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Callands TA, Taylor EN, Sileo KM, Gilliam SM, Hansen NB. Understanding the Effects of Trauma Exposure, Life Stress, Intimate Partner Violence, and Depression on Sexually Transmitted Infection Risk in Post-Conflict Liberia. ARCHIVES OF SEXUAL BEHAVIOR 2024; 53:1519-1530. [PMID: 38167991 DOI: 10.1007/s10508-023-02765-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/23/2021] [Revised: 09/29/2023] [Accepted: 11/27/2023] [Indexed: 01/05/2024]
Abstract
In sub-Saharan Africa, sexually transmitted infections (STIs) are a public health concern. The impact of STIs are exacerbated in post-conflict low- and middle-income countries, such as Liberia, where exposure to traumatic events is prevalent and access to mental health services are limited. Following a syndemics framework, this study used regression analyses to explore the independent, additive, and multiplicative effects of four psychosocial conditions (exposure to war-related traumatic events, intimate partner violence [IPV], stressful life events, and depressive symptoms) on self-reported STIs. Data were collected from 379 youth aged 18-30 years (n = 170 women; n = 179 men) in Montserrado County, Liberia. Results revealed that psychosocial variables correlated with each other and STI risk. In multivariable analysis, stressful life events, depressive symptoms, and IPV were statistically significant predictors of STI risk. We found support for an additive effect between the number of psychosocial conditions reported and STI risk, as well as a multiplicative effect (interaction) between IPV and depressive symptoms on STI risk. Our results suggest a synergy between experiencing psychosocial conditions and STI risk and point to the potential benefit of multi-level sexual health approaches that simultaneously address mental health and IPV among youth in Liberia.
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Affiliation(s)
- Tamora A Callands
- Department of Health Promotion and Behavior, College of Public Health, University of Georgia, Athens, GA, 30602, USA.
| | - Erica N Taylor
- Department of Health Promotion and Behavior, College of Public Health, University of Georgia, Athens, GA, 30602, USA
| | - Katelyn M Sileo
- Department of Public Health, College for Health, Community and Policy, The University of Texas at San Antonio, San Antonio, TX, USA
| | | | - Nathan B Hansen
- Department of Health Promotion and Behavior, College of Public Health, University of Georgia, Athens, GA, 30602, USA
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2
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Lee JS, Bainter SA, Tsai AC, Andersen LS, Stanton AM, Magidson JF, Kagee A, Joska JA, O'Cleirigh C, Safren SA. Intersecting Relationships of Psychosocial and Structural Syndemic Problems Among People with HIV in South Africa: Using Network Analysis to Identify Influential Problems. AIDS Behav 2023; 27:1741-1756. [PMID: 36309936 PMCID: PMC10148921 DOI: 10.1007/s10461-022-03906-z] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/15/2022] [Indexed: 11/27/2022]
Abstract
In South Africa, little is known about interrelationships between syndemic problems among people with HIV (PWH). A better understanding of syndemic problems may yield important information regarding factors amenable to mitigation. We surveyed 194 PWH in Khayelitsha, outside of Cape Town, South Africa. We used network analysis to examine the frequency of 10 syndemic problems and their interrelationships. Syndemic problems among PWH in South Africa were common; 159 (82.8%) participants reported at least 2 co-occurring syndemic problems and 90 (46.9%) endorsed 4 or more. Network analysis revealed seven statistically significant associations. The most central problems were depression, substance use, and food insecurity. Three clusters of syndemics were identified: mood and violence; structural factors; and behavioral factors. Depression, substance use, and food insecurity commonly co-occur among PWH in sub-Saharan Africa and interfere with HIV outcomes. Network analysis can identify intervention targets to potentially improve HIV treatment outcomes.
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Affiliation(s)
- Jasper S Lee
- Behavioral Medicine Program, Department of Psychiatry, Massachusetts General Hospital, One Bowdoin Sq, 7th Floor, Boston, MA, 02114, USA.
- Department of Psychiatry, Harvard Medical School, Boston, MA, USA.
| | - Sierra A Bainter
- Department of Psychology, University of Miami, Coral Gables, FL, USA
| | - Alexander C Tsai
- Center for Global Health and Mongan Institute, Massachusetts General Hospital, Boston, MA, USA
- Harvard Medical School, Boston, MA, USA
| | - Lena S Andersen
- Global Health Section, Department of Public Health, University of Copenhagen, Copenhagen, Denmark
| | | | | | - Ashraf Kagee
- Department of Psychology, Stellenbosch University, Stellenbosch, Western Cape, South Africa
| | - John A Joska
- HIV Mental Health Research Unit, Division of Neuropsychiatry, Department of Psychiatry and Mental Health, Neuroscience Institute, University of Cape Town, Cape Town, South Africa
| | - Conall O'Cleirigh
- Behavioral Medicine Program, Department of Psychiatry, Massachusetts General Hospital, One Bowdoin Sq, 7th Floor, Boston, MA, 02114, USA
- Department of Psychiatry, Harvard Medical School, Boston, MA, USA
| | - Steven A Safren
- Department of Psychology, University of Miami, Coral Gables, FL, USA
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3
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Closson K, Nicholson V, Lee M, McLinden T, Cassidy-Matthews C, G Card K, E Marziali M, Trigg J, Wang L, Parashar S, S G Montaner J, Gibbs A, Hart TA, Kaida A, Hogg RS. Associations between psychosocial factors and antiretroviral therapy outcomes differ by gender and sexual orientation among people living with HIV in British Columbia, Canada. AIDS Care 2023; 35:296-305. [PMID: 36169492 DOI: 10.1080/09540121.2022.2126959] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/14/2022]
Abstract
Little is known about how the co-occurrence of psychosocial factors affect sub-populations of people living with HIV (PLWH). We used cross-sectional data from 999 PLWH, aged ≥19, accessing antiretroviral therapy (ART) in British Columbia, Canada (2007-2010) to examine associations between psychosocial factors and ART-related outcomes separately for trans/cis inclusive women; heterosexual men; and gay, bisexual, and other men who have sex with men (gbMSM). Multivariable logistic regression examined associations between psychosocial factors (0-3): any violence in the past 6 months, depressive symptoms in the past week, and current street drug use (heroin, crack, meth or speedball) with sub-optimal adherence (outcome 1: average annual ART adherence <95% from interview until end of follow-up, death, or December 31st, 2018) and ever viral rebound (outcome 2) adjusting for potential confounders. Of 999 PLWH (264 women, 382 heterosexual men, and 353 gbMSM), women and heterosexual men had significantly higher median counts than gbMSM. Overall, higher counts were associated with sub-optimal adherence (adjusted odds ratio [aOR] = 1.26/1-unit increase, 95%CI = 1.07-1.49). All effect estimates were of a greater magnitude among gbMSM, but not significant for women or heterosexual men, highlighting the need for population (e.g., gender and sexual orientation)-centered care and research.
