A Group Intervention for HIV/STI Risk Reduction among Indian Couples

BACKGROUND

HIV in India is transmitted primarily by heterosexual contact. The present study sought to test the feasibility of a group HIV/STI risk re-duction intervention among heterosexual couples in India.

METHODS

Focus groups and key informant interviews were used in 2008 to cul-turally tailor the intervention. Thirty sexually active and HIV/STI negative cou-ples were enrolled and assessed regarding risk behavior and sexual barrier accept-ability. Gender-concordant group sessions used cognitive behavioral strategies for HIV/STI prevention.

RESULTS

At baseline, male condom use was low (36%); no participants re-ported use of female condoms or vaginal gels. HIV knowledge was low; women had more HIV knowledge and more positive attitudes towards con-dom use than men. Post-intervention, willingness to use all barrier products (t = 10.0, P< .001) and intentions to avoid risk behavior increased (t = 5.62, P< .001).

CONCLUSION

This study illustrates the feasibility of utilizing a group interven-tion to enhance HIV/STI risk reduction among Indian couples.

Translation of a comprehensive health behavior intervention for women living with HIV: the SMART/EST Women's Program

Translation of behavioral interventions into community settings for people living with HIV/AIDS can decrease the risk of comorbid conditions. This study was designed to determine whether a multiple health behavior intervention for women with HIV/AIDS could be effectively translated into community health centers (CHCs), delivered by CHC primary care staff. Health Resources and Services Administration-supported CHCs in Miami, FL, and the New York metropolitan area participated. Six health behavior domains were assessed at baseline, 6 months, and 12 months post-intervention: nutrition, physical activity, sexual risk behavior, alcohol use, drug use, and tobacco use. Behavioral outcomes were compared between research staff-led and CHC staff-led intervention groups. Research staff and CHC staff outcomes were similar for the majority of outcomes. Results indicate that complex, multicomponent behavioral interventions can be translated into community-based settings with existing CHC staff and can produce clinical effects similar to those achieved by research staff.

Efficacy of a lay health worker led group antiretroviral medication adherence training among non-adherent HIV-positive patients in KwaZulu-Natal, South Africa: results from a randomized trial

There is a lack of theory-based randomized controlled trials to examine the effect of antiretroviral adherence in sub-Saharan Africa. We assessed the effectiveness of a lay health worker lead structured group intervention to improve adherence to antiretroviral therapy (ART) in a cohort of HIV-infected adults. This two-arm randomized controlled trial was undertaken at an HIV clinic in a district hospital in South Africa. A total of 152 adult patients on ART and with adherence problems were randomized 1:1 to one of two conditions, a standard adherence intervention package plus a structured three session group intervention or to a standard adherence intervention package alone. Self-reported adherence was measured using the Adult AIDS Clinical Trials Group adherence instrument prior to, post intervention and at follow-up. Baseline characteristics were similar for both conditions. At post-intervention, adherence information knowledge increased significantly in the intervention condition in comparison to the standard of care, while adherence motivation and skills did not significantly change among the conditions over time. There was a significant improvement in ART adherence and CD4 count and a significant reduction of depression scores over time in both conditions, however, no significant intervention effect between conditions was found. Lay health workers may be a useful adjunct to treatment to enhance the adherence information component of the medication adherence intervention, but knowledge may be necessary but not sufficient to increase adherence in this sample. Psychosocial informational interventions may require more advanced skill training in lay health workers to achieve superior adherence outcomes in comparison standard care in this resource-constrained setting.

