Theresa M. Exner

A Review of HIV Interventions for At-Risk Women

This paper reviews published reports on primary prevention of sexual transmission of HIV with women from the beginning of the AIDS epidemic through March 1996. All reviewed interventions were conducted in the United States, Canada or Puerto Rico and the reports described a psychological, behavioral, or educational component specifically to address sexual risk reduction and included a behavioral evaluation component. Manual and computer searches identified 47 studies that targeted women and provided a female-specific analysis of intervention effects. Sixteen of the 47 studies fulfilling more rigorous methodological reporting standards were considered separately. Overall, the findings demonstrate that HIV prevention programs can be effective in reducing risky sexual behavior among at-risk women. Program effectiveness varied by intervention type, session duration, and whether studies included women alone or both men and women. The most efficacious HIV prevention programs were specifically directed toward women, focused on relationship and negotiation skills, and involved multiple, sustained contacts. Evidence also indicated that community-level interventions hold promise. This review includes a methodological critique, identification of research gaps, and recommendations for future intervention research with women.

The psychosexual development of urban lesbian, gay, and bisexual youths

An examination of cognitive sexual orientation, sexual partner activity, and sexual identity was conducted among 76 lesbian/bisexual female youths and 80 gay/bisexual male youths (age range of 14–21 years) recruited from community‐based or college organizations for lesbian / gay youths in New York City. Self‐identification as lesbian / gay or bisexual changed over time; more than half the youths who identified as lesbian / gay at the interview had considered themselves bisexual in the past, and vice versa. A modal developmental sequence of cognitions and behaviors was found: Most youths first became aware of a cognitive sexual orientation (e.g., attractions and fantasies) toward the same or other sex, then considered a lesbian / gay or bisexual identity, and finally felt certain of a lesbian / gay or bisexual identity. Age at initiation of sexual activity with females or males was inconsistently related to this pattern. Significant gender differences indicated that females were older than males when they ...

Effects of a behavioral intervention to reduce risk of transmission among people living with HIV: The Healthy Living Project randomized controlled study

Context:The US Centers for Disease Control and Prevention (CDC) strongly recommend comprehensive risk counceling and services for people living with HIV (PLH); yet, there are no evidence-based counseling protocols. Objective:To examine the effect of a 15-session, individually delivered, cognitive behavioral intervention on a diverse sample of PLH at risk of transmitting to others. Design:This was a multisite, 2-group, randomized, controlled trial. Participants:Nine hundred thirty-six HIV-infected participants considered to be at risk of transmitting HIV of 3818 persons screened were randomized into the trial. Participants were recruited in Los Angeles, Milwaukee, New York, and San Francisco. Intervention:Fifteen 90-minute individually delivered intervention sessions were divided into 3 modules: stress, coping, and adjustment; safer behaviors; and health behaviors. The control group received no intervention until the trial was completed. Both groups completed follow-up assessments at 5, 10, 15, 20, and 25 months after randomization. Main Outcome Measure:Transmission risk, as measured by the number of unprotected sexual risk acts with persons of HIV-negative or unknown status, was the main outcome measure. Results:Overall, a significance difference in mean transmission risk acts was shown between the intervention and control arms over 5 to 25 months (χ2 = 16.0, degrees of freedom = 5; P = 0.007). The greatest reduction occurred at the 20-month follow-up, with a 36% reduction in the intervention group compared with the control group. Conclusion:Cognitive behavioral intervention programs can effectively reduce the potential of HIV transmission to others among PLH who report significant transmission risk behavior.

A gender-specific HIV/STD risk reduction intervention for women in a health care setting: Short- and long-term results of a randomized clinical trial

This study assessed the short- and long-term effect of a gender-specific group intervention for women on unsafe sexual encounters and strategies for protection against HIV/STD infection. Family planning clients (N = 360) from a high HIV seroprevalence area in New York City were randomized to an eight-session, a four-session or a control condition and followed at one, six and 12 months post-intervention. Using an intention-to-treat analysis, women who were assigned to the eight-session group had about twice the odds of reporting decreased or no unprotected vaginal and anal intercourse compared to controls at one month (OR = 1.93, 95% confidence interval [CI] = 1.07, 3.48, p = 0.03) and at 12-month follow-up (OR = 1.65, 95% CI = 0.94, 2.90, p = 0.08). Relative to controls, women assigned to the eight-session condition reported during the previous month approximately three-and-a-half (p = 0.09) and five (p < 0.01) fewer unprotected sex occasions at one- and 12-month follow-up, respectively. Women in the eight-session group also reduced the number of sex occasions at both follow-ups, and had a greater odds of first time use of an alternative protective strategy (refusal, outercourse, mutual testing) at one-month follow-up. Results for the four-session group were in the expected direction but overall were inconclusive. Thus, gender-specific interventions of sufficient intensity can promote short- and long-term sexual risk reduction among women in a family planning setting.

The future of the female condom.

More than 10 years have elapsed since the female condom became widely available, and it remains the only femaleinitiated means of preventing both pregnancy and sexually transmitted infections (STIs), including HIV. The female condom was developed as an alternative to the male condom, and it was hailed as a method that would enable women to have greater control over their own protection from disease. With the support of the Joint United Nations Programme on HIV/AIDS (UNAIDS), public and private funders, and the manufacturer, more than 90 developing countries have introduced the method through public distribution, social marketing campaigns or commercial outlets. In several countries that have actively promoted its use, such as South Africa, Brazil, Ghana and Zimbabwe, steadily increasing female condom sales to the government suggest that effective programs can generate demand. At the same time, there have been disappointments. Uptake in the West and in some developing countries has been lower than was initially anticipated, demonstrating that successful introduction will not be as straightforward as was hoped. 1 A study by Kulczycki and colleagues published earlier this year shows that the method is not popular among some women. 2 Indeed, there are still gaps in knowledge about how acceptable the female condom is for long-term use and whether promoting it can help reduce STI rates. Despite both successes and disappointments, promotion of the female condom remains important, especially in the face of heterosexually acquired HIV infection rates that are soaring globally. It is unfortunate, therefore, that a discourse has emerged recently that marginalizes the female condom as a viable prevention option, out of concerns about its high cost and the need for women to obtain their partner’s cooperation in order to use it. 3 Such a conclusion is premature, as the picture is far more complex. In this viewpoint, we review what has been learned about the female condom over the past decade, and argue for a renewed commitment to behavioral intervention research and the implementation and evaluation of large-scale female condom programs.

