Stacey A. Shaw

Dual HIV risk and vulnerabilities among women who use or inject drugs: No single prevention strategy is the answer:

Purpose of reviewThis article examines the dual HIV and sexually transmitted infection (STI) risk behaviors engaged in by women who use or inject drugs; the individual, social, and structural drivers of HIV and STI risk; prevention strategies; and the implications for multilevel, combined, sex-specific HIV prevention strategies. Recent findingsWomen who use or inject drugs, especially female sex workers, are at dual risk for HIV, the hepatitic C virus (HCV), and other STIs. In countries with HIV prevalence higher than 20% among injecting drug users (IDUs), female IDUs have slightly higher HIV prevalence than male IDUs. Women who use or inject drugs face multilevel drivers that increase their vulnerabilities to HIV, HCV, and STIs. Despite advances in behavioral HIV prevention strategies for this population, most prevention studies have not sufficiently targeted dyadic, social, and structural levels. Few recent advances in biomedical HIV prevention have focused on women who use drugs and their unique needs. SummaryHIV prevention strategies and services need to address the unique and multilevel drivers that increase the vulnerabilities to HIV, HCV, and STIs among women who use drugs including those who engage in sex work. Scaling-up and improving access to multilevel and combined HIV prevention strategies for these women is central to combating the HIV epidemic.

Drug use as a driver of HIV risks: re-emerging and emerging issues.

Purpose of reviewWe reviewed the studies published in 2012–2013 that focused on re-emerging and emerging injection and noninjection drug use trends driving HIV risk behaviors and transmission in some parts of the world. Recent findingsAlthough HIV incidence has declined in many countries, HIV epidemics remain at troubling levels among key drug-using populations, including females who inject drugs (FWIDs), FWIDs who trade sex, sex partners of people who inject drugs, young people who inject drugs, and people who use noninjection drugs in a number of low-income and middle-income countries such as in Central Asia, Eastern Europe, Southeast Asia, and parts of Africa. SummaryHIV epidemics occur within the contexts of global economic and political forces, including poverty, human rights violations, discrimination, drug policies, trafficking, and other multilevel risk environments. Trends of injection and noninjection drug use and risk environments driving HIV epidemics in Central Asia, Eastern Europe, Southeast Asia, and parts of Africa call for political will to improve HIV and substance use service delivery, access to combination HIV prevention, and harm reduction programs.

Effects of a couple-based intervention to reduce risks for HIV HCV and STIs among drug-involved heterosexual couples in Kazakhstan: a randomized controlled trial.

Objective:Project Renaissance is a randomized controlled trial of an HIV/hepatitis C virus (HCV)/sexually transmitted infection (STI) prevention intervention conducted in Almaty, Kazakhstan. We hypothesized that couples assigned to the intervention of interest will have lower incidence of HIV, HCV, STIs, rates of unprotected sex, and unsafe injection over the 12-month follow-up period compared with those assigned to an attention control arm. Design:A total of 300 couples (600 participants) where one or both partners reported injecting drugs in the past 90 days were randomized to 1 of 2 arms: (1) a 5-session HIV/HCV/STI prevention intervention (risk reduction: RR) or (2) a 5-session Wellness Promotion (WP) intervention. Results:Over the 12-month follow-up period, assignment to RR compared with WP significantly lowered the incidence of HCV infection by 69% [incidence rate ratios (IRR) = 0.31, 95% (CI) confidence interval: 0.10 to 0.90, P = 0.031]. Although differences were not statistically significant, RR participants had a lower incidence of HIV infection by 51% (IRR = 0.49, 95% CI: 0.16 to 1.48, P = 0.204) and any STI by 37% (IRR = 0.63, 95% CI: 0.21 to 1.93, P = 0.418) than WP participants. RR participants reported significantly fewer numbers of unprotected vaginal sex acts with their study partners (IRR = 0.58, 95% CI: 0.36 to 0.93, P = 0.024) and more consistent condom use (odds ratios = 2.30, 95% CI: 1.33 to 4.00, P = 0.003) over the entire follow-up period compared with WP participants. Conclusions:Project Renaissance demonstrated a significant effect for biological and behavioral endpoints. Findings draw attention to an HIV/HCV/STI prevention intervention strategy that can be scaled up for drug-involved couples in harm reduction programs, drug treatment, and criminal justice settings.