Reducing the risk of HIV infection during pregnancy among South African women: a randomized controlled trial

Mpumalanga Province, South Africa has one of the highest HIV/AIDS diagnosis rates among pregnant women (~29.4%). This study sought to enhance male involvement in pregnancy to increase HIV disclosure, sexual communication, HIV knowledge and reduce unprotected sex. Participants attending Antenatal Clinics (ANC) completed HIV counseling and testing and were enrolled with male partners (n=239 couples, 478 individuals). Twelve ANCs were randomly assigned to provide a prevention of mother-to-child transmission (PMTCT) intervention or the standard of care, health education sessions plus PMTCT. Participants were assessed at baseline and post-intervention (approximately 6-8 weeks post-baseline) on demographics, sexual behavior, HIV-related knowledge, and conflict resolution strategies. Experimental participants increased HIV knowledge, use of negotiation, and decreased intimate partner violence. Additionally, they were more likely to have increased condom use from baseline to post-intervention (OR=5.1, 95% CI=[2.0, 13.3]). Seroconversions in the control condition exceeded experimental (6 vs. 0). HIV serostatus disclosure to partner did not increase over time for men or women within the experimental or control condition. Male involvement in pregnancy may be an important strategy to reduce sexual risk behavior and HIV transmission. Results support the utility of group interventions to enhance communication and HIV knowledge among pregnant couples.

HIV knowledge and sexual risk behavior among pregnant couples in South Africa: the PartnerPlus project

In sub-Saharan Africa, 60 % of people living with HIV are women and most are of childbearing age. Alarmingly, seroconversion rates during pregnancy are high and increase as pregnancy progresses, highlighting the importance of increasing HIV-knowledge among pregnant women and their partners. This study compared sexual risk behavior, HIV knowledge and condom use pre- to post-partum among South African couples (n = 239 couples) randomly assigned to an intervention or an enhanced standard of care with the PMTCT protocol at rural community health antenatal clinics. Consistent condom use and HIV-related knowledge increased baseline to post-intervention and was maintained at long term follow up post-partum among participants in the intervention condition. HIV knowledge mediated the relationship between the intervention and consistent condom use. Results from this pilot study provide support for the integration of HIV risk reduction interventions for both women and men into existing PMTCT services during and following pregnancy.

Quality of relationship and sexual risk behaviors among HIV couples in Lusaka, Zambia

Relationship quality and partner dynamics provide important insights into understanding sexual behavior within HIV sero-positive and sero-discordant couples. Individuals in long-term partnerships may be vulnerable to HIV/sexually transmitted infections (STI) within their relationships due to misperceptions of their partners risk behaviors and potential concurrent (e.g., extramarital, nonprimary) sexual partnerships. This study sought to examine relationship quality among HIV sero-positive and sero-discordant couples in Zambia, and its association with safer sex behavior. This study utilized data drawn from an ongoing translational study, The Partnership II Project - a couples-based sexual risk reduction intervention in Lusaka, Zambia. Couples (n=240) were assessed on demographics, relationship quality, and sexual risk behavior. Overall, couples perceiving their relationships more positively engaged in less risky sexual behavior (i.e., more condom use (b=0.011, t=3.14, p=0.002) and fewer partners (χ(2)=11.4, p=0.003). Within the dyad, condom use was "actor driven," indicating that the association between relationship quality and condom use did not depend on the partner's evaluation of the relationship. Safer sex behavior was positively influenced by communication about condoms. Results support the paradigm shift from prevention strategies with HIV-positive and at-risk individuals to concentrated efforts addressing male-female dyads, and suggest that interventions to address the role of couples' relationship quality, a modifiable target for decreasing sexual risk behavior, are needed.

Determinants of engagement in HIV treatment and care among Zambians new to antiretroviral therapy

This pilot study assessed the determinants of engagement in HIV care among Zambian patients new to antiretroviral (ARV) therapy, and the effect of an intervention to increase medication adherence. Participants (n = 160) were randomized to a 3-month group or individual intervention utilizing a crossover design. Psychophysiological (depression, cognitive functioning, health status), social (social support, disclosure, stigma), structural factors (health care access, patient-provider communication), and treatment engagement (adherence to clinic visits and medication) were assessed. Participants initially receiving the group intervention improved their adherence, but gains were not maintained following crossover to the individual intervention. Increased social support and patient-provider communication and decreased concern about HIV medications predicted increased clinic attendance across both arms. Results suggest that early participation in a group intervention may promote increased adherence among patients new to ARV therapy, but long-term engagement in care may be sustained by both one-on-one and group interventions by health care staff.