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Affiliation(s)
- Kalysha Closson
- School of Population and Public Health, University of British Columbia, Vancouver, Canada
- British Columbia Centre for Excellence in HIV/AIDS, Vancouver, Canada
| | - Valerie Nicholson
- British Columbia Centre for Excellence in HIV/AIDS, Vancouver, Canada
- Faculty of Health Sciences, Simon Fraser University, Burnaby, Canada
| | - Melanie Lee
- Faculty of Health Sciences, Simon Fraser University, Burnaby, Canada
| | - Taylor McLinden
- British Columbia Centre for Excellence in HIV/AIDS, Vancouver, Canada
| | | | - Kiffer G Card
- School of Public Health and Social Policy, University of Victoria, Victoria, Canada
| | - Megan E Marziali
- British Columbia Centre for Excellence in HIV/AIDS, Vancouver, Canada
- Department of Epidemiology, Mailman School of Public Health, Columbia University, New York, NY, USA
| | - Jason Trigg
- British Columbia Centre for Excellence in HIV/AIDS, Vancouver, Canada
| | - Lu Wang
- British Columbia Centre for Excellence in HIV/AIDS, Vancouver, Canada
| | - Surita Parashar
- British Columbia Centre for Excellence in HIV/AIDS, Vancouver, Canada
- Faculty of Health Sciences, Simon Fraser University, Burnaby, Canada
| | | | - Andrew Gibbs
- South African Medical Research Council, Gender and Health Unit, Durban, South Africa
- Centre for Rural Health, School of Nursing and Public Health, University of KwaZulu-Natal (UKZN), Durban, South Africa
| | - Trevor A Hart
- Department of Psychology, Ryerson University, Toronto, Canada
- Dalla Lana School of Public Health, University of Toronto, Toronto, Canada
| | - Angela Kaida
- Faculty of Health Sciences, Simon Fraser University, Burnaby, Canada
| | - Robert S Hogg
- British Columbia Centre for Excellence in HIV/AIDS, Vancouver, Canada
- Faculty of Health Sciences, Simon Fraser University, Burnaby, Canada
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4
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Logie CH, Okumu M, Malama K, Mwima S, Hakiza R, Kiera UM, Kyambadde P. Examining the substance use, violence, and HIV and AIDS (SAVA) syndemic among urban refugee youth in Kampala, Uganda: cross-sectional survey findings. BMJ Glob Health 2022; 7:bmjgh-2021-006583. [PMID: 35798442 PMCID: PMC9263932 DOI: 10.1136/bmjgh-2021-006583] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2021] [Accepted: 03/07/2022] [Indexed: 11/25/2022] Open
Abstract
Background Interactions between substance use, violence, HIV and AIDS, known as the ‘SAVA’ syndemic, are understudied among refugee youth. We assessed the synergistic effects of frequent alcohol use, depression and violence on HIV vulnerability among urban refugee youth aged 16–24 years in Kampala, Uganda. Methods We conducted a cross-sectional survey between January and April 2018 with a convenience sample of refugee youth aged 16–24 years living in informal settlements in Kampala (Kabalagala, Rubaga, Kansanga, Katwe, Nsambya). We assessed non-communicable health conditions (frequent [≥3 times per week] alcohol use [FAU]; depression); violence (young adulthood violence [YAV] at age ≥16 years, intimate partner violence [IPV]), and HIV vulnerability (past 12-month transactional sex; recent [past 3-month] multiple [≥2] sex partners). We calculated the prevalence and co-occurrence of non-communicable health conditions, violence and HIV vulnerability variables. We then conducted multivariable logistic regression analyses to first create unique profiles of FAU, depression, YAV and IPV exposures, and second to assess for interactions between exposures on HIV vulnerability outcomes. Results Most participants (n=445; mean age: 19.59, SD: 2.6; women: n=333, 74.8%, men: n=112, 25.2%) reported at least one non-communicable health condition or violence exposure (n=364, 81.8%), and over half (n=278, 62.4%) reported co-occurring exposures. One-fifth reported FAU (n=90; 20.2%) and one-tenth (n=49; 11%) major depression. In logistic regression models including all two-way product terms, adjusted for sociodemographics, we found (a) multiplicative interaction for joint effects of FAU and IPV (adjusted OR (aOR)=4.81, 95% CI: 1.32 to 17.52) on multiple sex partners, and (b) multiplicative interaction for joint effects of FAU and IPV (aOR=3.72, 95% CI: 1.42 to 9.74), and YAV and depression (aOR=7.13, 95% CI: 1.34 to 37.50), on transactional sex. Conclusion Findings signal the importance of addressing the SAVA syndemic among urban refugee youth in Uganda. Synergistic interactions indicate that addressing FAU, depression or violence may concomitantly reduce HIV vulnerability with urban refugee youth.