Efficacy of a group-based multimedia HIV prevention intervention for drug-involved women under community supervision: project WORTH.

Importance This study is designed to address the need for evidence-based HIV/STI prevention approaches for drug-involved women under criminal justice community supervision. Objective We tested the efficacy of a group-based traditional and multimedia HIV/STI prevention intervention (Project WORTH: Women on the Road to Health) among drug-involved women under community supervision. Design, Setting, Participants, and Intervention We randomized 306 women recruited from community supervision settings to receive either: (1) a four-session traditional group-based HIV/STI prevention intervention (traditional WORTH); (2) a four-session multimedia group-based HIV/STI prevention intervention that covered the same content as traditional WORTH but was delivered in a computerized format; or (3) a four-session group-based Wellness Promotion intervention that served as an attention control condition. The study examined whether the traditional or multimedia WORTH intervention was more efficacious in reducing risks when compared to Wellness Promotion; and whether multimedia WORTH was more efficacious in reducing risks when compared to traditional WORTH. Main Outcomes and Measures Primary outcomes were assessed over the 12-month post-intervention period and included the number of unprotected sex acts, the proportion of protected sex acts, and consistent condom use. At baseline, 77% of participants reported unprotected vaginal or anal sex (n = 237) and 63% (n = 194) had multiple sex partners. Results Women assigned to traditional or multimedia WORTH were significantly more likely than women assigned to the control condition to report an increase in the proportion of protected sex acts (β = 0.10; 95% CI = 0.02–0.18) and a decrease in the number of unprotected sex acts (IRR = 0.72; 95% CI = 0.57–0.90). Conclusion and Relevance The promising effects of traditional and multimedia WORTH on increasing condom use and high participation rates suggest that WORTH may be scaled up to redress the concentrated epidemics of HIV/STIs among drug-involved women in the criminal justice system. Trial Registration ClinicalTrials.gov NCT01784809

Efficacy of a Computerized Intervention on HIV and Intimate Partner Violence Among Substance-Using Women in Community Corrections: A Randomized Controlled Trial.

OBJECTIVES To test the efficacy of a computerized, group-based HIV and intimate partner violence (IPV) intervention on reducing IPV victimization among substance-using women mandated to community corrections. METHODS Between November 2009 and January 2012, we randomly allocated 306 women from community corrections in New York City to 3 study arms of a computerized HIV and IPV prevention trial: (1) 4 group sessions intervention with computerized self-paced IPV prevention modules (Computerized Women on the Road to Health [WORTH]), (2) traditional HIV and IPV prevention intervention group covering the same HIV and IPV content as Computerized WORTH without computers (Traditional WORTH), and (3) a Wellness Promotion control group. Primary outcomes were physical, injurious, and sexual IPV victimization in the previous 6 months at 12-month follow-up. RESULTS Computerized WORTH participants reported significantly lower risk of physical IPV victimization, severe injurious IPV victimization, and severe sexual IPV victimization at 12-month follow-up when compared with control participants. No significant differences were seen between Traditional WORTH and control participants for any IPV outcomes. CONCLUSIONS The efficacy of Computerized WORTH across multiple IPV outcomes highlights the promise of integrating computerized, self-paced IPV prevention modules in HIV prevention groups.

The Silk Road Health Project: How Mobility and Migration Status Influence HIV Risks among Male Migrant Workers in Central Asia.

Objectives We examined whether mobility, migrant status, and risk environments are associated with sexually transmitted infections (STIs) and HIV risk behaviors (e.g. sex trading, multiple partners, and unprotected sex). Methods We used Respondent Driven Sampling (RDS) to recruit external male migrant market vendors from Kyrgyzstan, Uzbekistan, and Tajikistan as well internal migrant and non-migrant market vendors from Kazakhstan. We conducted multivariate logistic regressions to examine the effects of mobility combined with the interaction between mobility and migration status on STIs and sexual risk behaviors, when controlling for risk environment characteristics. Results Mobility was associated with increased risk for biologically-confirmed STIs, sex trading, and unprotected sex among non-migrants, but not among internal or external migrants. Condom use rates were low among all three groups, particularly external migrants. Risk environment factors of low-income status, debt, homelessness, and limited access to medical care were associated with unprotected sex among external migrants. Conclusion Study findings underscore the role mobility and risk environments play in shaping HIV/STI risks. They highlight the need to consider mobility in the context of migration status and other risk environment factors in developing effective prevention strategies for this population.