Enhancing HIV medication adherence in India

BACKGROUND

This pilot study evaluated an intervention designed to enhance adherence among those new to antiretroviral therapy.

METHODS

Participants (n = 80) were recruited from a hospital clinic in Chandigarh, India, and randomized to a 3-month group intervention or individual enhanced standard of care followed by crossover of condition and assessed over 6 months. Adherence was measured by prescription refill, pill count, and self-report.

RESULTS

At baseline, 56% of group condition (immediate intervention) and 54% of individual condition (delayed intervention) participants were nonadherent by pill count and 23% of group and 26% of individual condition participants self-reported skipping medication at least once over the last 3 months. From the postintervention to long-term follow-up, adherence in the group condition (immediate intervention) improved in comparison with adherence in the individual condition (delayed intervention; χ(2) = 5.67, P = .02).

CONCLUSIONS

Results support the use of interventions early in treatment to provide information and social support to establish long-term healthy adherence behaviors.

Fantasy baseball: A new way to gamble or just another game?

The controversy over whether fantasy sports should be considered a new form of gambling was investigated. The predominance rule was used to operationally define gambling. This rule states that an activity is gambling if outcomes are due more to chance than to skill. Individuals active in a fantasy baseball league (commonly referred to as "owners") and individuals who had never entered any type of fantasy league ("non-owners") participated. Perceptions of skill-to-chance ratios were assessed and a content analysis of the specific skill and chance features involved in fantasy baseball was conducted. The results showed that fantasy baseball owners and non-owners judged outcomes to be more the result of skill. In an attempt to determine whether these results were supported by actual outcomes, a second study analyzed the records of a fantasy baseball league over an extended period. The findings of this additional study also suggest that skill may predominant over chance.

Promoting male involvement to improve PMTCT uptake and reduce antenatal HIV infection: a cluster randomized controlled trial protocol

BACKGROUND

Despite the availability of a dual therapy treatment protocol and infant feeding guidelines designed to prevent mother to child transmission (PMTCT) of HIV, of the over 1 million babies born in South Africa each year, only 70% of those born to HIV positive mothers receive dual therapy. Similar to other resource-poor nations facing the integration of PMTCT into routine pregnancy and infant care, efforts in South Africa to scale up PMTCT and reduce transmission to < 5% have fallen far short of the United Nation's goal of 50% reductions in paediatric HIV by 80% coverage of mothers.

METHODS/DESIGN

This study proposes to evaluate the impact of combining two evidence-based interventions: a couple's risk reduction intervention with an evidence based medication adherence intervention to enhance male participation in combination with improving medication and PMTCT adherence in antenatal clinics to increase PMTCT overall reach and effectiveness. The study will use a group-randomized design, recruiting 240 couples from 12 clinics. Clinics will be randomly assigned to experimental and control conditions and effectiveness of the combined intervention to enhance PMTCT as well as reduce antenatal seroconversion by both individuals and clinics will be examined.

DISCUSSION

Shared intervention elements may decrease sexual risk and enhance PMTCT uptake, e.g., increased male participation, enhanced communication, HIV counselling and testing, adherence, serostatus disclosure, suggest that a combined sexual risk reduction and adherence intervention plus PMTCT can increase male participation, increase couples' communication and encourage adherence to the PMTCT process. The findings will impact public health and will enable the health ministry to formulate policy related to male involvement in PMTCT, which will result in PMTCT.

TRIAL REGISTRATION

PACTR201109000318329.

The many faces of translational research: a tale of two studies

Translational research can take many forms: bench to bedside, across cultural groups, across geographical boundaries, among others. This case study will share how we addressed all three "translational" issues using two evidence-based studies (USA, Zambia) to illustrate these "roads less traveled." Our implementation and dissemination efforts were anchored by the "train the trainer" strategy, and the Glasgow RE-AIM model provided programmatic guideposts and direction. Keeping all stakeholders (scientific, community, political) involved in the implementation and dissemination process was an essential, perhaps determining factor in the success of the translation process.