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Affiliation(s)
- Carmen H Logie
- Factor-Inwentash Faculty of Social Work, University of Toronto, Toronto, Ontario, Canada .,Centre for Gender and Sexual Health Equity, Vancouver, British Columbia, Canada.,Women's College Research Institute, Women's College Hospital, Toronto, Ontario, Canada.,United Nations University Institute for Water, Environment & Health, Hamilton, Ontario, Canada
| | - Moses Okumu
- School of Social Work, University of Illinois at Urbana-Champaign, Urbana, Illinois, USA.,School of Social Science, Uganda Christian University, Mukono, Uganda
| | - Kalonde Malama
- Factor-Inwentash Faculty of Social Work, University of Toronto, Toronto, Ontario, Canada
| | - Simon Mwima
- School of Social Work, University of Illinois at Urbana-Champaign, Urbana, Illinois, USA.,National AIDS Coordinating Program, Uganda Ministry of Health, Kampala, Uganda
| | - Robert Hakiza
- Young African Refugees for Integral Development, Kampala, Uganda
| | - Uwase Mimy Kiera
- Young African Refugees for Integral Development, Kampala, Uganda
| | - Peter Kyambadde
- National AIDS Coordinating Program, Uganda Ministry of Health, Kampala, Uganda.,Most At Risk Population Initiative (MARPI), Mulago National Referral Hospital, Kampala, Uganda
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5
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Lemke MK, Wolf DA, Drake SA. A Call for Complex Systems and Syndemic Theory in Firearm Violence Research. Am J Prev Med 2022; 62:459-465. [PMID: 34879969 DOI: 10.1016/j.amepre.2021.08.026] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/03/2021] [Revised: 07/27/2021] [Accepted: 08/18/2021] [Indexed: 11/01/2022]
Affiliation(s)
- Michael K Lemke
- Department of Social Sciences, College of Humanities and Social Sciences, University of Houston-Downtown, Houston, Texas.
| | - Dwayne A Wolf
- Medical Examiner's Office, Harris County Institute of Forensic Sciences, Houston, Texas
| | - Stacy A Drake
- College of Nursing, Texas A&M University, Houston, Texas
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6
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JOSEPH DAVEY DL, LE ROUX SM, BRITTAIN K, DOVELL K, SHOPTAW S, Miller AP, PHILLIPS TK, ZERBE A, ABRAMS EJ, MYER L. Alcohol use and intimate partner violence in HIV-uninfected pregnant women in Cape Town, South Africa. AIDS Care 2022; 34:214-219. [PMID: 34495777 PMCID: PMC8857014 DOI: 10.1080/09540121.2021.1975626] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
In settings with a high burden of HIV, pregnant women often experience a cluster of risk factors, including alcohol use and intimate partner violence (IPV). These interrelated risks are poorly understood among pregnant women at risk of HIV in sub-Saharan Africa. We aim to determine cross-sectional associations between pregnant women's alcohol use and victimization due to IPV in the HIV-Unexposed-Uninfected Mother-Infant Cohort Study in Cape Town, South Africa. Women who tested HIV-negative at first antenatal care (ANC) visit were followed to delivery. Trained interviewers collected demographic and psychosocial information, including recent alcohol use and experiences of IPV victimization. We assess the prevalence of alcohol use and associations with IPV using multivariable logistic regression. In 406 HIV-uninfected pregnant women (mean age = 28 years; mean gestational age = 21 weeks), 41 (10%) reported alcohol consumption in the past 12 months; 30/41 (73%) of these at hazardous levels. Any and hazardous alcohol use were associated with greater odds of reporting past year IPV (adjusted odds ratio [aOR] for hazardous use: 3.24, 95% CI = 1.11, 7.56; aOR for any alcohol use: 2.97, 95% CI = 1.19, 7.45). These data suggest the occurrence of overlapping HIV risk factors among pregnant women and may help design improved health interventions in this population.
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Affiliation(s)
- Dvora L. JOSEPH DAVEY
- Department of Epidemiology, Fielding School of Public Health, University of California, Los Angeles, US,Division of Epidemiology and Biostatistics, School of Public Health and Family Medicine, University of Cape Town, South Africa
| | - Stanzi M. LE ROUX
- Division of Epidemiology and Biostatistics, School of Public Health and Family Medicine, University of Cape Town, South Africa
| | - Kirsty BRITTAIN
- Division of Epidemiology and Biostatistics, School of Public Health and Family Medicine, University of Cape Town, South Africa
| | - Kathryn DOVELL
- Division of Infectious Diseases, Geffen School of Medicine, University of California, Los Angeles, US
| | - Steve SHOPTAW
- Department of Family Medicine, Geffen School of Medicine, University of California, Los Angeles, US,Department of Psychiatry, University of Cape Town, South Africa
| | - Amanda P. Miller
- Division of Epidemiology and Biostatistics, School of Public Health and Family Medicine, University of Cape Town, South Africa
| | - Tamsin K. PHILLIPS
- Division of Epidemiology and Biostatistics, School of Public Health and Family Medicine, University of Cape Town, South Africa
| | - Allison ZERBE
- Department of Psychiatry, University of Cape Town, South Africa
| | - Elaine J. ABRAMS
- Department of Psychiatry, University of Cape Town, South Africa,ICAP at Columbia University, Mailman School of Public Health, Columbia University, New York, US,Vagelos College of Physicians and Surgeons, Columbia University, New York, US
| | - Landon MYER
- Division of Epidemiology and Biostatistics, School of Public Health and Family Medicine, University of Cape Town, South Africa
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7
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Differences in Access to HIV Services and Risky Sexual Behaviors Among Malawian Women at Social Venues Who Do and Do Not Engage in Sex Work. AIDS Behav 2021; 25:2920-2928. [PMID: 33987782 DOI: 10.1007/s10461-021-03289-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/23/2021] [Indexed: 10/21/2022]
Abstract
In the high HIV-burden country of Malawi, female sex workers (FSW) are one of the populations most profoundly affected by HIV. The Malawi Priorities for Local AIDS Control Efforts (PLACE) surveyed 1,004 self-identified FSW, 213 other FSW (OFSW), and 130 other high risk women (OHRW) at social venues. Analyses compared the three groups using survey-weighted log binomial regression models. Each group had a distinct pattern of usage and access to services: OFSW and FSW had greater access to condoms, while using a condom ever was greatest among FSW. Nearly all women knew where to get tested for HIV but very few used FSW drop-in centers. HIV prevalence was high in all three groups (35% FSW, 20% OFSW, 20% OHRW). Given these results, HIV services should be targeted to all women at social venues in Malawi, regardless of sex worker status to improve health outcomes and limit onward transmission of HIV.