Bridge Builders: A Qualitative Study Exploring the Experiences of Former Refugees Working as Caseworkers in the United States

ABSTRACT. Individuals who come to the United States as refugees and work as resettlement caseworkers offer peer support, modeling, and assistance with integration to newly arriving refugees, despite often having limited training or experience in social service provision. A phenomenological approach was utilized to gain understanding about the experiences of refugee caseworkers. Nine caseworkers who came to the United States as refugees completed in-depth interviews. Thematic analysis was used to identify primary themes, including: a) the caseworkers bridge-building role with clients; b) their role in building bridges with others in the community, including the resettlement agency; and c) the caseworkers’ experience as bridge builders, including motivations, perspectives toward their role, and needed supports. Refugee service providers face unique challenges in negotiating boundaries with clients and meeting the expectations of their ethnolinguistic community members. Their strengths in understanding household experiences and in building agency and community understanding highlight their ability to contribute to positive resettlement outcomes. The findings from this study have implications for agencies serving refugees and for other social services that utilize peer-support strategies, particularly in regards to staff training and support. Findings highlight the need for research examining effective resettlement strategies and the perspectives of refugees toward resettlement approaches.

HIV/AIDS Education: What African Youth Say Is Effective

This study on HIV/AIDS-education programs was conducted with the Uganda Ministry of Education and Sports in a national sample of 76 secondary schools in Uganda. Participants included secondary students (N = 883) who critiqued their formal and informal school curricula and offered youth perspectives regarding what teaching mediums and programs of HIV/AIDS prevention are most effective. Results indicated that HIV/AIDS education is not taught in their respective school curricula. Students report on informal ways that are helpful in learning about AIDS, recommend changes to their schools curriculum, and report that reactions from various groups in their lives to HIV/AIDS education in their school would be positive. This study provides students, parents of students, educators, social workers, and policymakers with insights on how to better develop, update, and improve HIV/AIDS programs.

HIV risks among injecting and non-injecting female partners of men who inject drugs in Almaty, Kazakhstan: Implications for HIV prevention, research, and policy

BACKGROUND Kazakhstan and other countries in Central Asia are experiencing a rapidly growing HIV epidemic, which has historically been driven by injection drug use, but is more recently being fueled by heterosexual transmission. METHODS This paper examines HIV and HCV infection, as well as sexual and drug-related risks among female partners of men who inject drugs (MWID), comparing females who inject drugs (FWID) to non-injecting female partners on socio-demographic, relationship context, and structural characteristics. RESULTS The prevalence rate of HIV was 30.1% among FWID and 10.4% among non-IDU female partners of MWID. The prevalence rate of HCV was 89.8% among FWID and 14.8% among female non-IDUs. Less than one-fifth of all female participants had access to HIV education and services or harm reduction programs. Although high rates of non-injection drug use and sexual risk behaviors were found among both FWID and non-injecting female partners of MWID, we found that FWID were more likely to be HIV seropositive (aRR=3.03; 95% CI=1.78, 5.18) and HCV seropositive than non-IDU females (aRR=6.05; 95% CI=4.05, 9.04), were more likely to have used alcohol or drugs before sex (aRR=1.67; 95% CI=1.40, 2.00), and were more likely to have used sedatives, barbiturates, tranquilizers, sleeping pills, or painkillers that were not prescribed by a physician (aRR=17.45; 95% CI=8.01, 38.01). CONCLUSION Given the spread of the HIV epidemic to heterosexual partners in Kazakhstan, more attention is needed in research, prevention, and policies regarding female partners of male injection drug users.

Changing Patterns of Family Care in Uganda: Father Absence and Patrilineal Neglect in the Face of HIV/AIDS

In this study, 162 HIV-positive mothers in Uganda were interviewed about the involvement of fathers and paternal kin, regarding current support they provide to children and as child placement options in the event of the mothers death. More than half of the children had fathers who were already deceased. Another one third had fathers who were alive but did not live with the children. Only 16% of the children were living with and being supported by their fathers. Mothers indicated a strong preference for placement with maternal kin, in contrast to traditional expectations of paternal kin care. Patterns of change in kin care throughout Uganda and sub-Saharan Africa, and implications are discussed in the context of the HIV/AIDS pandemic.