A Cultural Perspective on Sexual Health: HIV Positive and Negative Monolingual Hispanic Women in South Florida

This study explored feelings and attitudes with regard to HIV and sexual health among 82 monolingual Spanish-speaking, HIV-positive (n = 30) and at-risk women (n = 52), participating in the NOW en Español Project-a cognitive behavioral sexual risk-reduction intervention in Miami, Florida. Hispanic cultural values and beliefs, such as machismo, marianismo, and sexual silence, emerged throughout the intervention as important determinants of sexual behavior. Recommendations for integrating these culture-specific issues in sexual health interventions for Hispanic women are provided.

Direct imprinting of porous substrates: a rapid and low-cost approach for patterning porous nanomaterials

This work describes a technique for one-step, direct patterning of porous nanomaterials, including insulators, semiconductors, and metals without the need for intermediate polymer processing or dry etching steps. Our process, which we call "direct imprinting of porous substrates (DIPS)", utilizes reusable stamps with micro- and nanoscale features that are applied directly to a porous material to selectively compress or crush the porous network. The stamp pattern is transferred to the porous material with high fidelity, vertical resolution below 5 nm, and lateral resolution below 100 nm. The process is performed in less than one minute at room temperature and at standard atmospheric pressure. We have demonstrated structures ranging from subwavelength optical components to microparticles and present exciting avenues for applications including surface-enhanced Raman spectroscopy (SERS), label-free biosensors, and drug delivery.

The effects of reinvestment of conscious processing on switching focus of attention

The effects of switching focusing strategies on complex motor skill learning were investigated using a dart-throwing task. Participants were screened for reinvestment of conscious processing by completing the Reinvestment Scale (RS) of Masters, Polman, and Hammond (1993). After an initial baseline phase, two focusing strategies were described. Low and high reinvestors were then asked which of the strategies was used during baseline. Regardless of preference, they were requested to change focus. Novice dart-players used either a nonpreferred internal focus (EI), in which they were asked to concentrate on movements of their body, or a nonpreferred external focus (JE), in which they were asked to focus on the effects of their movements. This procedure produced two separate groups, El and 1E. Those scoring low and high on the RS were separated, thus producingfourgroups. Participants in the El high group were the least successful. These results support the findings of earlier studies suggesting that switching to an El is detrimental. Additionally, it appears that high reinvestors switching from a preferred 1E to a nonpreferred El are the most susceptible to unsuccessful performance.

Enhancing the health of women living with HIV: the SMART/EST Women's Project

THE PRINCIPAL OBJECTIVE OF THESE MULTISITE STUDIES (FLORIDA, NEW YORK, NEW JERSEY: epicenters for human immunodeficiency virus [HIV] among women) was to develop and implement effective combinations of behavioral interventions to optimize the health status of the most neglected and understudied population affected by the acquired immunodeficiency syndrome (AIDS) epidemic in the United States: poor women of color living with HIV. The two studies enrolled nearly 900 women randomly assigned to "high intensity" (cognitive-behavioral stress management training combined with expressive-supportive therapy [CBSM]+ group) or "low intensity" (individual psychoeducational program) treatment conditions over a period of 9 years. The initial study of the stress management and relaxation training/expressive-supportive therapy (SMART/EST) Women's Project (SWP I) focused on reducing depression and anxiety, as well as improving self-efficacy and overall quality of life for women with case-defined AIDS. Findings from this study demonstrated the utility of CBSM+ in reducing distress (depression, anxiety) and denial, while improving social support, self-efficacy, coping skills, and quality of life. The second study (SWP II), which included all women living with HIV, extended these findings by demonstrating that exposure to CBSM+ significantly improved the ability of the participants to take advantage of a health behavior change program encouraging the adoption and maintenance of healthier lifestyle behaviors (high levels of medication adherence, appropriate nutritional intake and physical activity, safer sexual practices, and reduced alcohol use/abuse) essential for optimal health in the context of living with HIV. SWP II also determined that the intervention program was equally beneficial to less-acculturated segments of the affected population (ie, non-English speaking HIV+ women) through the creation of culturally and linguistically sensitive Spanish and Creole versions of the program. A third study (SWP III) is currently underway to "translate" this evidence-based treatment program into Community Health Centers in Miami, New York City, and metropolitan New Jersey.