Lifetime sexual behaviors among runaway males and females

Lifetime sexual behaviors were examined among 206 male and female runaway adolescents aged 11–18 in New York City who were predominantly Black or Hispanic. Most youths experienced oral, anal or vaginal sex with opposite‐sex partners (84%), began to engage in these heterosexual activities at a relatively young age (M = 12.9 years), and used condoms inconsistently or not at all (56%). Among sexually active youths, males initiated heterosexual activity at a significantly earlier age than females, reported more opposite‐sex partners, and had a higher prevalence rate of trading sex for money or drugs. These findings indicate specific areas for targeting AIDS prevention programs for runaway youths.

HIV Sexual Risk Reduction Interventions With Heterosexual Men: The Forgotten Group

This paper reviews published evaluations (through fall 1998) of HIV sexual risk reduction programs conducted in the United States that have targeted adult heterosexual men. The review was limited to studies that provided a male-specific analysis of intervention effects on sexual risk behavior. Fifteen of 20 peer-reviewed studies meeting inclusion criteria demonstrated that HIV sexual risk reduction programs can be effective in reducing mens heterosexual risk behavior, although effect sizes were usually modest. Outcomes varied and included biological markers and self-reported behavior. No clear pattern distinguished effective from ineffective interventions. All intervention types (information-only; condom skills/distribution; behavioral skills–focused; HIV counseling and testing; individual risk counseling; street outreach) showed some efficacy, and there were no discernable differences by targeted population. Both group and individual delivery formats were effective. The review includes a methodologic critique, identifies research gaps, and provides recommendations for future research efforts with heterosexually active men.

Intimate Partner Violence and Safer Sex Negotiation: Effects of a Gender-Specific Intervention

This study examined the effects of a gender-specific HIV/STD prevention intervention with two dosage levels (four-session, eight-session) among women reporting physical abuse by a current or recent (past year) intimate partner. From 360 women included in the full randomized trial, we conducted subgroup analyses among 152 women who experienced partner physical abuse within the past year. Unprotected vaginal and anal sex occasions and negotiation skills were examined as outcomes. We also assessed whether the intervention increased previously abused womens subsequent risk of physical abuse. Among abused women, those in the eight-session, but not the four-session, intervention decreased their unprotected sex occasions or maintained consistent safer sex at both 1-month (OR = 3.63, 95% CI = 1.50–8.80) and 1-year (OR = 2.88, 95% CI = 1.17–7.10) postintervention. In the short-term, abused women in both the four- and eight-session groups had a greater odds of using an alternative strategy (e.g., refusal, “outercourse,” or mutual testing) and of having a safer sex discussion with their partners relative to their controls, and they scored higher on intention to negotiate safer sex. The intervention did not increase or decrease the incidence of subsequent abuse during the 1-year follow-up period. A gender-specific intervention that focuses on negotiation skills in the context of potentially abusive partners benefits, and does not appear to harm, recently abused women.

Beyond the Male Condom: The Evolution of Gender-Specific HIV Interventions for Women

Abstract As the number of HIV infections in women has increased, there has been a concomitant recognition that prevention efforts to reduce sexual transmission must address the gendered context in which risk behavior occurs. This paper provides a longitudinal perspective on the emergence of the HIV epidemic in U.S. women and the parallel development of interventions to reduce risk. In the first portion of this paper, we briefly discuss the growth of the epidemic among women and how public health responses reflected the early discourse about infected women. We also address methods of protection available to women, and the emerging recognition of the importance of gender relations. In the second half of this paper, we show how gender-specificity in prevention efforts has evolved, using a framework developed by Geeta Gupta (2001) and relying on published reviews of the intervention literature in the past 10 years. Finally, we discuss in detail several recent examples. We conclude with a discussion of future directions.

It's not just what you say: Relationships of HIV dislosure and risk reduction among MSM in the post-HAART era

Abstract In the post-HAART era, critical questions arise as to what factors affect disclosure decisions and how these decisions are associated with factors such as high-risk behaviors and partner variables. We interviewed 1,828 HIV-positive men who have sex with men (MSM), of whom 46% disclosed to all partners. Among men with casual partners, 41.8% disclosed to all of these partners and 21.5% to none. Disclosure was associated with relationship type, perceived partner HIV status and sexual behaviors. Overall, 36.5% of respondents had unprotected anal sex (UAS) with partners of negative/unknown HIV status. Of those with only casual partners, 80.4% had >1 act of UAS and 58% of these did not disclose to all partners. This 58% were more likely to self-identify as gay (versus bisexual), be aware of their status for <5 years and have more partners. Being on HAART, viral load and number of symptoms were not associated with disclosure. This study—the largest conducted to date of disclosure among MSM and one of the few conducted post-HAART—indicates that almost 1/5th reported UAS with casual partners without disclosure, highlighting a public health challenge. Disclosure needs to be addressed in the context of relationship type, partner status and broader risk-reduction strategies.