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8
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Transactional Sex, Alcohol Use and Intimate Partner Violence Against Women in the Rakai Region of Uganda. AIDS Behav 2021; 25:1144-1158. [PMID: 33128109 DOI: 10.1007/s10461-020-03069-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/21/2020] [Indexed: 01/30/2023]
Abstract
Transactional sex (TS) is prevalent in sub-Saharan Africa. Women's engagement in TS is linked with HIV infection; little is known about the relationship between TS, intimate partner violence (IPV) and alcohol use-established HIV risk behaviors. Using modified Poisson regression, we assessed associations between TS and physical, verbal and sexual IPV among 8248 women (15-49 years) who participated in the Rakai Community Cohort Study across forty communities in Uganda. An interaction term assessed moderation between alcohol use and TS and no significant interaction effects were found. In adjusted analysis, alcohol use and TS were significantly associated with all forms of IPV. In stratified analysis, TS was only associated with IPV in agrarian communities; alcohol use was not associated with physical IPV in trade communities or sexual IPV in trade and fishing communities. Identifying differences in IPV risk factors by community type is critical for the development of tailored interventions.
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9
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Couture MC, Evans JL, Draughon Moret J, Stein ES, Muth S, Phou M, Len A, Ngak S, Sophal C, Neak Y, Carrico AW, Maher L, Page K. Syndemic Psychosocial Health Conditions Associated with Recent Client-Perpetrated Violence Against Female Entertainment and Sex Workers in Cambodia. ARCHIVES OF SEXUAL BEHAVIOR 2020; 49:3055-3064. [PMID: 32342257 PMCID: PMC7935451 DOI: 10.1007/s10508-020-01705-y] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/27/2018] [Revised: 03/30/2020] [Accepted: 04/01/2020] [Indexed: 05/23/2023]
Abstract
Female entertainment and sex workers (FESW) are vulnerable to violence, which impedes safer sex behaviors and increases risk of HIV. FESW are also disproportionately affected by co-occurring psychosocial health conditions, including substance use, depression, and economic insecurity, which increased risk of exposure to violence. We used a syndemic framework to examine the effects of co-occurring psychosocial conditions on the risk of client-perpetrated physical and sexual violence against FESW. Data were collected among 1198 Cambodian FESW on recent client-perpetrated physical and sexual violence, and psychosocial conditions (psychological distress, alcohol consumption, amphetamine-type stimulant (ATS) use, debts, housing, and food insecurity). Bivariate and multivariate logistic regressions were conducted. Prevalence of physical and sexual violence from clients was 4.8% and 6.9%, respectively. Client-perpetrated physical violence was associated with housing insecurity, ATS use, and psychological distress. All psychosocial conditions, except ATS, were associated with exposure to sexual violence. In multivariable models, odds of client-perpetrated physical violence were twice higher among women with ≥ 4 compared to ≤ 3 psychosocial conditions. Risk of sexual violence increased with the number of psychosocial conditions. Compared to those with ≤ 1 condition, FESW with two psychosocial conditions had twice the odds (AOR = 2.08; 95% CI 1.00-4.31) and women with 5-6 psychosocial conditions had eightfold higher odds (AOR = 8.10; 95% CI 3.4-19.31) of sexual violence from clients. Our findings support a syndemic model of co-occurring psychosocial conditions among FESW that are associated with increased risk of violence. Violence prevention interventions targeting FESW should adopt comprehensive approaches that address co-occurring psychosocial conditions.
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Affiliation(s)
- Marie-Claude Couture
- Department of Population Health Sciences, School of Nursing and Health Professions, University of San Francisco, 2130 Fulton, San Francisco, CA, 94117, USA.