Self-efficacy and distress in women with AIDS: the SMART/EST women's project

Though African American and Hispanic women accounted for 14% of the female population in the USA, they represented 66% of the total HIV/AIDS diagnoses among women in 2007. Among men living with HIV, increased coping self-efficacy (SE) following a cognitive behavioral intervention has been related to decreased distress, anxiety, anger, and confusion, but comparable studies had not been carried out with HIV+ women. The purpose of this study was to examine the impact of changes in SE following a cognitive behavioral stress management plus expressive supportive therapy (CBSM+) intervention on depression and anxiety in low-income urban predominantly minority women living with AIDS. Women (n=451) were randomized to a group CBSM+ or individual informational intervention condition and completed baseline, post-intervention and long-term follow-up (12 months) assessments of depression, anxiety and SE. Women who were assigned to the CBSM+ group condition and increased their level of cognitive behavioral SE reported significant decreases in anxiety and depression at post-intervention and long-term follow-up in comparison with controls who did not improve. Results suggest that both cognitive behavioral skills and a concomitant increase in the perceived level of SE in the use of those skills are predictive of distress reduction.

Acceptability of neonatal circumcision by Hispanics in southern Florida

This study attempted to determine the acceptability of neonatal circumcision in Hispanic expectant and new parents and to explore potential associations with lower acceptability. Overall, we found surprisingly high rates of acceptability in this community that contrasts with the actual low rates of circumcision in Hispanics in the USA. This gap is important since newborn circumcision has been suggested as an additional long-range tool in reducing longstanding ethnic disparities in HIV incidence in the USA. A larger study will be needed to determine what factors are associated with low acceptability and how one might effectively address these concerns in this population.

Making the case for circumcision as a public health strategy: opening the dialogue

Hispanics in the United States have lower rates of male circumcision and higher rates of HIV. Although MC has been demonstrated to reduce the risk of acquisition of several sexual transmitted diseases such as HIV, human papilloma virus infection, and herpes simplex virus type 2, MC is only medically reimbursable by insurance for adults or children following recurrent infection, injury, or malformation of the penis. We conducted two studies of attitudes regarding MC among health care providers to Hispanic clients at Miami, Florida STD and Prenatal Clinics. This study presents qualitative data drawn from intensive interviews with 21 providers, including a mohel. Qualitative data was analyzed for dominant themes and collapsed into overarching themes. Thirteen themes emerged; acceptability, appearance, circumcision and children, circumcision and HIV, cost, cultural differences, health benefits, knowledge and personal experiences, pain and injury to the penis, perceived HIV risk, religion, sexual performance, and sexual pleasure. Except for the mohel, Hispanic male providers related MC acceptability to American Pediatric Association guidelines, personal circumcision status, and were skeptical regarding health benefits for sexually transmitted disease (STD)/HIV risk reduction. Female providers focused on the financial burden to parents, lack of information, and low acceptability among Hispanic men. This study illustrates the differing attitudes on circumcision held by providers, and suggests that gender, culture, cost, and providers themselves may limit MC acceptability among Hispanic clients. Results suggest that promotion of MC as an HIV risk reduction strategy must begin with the support of medical practitioners to promote the endorsement of MC as a prevention strategy.

