solution to the development of prevention strategies at the community level that makes use of community collaborations and community capacity. CR was administered in the U.S. Virgin Islands on St. Thomas, St. Croix, and St. John. All three islands scored lowest on dimensions of community climate and highest on knowledge of efforts to fight HIV/AIDS. The findings suggest that initial intervention efforts should improve the community climate of HIV/AIDS denial and stigma prior to introducing interventions that address HIV/AIDS risk behaviors. Community collaborators identify the interplay of social, structural, and political-economic factors for effective prevention. *This Special Issue of SUM explores the nexus between “substance use” and STD/HIV/AIDS for necessary intervention planning, implementation and assessment. This article is included even though it does not include substance use as a primary focus. It offers a community intervention paradigm that has been field-tested many times, which readers should be aware of. It introduces community processes (community engagement and community alliances) that are akin to the necessary treatment processes of therapeutic engagement and therapeutic community alliances. Editors Note.

Alcohol, Drugs, Sexual Behavior, and HIV in Trinidad and Tobago—The Way Forward

The HIV epidemic in Trinidad and Tobago is primarily heterosexual, fueled by a high level of risky sex, gender inequality, and alcohol and drug use; however, the influence of alcohol and drugs has been neglected in the literature. Research shows that current HIV prevention approaches have failed to substantially impact sexual behavior change. This may be so because they do not incorporate a comprehensive understanding of the sociocultural factors underlying sexual behavior. There is an urgent need to understand how socially accepted patterns of alcohol and drug use contribute to sexual behaviors and HIV risk in Trinidad and Tobago. Moreover, specialized, evidence-based interventions are needed for HIV-infected substance abusers. Using an adaptation of the cognitive behavioral stress management (CBSM) protocol, this intervention project aimed to assess effectiveness in reducing relapse and risky behaviors among recovering HIV-infected substance abusers in Trinidad and Tobago.

The Continuing Challenge of Reducing HIV Risk among Haitian Youth The Need for Intervention

There is a dire need for interventions that will address the multiple factors—poverty, substance use, early sexual debut, and violence—that influence Haitian youth’s engagement in risky behaviors. The deteriorating socioeconomic and political state of the country has had a deleterious effect on the sociocultural milieu and on the boundaries that have heretofore kept risky behaviors in check. Historically, the lakou system, a community-based approach that supports the family unit, has disintegrated, leading to the disruption of traditional parenting patterns. The unstable economic system has also led to the increasing use of children from poor families, who through the restavek system, are sent to work as servants in other households. The breakdown of traditional systems, coupled with the increasing economic and political instability, has had a significant effect on Haitian adolescents. Among boys, increased levels of substance use have been associated with multiple sex partnerships and very early sexual debut. Among girls, extremely high rates of sexual abuse and forced sex have led to relatively high levels of HIV. While the majority of them have been exposed to behavior change messages, behavior change itself has lagged because many adolescents do not accurately perceive their risk exposure. This review explores the risks of HIV transmission among Haitian youth, with a focus on vulnerability factors, including substance use, culture, and the socioeconomic context, and provides recommendations for intervention. An ecosystemic approach, designed specifically for Haitian youth and that takes environmental context and culture into account, is needed.