Tracy Kline

Double jeopardy--Drug and sex risks among Russian women who inject drugs: Initial feasibility and efficacy results of a small randomized controlled trial:

BackgroundWith HIV prevalence estimated at 20% among female injecting drug users (IDUs) in St. Petersburg, Russia, there is a critical need to address the HIV risks of this at-risk population. This study characterized HIV risks associated with injecting drug use and sex behaviors and assessed the initial feasibility and efficacy of an adapted Woman-Focused intervention, the Womens CoOp, relative to a Nutrition control to reduce HIV risk behaviors among female IDUs in an inpatient detoxification drug treatment setting.MethodWomen (N = 100) were randomized into one of two one-hour long intervention conditions--the Woman-Focused intervention (n = 51) or a time and attention-matched Nutrition control condition (n = 49).ResultsThe results showed that 57% of the participants had been told that they were HIV-positive. At 3-month follow-up, both groups showed reduced levels of injecting frequency. However, participants in the Woman-Focused intervention reported, on average, a lower frequency of partner impairment at last sex act and a lower average number of unprotected vaginal sex acts with their main sex partner than the Nutrition condition.ConclusionThe findings suggest that improvements in sexual risk reduction are possible for these at-risk women and that more comprehensive treatment is needed to address HIV and drug risks in this vulnerable population.

Transactional sex among men and women in the south at high risk for HIV and other STIs.

Transactional sex refers to selling sex (exchanging sex for money, drugs, food, shelter, or other items) or purchasing sex (exchanging money, drugs, food, shelter, or other items for sex). These activities have been associated with a higher risk for HIV and other sexually transmitted infections in a variety of populations and settings. This paper examines correlates of purchasing and selling sex in a large sample of drug users, men who have sex with men, and sex partners of these groups. Using respondent-driven sampling, participants were recruited between 2005 and 2008 in two urban and two rural counties in North Carolina. We used multiple logistic regressions to examine separate models for selling and purchasing sex in men and women. In addition, we estimated direct and indirect associations among independent variables in the logistic regression models and transactional sex using structural equation models. The analysis shows that factors associated with women selling and buying sex include being homeless, use of stimulants, bisexual behavior, and neighborhood disorder. There was also a significant difference by race. For men, the factors associated with selling and buying sex include being homeless, bisexual behavior, and not being in a relationship. Although neighborhood violence and disorder show significance in bivariate associations with the outcome, these associations disappear in the structural equation models.

Preliminary Findings of an Adapted Evidence-Based Woman-Focused HIV Intervention on Condom Use and Negotiation Among At-Risk Women in Pretoria, South Africa

This article presents the results of a randomized trial in South Africa of an adapted evidence-based Woman-Focused intervention on condom use with primary sex partners. The preliminary findings show that regardless of HIV status, condom negotiation was significantly associated with condom use at the 3- and 6-month follow-ups. By intervention group, significant intervention effects were found at 6-month follow-up for HIV-positive and HIV-unknown status women in the Woman-Focused intervention who were more likely than women in the Standard intervention to report condom use with a primary male partner. Among HIV-positive women, those in the Woman-Focused group and those with greater sexual control were more likely to report condom use at the 6-month follow-up. The findings indicate that gender-based interventions for women may result in increased condom negotiation skills.

Substance abuse, treatment needs and access among female sex workers and non-sex workers in Pretoria, South Africa.

BackgroundThis study examined cross-sectional data collected from substance-using female sex workers (FSW) and non-sex workers (non-SW) in Pretoria, South Africa, who entered a randomized controlled trial.MethodsWomen who reported alcohol use and recently engaging in sex work or unprotected sex were recruited for a randomized study. The study sample (N = 506) comprised 335 FSW and 171 female non-SW from Pretoria and surrounding areas. Self-reported data about alcohol and other drug use as well as treatment needs and access were collected from participants before they entered a brief intervention.ResultsAs compared with female non-SW, FSW were found to have a greater likelihood of having a past year diagnosis of alcohol or other drug abuse or dependence, having a family member with a history of alcohol or other drug abuse, having been physically abused, having used alcohol before age 18, and having a history of marijuana use. In addition, the FSW were more likely to perceive that they had alcohol or other drug problems, and that they had a need for treatment and a desire to go for treatment. Less than 20% of participants in either group had any awareness of alcohol and drug treatment programs, with only 3% of the FSW and 2% of the non-SW reporting that they tried but were unable to enter treatment in the past year.ConclusionFSW need and want substance abuse treatment services but they often have difficulty accessing services. The study findings suggest that barriers within the South African treatment system need to be addressed to facilitate access for substance-using FSW. Ongoing research is needed to inform policy change that fosters widespread educational efforts and sustainable, accessible, woman-sensitive services to ultimately break the cycle for current and future generations of at-risk South African women.