Influencing medication adherence among women with AIDS

This study examined the effects of a ten-session cognitive-behavioural stress management/expressive supportive therapy (CBSM+) intervention on adherence to antiretroviral medication. Although the intervention was not designed to influence adherence, it was theorized that improved coping and social support could enhance adherence. Women with AIDS (N = 174) in Miami, New York and New Jersey, USA, were randomized to a group CBSM+ intervention or individual control condition. Participants were African American (55%), Latina (18%) and Caribbean (18%) with drug (55%) and/or alcohol (32%) histories. Participants were assessed on self-reported medication adherence over seven days, HIV-related coping strategies and beliefs regarding HIV medication. Baseline overall self-reported adherence rates were moderate and related to coping strategies and HIV medication beliefs. Low adherent (80%) participants in the intervention condition increased their mean self-reported medication adherence (30.4% increase, t44 = 3.1, p < 0.01), whereas low adherent women in the control condition showed a non-significant trend (19.6% increase, t44 = 2.0, p > 0.05). The intervention did not improve adherence in this population; conditions did not differ significantly on self-reported adherence. Low adhering intervention participants significantly decreased levels of denial-based coping (F1,88 = 5.97, p < 0.05). Results suggest that future interventions should utilize group formats and address adherence using coping and medication-knowledge focused strategies.

Mental health in HIV seronegative and seropositive IDUs in South Florida

About one-third of HIV-infected people in the USA have a history of injection-drug use. Injecting drugs are a primary vector for HIV transmission. Drug and alcohol use are significant contributors to sexual transmission of the virus. In South Florida, urban injection-drug users (IDUs) represent a substantial population at risk for infection. Substance use management in this group is critical. As part of a larger study of at-risk populations in South Florida, we examined mental health differences among IDUs (n=117), HIV seropositive IDUs (n=130), and HIV seronegative non-IDUs (n=169). We explored factors associated with depression and anxiety between groups, and found HIV seronegative and seropositive IDUs not receiving antiretroviral (ARV) treatment to have poorer overall mental health than both HIV seropositive participants on ARVs and non-IDU participants. Our data support systems enhancement to meet the various psychosocial and health care needs among IDUs and highlight the need for resource allocation to target community-based integrated mental health services in urban populations. In addition, our data underscore the need for primary and secondary HIV prevention interventions to address the drug-use risk behaviors among IDUs to reduce the likelihood of HIV infection and transmission in this population.

Violence, coping, and consistent medication adherence in HIV-positive couples

The purpose of this study was to investigate the extent to which intimate partner violence (IPV) influences antiretroviral medication adherence. Furthermore, it was hypothesized that adherence would differ for men and women based on degree of violence and coping strategies employed by each gender. A sample of HIV seroconcordant and serodiscordant heterosexual couples was recruited from the Miami area and assessed on rates of medication adherence, conflict resolution tactics, and coping strategies. Of these, 190 individual participants were prescribed antiretroviral medication. Baseline rates of adherence were 90.29% for men and 87.77% for women. Acts of violence were found to have negative effects on adherence for women but not for men. However, negative coping strategies were predictive of poor adherence for men but not women. Violence was found to be related to poor coping styles for both men and women. This study offers support for the inclusion of partners in conducting interventions. Furthermore, it underlines the importance of recognizing IPV as a barrier to medication adherence.

Sexual risk reduction among Zambian couples

Zambia has over 1 million HIV infections nationwide and an urban prevalence rate of 23%. This study compared the impact of male involvement in multiple and single session risk reduction interventions among inconsistent condom users in Zambia and the role of serostatus among HIV-seropositive and serodiscordant couples. Couples (N=392) were randomised into intervention arms. Among inconsistent condom users at baseline (N=83), condom use increased in both conditions and this increase was maintained over a 12- month period. At 12 months, seronegative men in the multiple session condition increased sexual barrier (male and female condoms) use in comparison with those in the single session condition (F=16.13, =0.001) while seropositive individuals increased sexual barrier use regardless of condition. Results illustrate the importance of both single and multiple session risk reduction counseling among seronegative men in serodiscordant couples in Zambia, and highlight the differing perception of risk between seropositive and serodiscordant persons.