| | - Jennifer L Evans
- Institute for Global Health Sciences, University of California San Francisco, San Francisco, CA, USA
| | - Jessica Draughon Moret
- The Betty Irene Moore School of Nursing, University of California Davis, Sacramento, CA, USA
| | - Ellen S Stein
- Institute for Global Health Sciences, University of California San Francisco, San Francisco, CA, USA
| | | | | | | | | | - Chhit Sophal
- Department of Mental Health and Substance Abuse, Ministry of Health, Phnom Penh, Cambodia
| | - Yuthea Neak
- National Authority for Combating Drugs, Phnom Penh, Cambodia
| | - Adam W Carrico
- Department of Public Health Sciences, University of Miami School of Medicine, Miami, FL, USA
| | - Lisa Maher
- Kirby Institute for Infection and Immunity, UNSW Sydney, Sydney, NSW, Australia
| | - Kimberly Page
- Division of Epidemiology, Biostatistics and Preventive Medicine, Department of Internal Medicine, University of New Mexico Health Sciences Center, Albuquerque, NM, USA
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10
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Willie TC, Kershaw TS, Blackstock O, Galvao RW, Safon CB, Tekeste M, Ogburn DF, Wilbourn B, Modrakovic D, Taggart T, Kaplan C, Caldwell A, Calabrese SK. Racial and ethnic differences in women's HIV risk and attitudes towards pre-exposure prophylaxis (PrEP) in the context of the substance use, violence, and depression syndemic. AIDS Care 2020; 33:219-228. [PMID: 32408837 DOI: 10.1080/09540121.2020.1762067] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
Women with syndemic conditions, i.e., two or more co-occurring epidemics, are at elevated risk for HIV acquisition and are therefore prime candidates for pre-exposure prophylaxis (PrEP). However, PrEP uptake remains low among women, especially among Black and Hispanic women. This study examined associations of syndemic conditions with PrEP attitudes and HIV risk among women, and the moderating effect of race and ethnicity. In 2017, 271 non-Hispanic Black, non-Hispanic White, and Hispanic, PrEP-eligible women engaged in care at Planned Parenthood in the northeastern region of the U.S. completed an online survey. Participants reported syndemic conditions (i.e., intimate partner violence, depression, substance use), PrEP attitudes (e.g., PrEP interest), HIV sexual risk (e.g., multiple male sexual partners), and sociodemographics. Structural equation modeling was used to examine the effects of syndemic conditions on PrEP attitudes and HIV risk, and the moderating effect of race and ethnicity. Women with more syndemic conditions had a higher odds of reporting multiple male sexual partners. Syndemic conditions were positively associated with PrEP attitudes for Hispanic women than non-Hispanic Black and White women. Women with syndemic conditions, particularly Hispanic women, may be receptive to interventions promoting PrEP.
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Affiliation(s)
- Tiara C Willie
- Department of Mental Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Trace S Kershaw
- Department of Social and Behavioral Sciences, Yale School of Public Health, New Haven, CT, USA
| | - Oni Blackstock
- New York City Department of Health & Mental Hygiene, New York, NY, USA
| | - Rachel W Galvao
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Cara B Safon
- Department of Social and Behavioral Sciences, Yale School of Public Health, New Haven, CT, USA.,Department of Health Law, Policy, and Management, Boston University, Boston, MA, USA
| | - Mehrit Tekeste
- Department of Psychological and Brain Sciences, George Washington University, Washington, DC, USA
| | - Damon F Ogburn
- National Center for Health Statistics, Centers for Disease Control and Prevention, Atlanta, GA, USA
| | - Brittany Wilbourn
- Department of Epidemiology and Biostatistics, George Washington University, Washington, DC, USA
| | - Djordje Modrakovic
- Department of Psychological and Brain Sciences, George Washington University, Washington, DC, USA
| | - Tamara Taggart
- Department of Social and Behavioral Sciences, Yale School of Public Health, New Haven, CT, USA.,Department of Prevention and Community Health, Milken Institute School of Public Health, George Washington University, Washington, DC, USA
| | - Clair Kaplan
- Planned Parenthood of Southern New England, New Haven, CT, USA
| | | | - Sarah K Calabrese
- Department of Psychological and Brain Sciences, George Washington University, Washington, DC, USA.,Department of Prevention and Community Health, Milken Institute School of Public Health, George Washington University, Washington, DC, USA
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11
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Abstract
The aim of the present study is to use the syndemic framework to investigate the risk of contracting HIV in the US population. Cross-sectional analyses are from The National Health and Nutrition Examination Survey. We extracted and aggregated data on HIV antibody test, socio-demographic characteristics, alcohol use, drug use, depression, sexual behaviours and sexually transmitted diseases from cycle 2009-2010 to 2015-2016. We carried out weighted regression among young adults (20-39 years) and adults (40-59 years) separately. In total, 5230 men and 5794 women aged 20-59 years were included in the present analyses. In total, 0.8% men and 0.2% women were tested HIV-positive. Each increasing HIV risk behaviour was associated with elevated odds of being tested HIV-positive (1.15, 95% CI 1.15-1.15) among young adults and adults (1.61, 95% CI 1.61-1.61). Multi-faceted, community-based interventions are urgently required to reduce the incidence of HIV in the USA.
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12
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Velloza J, Njoroge J, Ngure K, Thuo N, Kiptinness C, Momanyi R, Ayub S, Gakuo S, Mugo N, Simoni J, Heffron R. Cognitive testing of the PHQ-9 for depression screening among pregnant and postpartum women in Kenya. BMC Psychiatry 2020; 20:31. [PMID: 31996166 PMCID: PMC6990517 DOI: 10.1186/s12888-020-2435-6] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/08/2019] [Accepted: 01/08/2020] [Indexed: 12/14/2022] Open
Abstract
BACKGROUND African women face high rates of depression, particularly during pregnancy or postpartum or after a recent HIV diagnosis. The Patient Health Questionnaire-9 (PHQ-9) depression screening tool has been quantitatively validated and extensively used to identify depression and link individuals to care. However, qualitative work is necessary to identify important opportunities to improve PHQ-9 question comprehension and performance among Kenyan women. METHODS We administered the Kiswahili or English PHQ-9 (based on preference) to 29 pregnant and postpartum women in Thika, Kenya. Following administration, we conducted cognitive interviews with a purposive sample of 20 women. We used analytic memos and data matrices to identify themes around scale acceptability, comprehension, and decision and response processes. RESULTS Most participants preferred to answer the PHQ-9 in Kiswahili (N = 15; 52%). Among the 20 interview participants, 12 (60%) had scores ≥5, indicating depressive symptoms. Overall, participants found the scale acceptable as an interviewer-administered tool. Participants reported few problems related to comprehension but had difficulty answering items not relevant to their lives (e.g., "watching television") and double-barreled items (e.g., "poor appetite or overeating"). They were hesitant to endorse items related to "duties as a wife and mother" and suicidal ideation. Most participants had difficulty distinguishing between response options of "several days" and "more than half the days". CONCLUSIONS We detected several problems related to PHQ-9 comprehension, decision processes, and response processes. We provide recommended changes to instructions and item wording to improve PHQ-9 validity among Kenyan women.