A brief intervention for drug use, sexual risk behaviours and violence prevention with vulnerable women in South Africa: a randomised trial of the Women's Health CoOp

Objective To assess the impact of the Womens Health CoOp (WHC) on drug abstinence among vulnerable women having HIV counselling and testing (HCT). Design Randomised trial conducted with multiple follow-ups. Setting 15 communities in Cape Town, South Africa. Participants 720 drug-using women aged 18–33, randomised to an intervention (360) or one of two control arms (181 and 179) with 91.9% retained at follow-up. Interventions The WHC brief peer-facilitated intervention consisted of four modules (two sessions), 2u2005h addressing knowledge and skills to reduce drug use, sex risk and violence; and included role-playing and rehearsal, an equal attention nutrition intervention, and an HCT-only control. Primary outcome measures Biologically confirmed drug abstinence measured at 12-month follow-up, sober at last sex act, condom use with main and casual sex partners, and intimate partner violence. Results At the 12-month endpoint, 26.9% (n=83/309) of the women in the WHC arm were abstinent from drugs, compared with 16.9% (n=27/160) in the Nutrition arm and 20% (n=31/155) in the HCT-only control arm. In the random effects model, this translated to an effect size on the log odds scale with an OR of 1.54 (95% CI 1.07 to 2.22) comparing the WHC arm with the combined control arms. Other 12-month comparison measures between arms were non-significant for sex risk and victimisation outcomes. At 6-month follow-up, women in the WHC arm (65.9%, 197/299) were more likely to be sober at the last sex act (OR1.32 (95% CI 1.02 to 1.84)) than women in the Nutrition arm (54.3%, n=82/152). Conclusions This is the first trial among drug-using women in South Africa showing that a brief intervention added to HCT results in greater abstinence from drug use at 12u2005months and a larger percentage of sexual activity not under the influence of substances. Trial registration number NCT00729391 ClinicalTrials.gov

Effectiveness of an Adapted Evidence-Based Woman-Focused Intervention for Sex Workers and Non-Sex Workers: The Women's Health CoOp in South Africa:

South Africas concurrent epidemics of HIV, substance use, and gender-based violence point to the urgent need for interventions that address the intersectional nature of these issues. A community-based randomized trial assessed the efficacy of an adapted evidence-based Woman-Focused HIV intervention addressing all three issues with sex workers and non-sex workers. At 6-month follow-up, non-sex workers in the Woman-Focused intervention reported significantly lower mean numbers of days drinking alcohol in the previous 30 days, were significantly less likely to meet DSM-IV criteria for alcohol dependence, were more likely to report using a condom at last sex with a main partner, and were less likely to report sexual abuse by a main partner in the previous 90 days. Sex workers in the Woman-Focused intervention were significantly less likely to report physical abuse by a main partner. The findings suggest that gender-focused interventions can be effective for vulnerable women and should be offered more broadly.

The relationship of alcohol and other drug use typologies to sex risk behaviors among vulnerable women in Cape Town, South Africa

BACKGROUND: Alcohol and other drug (AOD) use remains an important contributing factor to the spread of HIV in South Africa, mainly because of the strong associations found between AOD use and sex risk behaviors. Specifically, AOD use can lead to disinhibition and impaired judgment that may result in inconsistent condom use and other risky sex behaviors among vulnerable and disempowered women. METHODS: Latent Class Analysis was used to identify AOD use typologies among 720 vulnerable women from a randomized trial baseline assessment in Cape Town, South Africa and to examine whether these AOD use classes predict sex risk for HIV. RESULTS: Three classes emerged with distinct differences in AOD use: the Marijuana and Alcohol class (34.6%) mainly comprised participants who used marijuana and drank alcohol frequently; the High AOD Risk class (26.1%) mainly comprised participants who used methamphetamine and marijuana, reported heavy drinking, and moderate probabilities of Mandrax use; and the Polydrug use class (39.3%) predominately comprised participants who used methamphetamine, marijuana, and Mandrax. Participants in the Marijuana and Alcohol class were less likely to report past-month unprotected sex with their main sex partner compared with participants in the Polydrug Use class. When examining the adjusted model, Black African women were significantly less likely to report past-month unprotected sex with their main sex partner compared with Coloured women. Women who were HIV negative were more likely to report unprotected sex with their main sex partner than women who were HIV positive. CONCLUSION: The fewer substances that women used seemed to serve as protective factors against engaging in AOD-impaired sex. This study provides an important contribution to understand the intersection of AOD use and sexual risk for HIV by measuring polydrug use among vulnerable women and its association with sexual risk taking.