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Affiliation(s)
- Jennifer Velloza
- Department of Global Health, University of Washington, Seattle, USA. .,Department of Epidemiology, University of Washington, Seattle, USA. .,International Clinical Research Center, University of Washington, Box 359927, 325 Ninth Avenue, Seattle, WA, 98104, USA.
| | - John Njoroge
- Partners in Health and Research Development, Nairobi, Kenya
| | - Kenneth Ngure
- 0000 0000 9146 7108grid.411943.aDepartment of Community Health Jomo Kenyatta University of Agriculture and Technology, Nairobi, Kenya
| | - Nicholas Thuo
- Partners in Health and Research Development, Nairobi, Kenya
| | | | | | - Snaidah Ayub
- Partners in Health and Research Development, Nairobi, Kenya
| | - Stephen Gakuo
- Partners in Health and Research Development, Nairobi, Kenya
| | - Nelly Mugo
- 0000000122986657grid.34477.33Department of Global Health, University of Washington, Seattle, USA ,Partners in Health and Research Development, Nairobi, Kenya ,0000 0001 0155 5938grid.33058.3dCenter for Clinical Research, Kenya Medical Research Institute, Nairobi, Kenya
| | - Jane Simoni
- 0000000122986657grid.34477.33Department of Global Health, University of Washington, Seattle, USA ,0000000122986657grid.34477.33Department of Psychology, University of Washington, Seattle, USA
| | - Renee Heffron
- 0000000122986657grid.34477.33Department of Global Health, University of Washington, Seattle, USA ,0000000122986657grid.34477.33Department of Epidemiology, University of Washington, Seattle, USA
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Raggio GA, Psaros C, Fatch R, Goodman G, Matthews LT, Magidson JF, Amanyire G, Cross A, Asiimwe S, Hahn JA, Haberer JE. High Rates of Biomarker-Confirmed Alcohol Use Among Pregnant Women Living With HIV in South Africa and Uganda. J Acquir Immune Defic Syndr 2019; 82:443-451. [PMID: 31567551 PMCID: PMC6857734 DOI: 10.1097/qai.0000000000002156] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2019] [Accepted: 07/22/2019] [Indexed: 01/06/2023]
Abstract
BACKGROUND Alcohol use is common among people living with HIV and particularly harmful during pregnancy. However, objective data on alcohol use in pregnant women living with HIV (WLWH) are lacking. In areas with high levels of alcohol use generally, such as South Africa and Uganda, these data are needed to inform interventions. METHODS Pregnant and nonpregnant, antiretroviral therapy-naive WLWH were recruited from outpatient clinics in South Africa and Uganda. Women provided self-report data on previous three-month alcohol use and potential mental health correlates of alcohol use (depression and stigma). Blood samples were used to measure phosphatidylethanol (PEth), an objective biomarker of recent alcohol intake. We analyzed any alcohol use (ie, any self-reported use or PEth-positive [≥8 ng/mL]) and under-reporting of alcohol use (ie, no self-reported use with concurrent PEth-positive). RESULTS Among pregnant WLWH (n = 163, median age was 26 [interquartile range: 23-29], median gestational age was 20 weeks [interquartile range: 16-26]), 40% were using alcohol and 16% under-reported alcohol use. Neither any alcohol use nor under-reporting of alcohol use differed significantly between pregnant and nonpregnant women or by country (P > 0.05). Greater depression (but not greater stigma) was significantly associated with any alcohol use (adjusted odds ratio = 1.41, 95% confidence interval: [1.01 to 1.99]; P = 0.045). CONCLUSIONS Alcohol use was prevalent and under-reported among pregnant WLWH in South Africa and Uganda, similar to nonpregnant participants, and associated with depression. General health care and antenatal clinic settings present opportunities to provide integrated alcohol-based counseling and depression treatment.
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Affiliation(s)
- Greer A. Raggio
- Department of Psychiatry, Massachusetts General Hospital, Harvard Medical School, Boston, MA
- National Center for Weight and Wellness, Washington, DC
| | - Christina Psaros
- Department of Psychiatry, Massachusetts General Hospital, Harvard Medical School, Boston, MA
| | - Robin Fatch
- Department of Medicine, University of California San Francisco, San Francisco, CA
| | - Georgia Goodman
- Department of Psychiatry, Massachusetts General Hospital, Harvard Medical School, Boston, MA
| | - Lynn T. Matthews
- Center for Global Health, Massachusetts General Hospital, Boston, MA
- Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA
- Department of Infectious Disease, University of Alabama at Birmingham, Birmingham, AL
| | | | | | - Anna Cross
- Desmond Tutu HIV Foundation, University of Cape Town, Cape Town, South Africa;
| | - Stephen Asiimwe
- Center for Global Health, Massachusetts General Hospital, Boston, MA
- Department of Community Health, Mbarara University of Science and Technology, Mbarara, Uganda; and
- Kabwohe Clinical Research Center, Kabwohe, Uganda.
| | - Judith A. Hahn
- Department of Medicine, University of California San Francisco, San Francisco, CA
| | - Jessica E. Haberer
- Center for Global Health, Massachusetts General Hospital, Boston, MA
- Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA
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Martinez I, Kershaw TS, Keene D, Perez-Escamilla R, Lewis JB, Tobin JN, Ickovics JR. Acculturation and Syndemic Risk: Longitudinal Evaluation of Risk Factors Among Pregnant Latina Adolescents in New York City. Ann Behav Med 2019; 52:42-52. [PMID: 28707175 DOI: 10.1007/s12160-017-9924-y] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Abstract
Background Syndemics are co-occurring epidemics that synergistically contribute to specific risks or health outcomes. Although there is substantial evidence demonstrating their existence, little is known about their change over time in adolescents. Purpose The objectives of this paper were to identify longitudinal changes in a syndemic of substance use, intimate partner violence, and depression and determine whether immigration/cultural factors moderate this syndemic over time. Methods In a cohort of 772 pregnant Latina adolescents (ages 14-21) in New York City, we examined substance use, intimate partner violence, and depression as a syndemic. We used longitudinal mixed-effect modeling to evaluate whether higher syndemic score predicted higher syndemic severity, from pregnancy through 1 year postpartum. Interaction terms were used to determine whether immigrant generation and separated orientation were significant moderators of change over time. Results We found a significant increasing linear effect for syndemic severity over time (β = 0.0413, P = 0.005). Syndemic score significantly predicted syndemic severity (β = -0.1390, P ≤ 0.0001), as did immigrant generation (βImmigrant = -0.1348, P ≤ 0.0001; β1stGen = -0.1932, P = 0.0005). Both immigrant generation (βImmigrant = -0.1125, P = 0.0035; β1stGen = -0.0135, P = 0.7279) and separated orientation (β = 0.0946, P = 0.0299) were significantly associated with change in severity from pregnancy to 1 year postpartum. Conclusion Pregnancy provides an opportunity for reducing syndemic risk among Latina adolescents. Future research should explore syndemic changes over time, particularly among high-risk adolescents. Prevention should target syndemic risk reduction in the postpartum period to ensure that risk factors do not increase after pregnancy.
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Affiliation(s)
- Isabel Martinez
- Department of Social and Behavioral Sciences, Harvard T.H. Chan School of Public Health, Boston, MA, USA
| | - Trace S Kershaw
- Department of Chronic Disease Epidemiology, Yale University School of Public Health and Center for Interdisciplinary Research on AIDS, New Haven, CT, USA
| | - Danya Keene
- Department of Chronic Disease Epidemiology, Yale University School of Public Health and Center for Interdisciplinary Research on AIDS, New Haven, CT, USA
| | - Rafael Perez-Escamilla
- Department of Chronic Disease Epidemiology, Yale University School of Public Health and Center for Interdisciplinary Research on AIDS, New Haven, CT, USA
| | - Jessica B Lewis
- Department of Chronic Disease Epidemiology, Yale University School of Public Health and Center for Interdisciplinary Research on AIDS, New Haven, CT, USA
| | | | - Jeannette R Ickovics
- Department of Chronic Disease Epidemiology, Yale University School of Public Health and Center for Interdisciplinary Research on AIDS, New Haven, CT, USA
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15
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Identification of a Syndemic of Blood-Borne Disease Transmission and Injection Drug Use Initiation at the US-Mexico Border. J Acquir Immune Defic Syndr 2019; 79:559-565. [PMID: 30222661 DOI: 10.1097/qai.0000000000001858] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
Abstract
BACKGROUND Efforts to prevent injection drug use (IDU) are increasingly focused on the role that people who inject drugs (PWID) play in the assistance with injection initiation. We studied the association between recent (ie, past 6 months) injection-related HIV risk behaviors and injection initiation assistance into IDU among PWID in the US-Mexico border region. SETTING Preventing Injecting by Modifying Existing Responses (PRIMER) is a multicohort study assessing social and structural factors related to injection initiation assistance. This analysis included data collected since 2014 from 2 participating cohorts in San Diego and Tijuana. METHODS Participants were 18 years and older and reported IDU within the month before study enrollment. Logistic regression analyses were conducted to assess the association between recent injection-related HIV risk behaviors (eg, distributive/receptive syringe sharing, dividing drugs in a syringe, and paraphernalia sharing) and recent injection initiation assistance. RESULTS Among 892 participants, 41 (4.6%) reported recently providing injection initiation assistance. In multivariable analysis adjusting for potential confounders, reporting a higher number of injection-related risk behaviors was associated with an increased odds of recently assisting others with injection initiation (adjusted odds ratio per risk behavior: 1.3; 95% confidence interval: 1.0 to 1.6, P = 0.04). CONCLUSIONS PWID who recently engaged in one or more injection-related HIV risk behavior were more likely to assist others in injection initiation. These results stress the syndemic of injection initiation and risk behaviors, which indicates that prevention of injection-related HIV risk behaviors might also reduce the incidence of injection initiation.
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Sileo KM, Kershaw TS, Callands TA. A syndemic of psychosocial and mental health problems in Liberia: Examining the link to transactional sex among young pregnant women. Glob Public Health 2019; 14:1442-1453. [PMID: 31010396 PMCID: PMC6938027 DOI: 10.1080/17441692.2019.1607523] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2018] [Accepted: 04/01/2019] [Indexed: 01/12/2023]
Abstract
Transactional sex may be a driver of the rising HIV epidemic in Liberia, especially among young women. The goal of this study was to explore the independent and additive effects of psychosocial conditions on engagement in transactional sex among 191 pregnant women in Monrovia, Liberia. Between March and August 2016, women receiving prenatal services completed a cross-sectional structured questionnaire. These data were used to examine the independent and additive effects of exposure to trauma, depression, post-traumatic stress disorder symptoms, and intimate partner violence on transactional sex. Overall, the results are in support of our hypothesis that these psychosocial conditions cluster together and are independently associated with transactional sex. Multivariate logistic regression analysis demonstrated an additive effect of the number of psychosocial conditions experienced on transactional sex. Women experiencing 2 psychosocial conditions had 5.96 greater odds of engaging in transactional sex compared to women reporting 0 conditions (AOR: 5.96, 95% CI: 2.22-15.99), and women experiencing 3 or 4 psychosocial conditions had 11.91 greater odds of engaging in transactional sex compared to women report 0 conditions (AOR: 11.91, 95% CI: 4.12-34.45). Our results demonstrate the need for comprehensive HIV prevention programming inclusive of mental health support and IPV prevention for Liberian women.