Ethnic differences in alcohol and drug use and related sexual risks for HIV among vulnerable women in Cape Town, South Africa: implications for interventions

BackgroundAlcohol and other drug (AOD) use among poor Black African and Coloured women in South Africa compounds their sexual risk for HIV. Given South Africa’s history of ethnic disparities, ethnic differences in sex risk profiles may exist that should be taken into account when planning HIV risk reduction interventions. This paper aims to describe ethnic differences in AOD use and AOD-related sexual risks for HIV among vulnerable women from Cape Town, South Africa.MethodCross-sectional data on 720 AOD-using women (324 Black African; 396 Coloured) recruited from poor communities in Cape Town were examined for ethnic differences in AOD use and AOD-related sexual risk behavior.ResultsEthnic differences in patterns of AOD use were found; with self-reported drug problems, heavy episodic drinking and methamphetamine use being most prevalent among Coloured women and cannabis use being most likely among Black African women. However, more than half of Black African women reported drug-related problems and more than a third tested positive for recent methamphetamine use. More than a third of women reported being AOD-impaired and having unprotected sex during their last sexual encounter. Coloured women had four-fold greater odds of reporting that their last sexual episode was AOD-impaired and unprotected than Black African women. In addition, close to one in two women reported that their sexual partner was AOD-impaired at last sex, with Coloured women having three-fold greater odds of reporting that their partner was AOD-impaired at last sex than Black African women.ConclusionsFindings support the need to develop and test AOD risk reduction interventions for women from both ethnic groups. In addition, findings point to the need for tailored interventions that target the distinct profiles of AOD use and AOD-related sex risks for HIV among Black African and Coloured women.

Health services utilization among South African women living with HIV and reporting sexual and substance-use risk behaviors.

HIV health services are critical in sub-Saharan African where the burden of the HIV pandemic is devastating. Existing studies suggest that HIV-infected individuals from marginalized populations who know their status do not seek health services because they are unaware of available treatment and care options, may not understand how to access services, or have poor access to and utilization of health care services. This study examined factors associated with health service utilization in a sample of poor, underserved recently diagnosed HIV-positive South African women with sexual and substance use risk behaviors. The data were collected between June 2004 and May 2008. Primary outcomes included consultation with a medical professional and utilization of any health services since learning of HIV status at 3- and 6-month follow-up assessments. The study findings suggest that denial of HIV status may be a barrier to care, leading study participants to avoid utilizing health services specific to their disease and to prefer more general medical care services. In multivariate analyses, prior use of health services, financially supporting others, and sex trading were strongly associated with health service use at follow-up assessments. The study findings suggest a reduced likelihood of health services utilization among participants who met DSM-IV criteria for drug abuse as well as participants with greater numbers of poor physical health symptoms. As an important preliminary step in examining the issue of health services utilization in sub-Saharan Africa, the findings suggest an urgent need to promote HIV prevention and early testing, to strengthen long-term HIV care services, and to increase access to services.

Pregnant and Nonpregnant Women in Cape Town, South Africa: Drug Use, Sexual Behavior, and the Need for Comprehensive Services

The multiple risks associated with methamphetamine use are of serious concern for women. These risks and consequences are magnified during pregnancy. This secondary analysis of a parent study compared 26 pregnant to 356 nonpregnant women in Cape Town, South Africa, on selected demographic, psychosocial, and HIV-risk domains to identify their treatment service needs. Proportionally, more pregnant than nonpregnant women are using methamphetamine, P = .01, although a very high rate of women used methamphetamine. Women reported similar monthly rates of sexual intercourse, but pregnant women were significantly less likely to report condom use, P < .0001, maintaining their risky behavior. Both groups reported elevated Center for Epidemiological Studies Depression Scale CES-D means, suggesting a need for depression treatment. Results demonstrate a pervasive need for womens comprehensive treatment, regardless of pregnancy status. Moreover, findings support the urgent need for women-focused and pregnancy-specific treatment services for methamphetamine use. Finally, a job-skills training/employment component focus is suggested.