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Affiliation(s)
- Katelyn M. Sileo
- The Center for Interdisciplinary Research on AIDS, Yale University, New Haven, CT, USA
| | - Trace S. Kershaw
- The Center for Interdisciplinary Research on AIDS, Yale University, New Haven, CT, USA
- Department of Social and Behavioral Sciences, Yale School of Public Health, New Haven, CT, USA
| | - Tamora A. Callands
- Department of Health Promotion and Behavior, University of Georgia, Athens, GA, USA
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17
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Gender Differences and Psychosocial Factors Associated with Problem Drinking Among Adults Enrolling in HIV Care in Tanzania. AIDS Behav 2019; 23:1612-1622. [PMID: 30465107 DOI: 10.1007/s10461-018-2340-x] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
Problem drinking is commonly reported among people living with HIV (PLWH), associated with suboptimal HIV care outcomes and differs by gender. Psychosocial factors associated with problem drinking among PLWH remain poorly understood, including whether they differ by gender. This analysis examines the relationship between psychosocial factors and problem drinking separately by gender among PLWH in Tanzania. Cross-sectional data were collected from 812 men and non-pregnant women living with HIV aged 18 or older enrolling in HIV care at four health facilities in Tanzania. Problem drinking was assessed with the CAGE Questionnaire and defined as responding yes to two or more items. Sex-stratified multivariable logistic regression modeled the association of social support, HIV-related stigma, and physical or sexual violence on problem drinking, controlling for age, relationship status, employment, having been away from home for more than one month, and timing of first HIV-positive diagnosis. Thirteen percent of the sample reported problem drinking, with problem drinking significantly more commonly reported among men than non-pregnant women (17.6% vs. 9.5%). Among men and non-pregnant women, in multivariable analyses, enacted and internalized HIV-related stigma were significantly positively associated with problem drinking. Screening and treatment of problem drinking should be integrated into HIV care. Evidence-based substance abuse interventions should be adapted to address HIV-related stigma. Future research should longitudinally investigate the interrelationships between stigma, violence, and problem drinking among PLWH.
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18
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Mwangi C, Karanja S, Gachohi J, Wanjihia V, Ngang'a Z. Depression, injecting drug use, and risky sexual behavior syndemic among women who inject drugs in Kenya: a cross-sectional survey. Harm Reduct J 2019; 16:35. [PMID: 31146748 PMCID: PMC6543607 DOI: 10.1186/s12954-019-0307-5] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2018] [Accepted: 05/16/2019] [Indexed: 02/07/2023] Open
Abstract
BACKGROUND Injecting drug use (IDU) is a key driver of the HIV epidemic particularly when individuals experience psychosocial conditions and risky sexual behavior in a syndemic manner. This study sets out to assess evidence of a syndemic pattern of psychosocial conditions (IDU, depression, intimate partner violence (IPV)) on one the hand and risky sexual behavior on the other while accounting for the socio-economic disadvantage among women who inject drugs (WWID) in low-income urban settings in Kenya. METHODS Using a cross-sectional study design, this study recruited 306 WWIDs from two sites in Nairobi between January 2017 and July 2017. Multiple methodologies including descriptive analyses of co-occurrences of psychosocial conditions at the individual level, standard logistic regression analyses to examine relationships and interactions within and between psychosocial conditions and risky sexual behavior, and classification trees algorithm for predictive modeling via machine learning were employed. RESULTS The prevalence of the psychosocial conditions was as follows: IDU, 88%; depression, 77.1%; and IPV, 84%. The prevalence of risky sexual behavior was 69.3%. IDU and depression were related to each other (P < 0.05) and each of them with risky sexual behavior (P < 0.05). The highest 2-way and 3-way co-occurrence of conditions were reported in IDU and depression (72%) and in IDU, depression, and risky sexual behavior (62%), respectively, indicating clustering of the conditions at the individual level. Further, each additional psychosocial condition (IDU and depression) was associated with sixfold odds (P = 0.000) of having risky sexual behavior suggesting a dose-response relationship. Logistic regression analyses incorporating multiplicative interactive effects returned three significant variables (P < 0.05): IDU*depression interaction effect, "Age when delivered the first child," and "Income." Classification tree modeling represented a 5-level interaction analysis with IDU and depression predicted to have the highest influence on risky sexual behavior. CONCLUSION Findings provide possible evidence of a syndemic pattern involving IDU, depression, and risky sexual behavior suggesting the need for an integrated approach to the implementation of harm reduction interventions among WWID in low-income urban settings in Kenya. This work highlights the need for further studies to authenticate the findings and to characterize pathways in the syndemic development in WWID.
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Affiliation(s)
- Catherine Mwangi
- School of Public Health, Jomo Kenyatta University of Agriculture & Technology, Juja, Kenya.,Partners for Health and Development in Africa, Nairobi, Kenya
| | - Simon Karanja
- School of Public Health, Jomo Kenyatta University of Agriculture & Technology, Juja, Kenya
| | - John Gachohi
- School of Public Health, Jomo Kenyatta University of Agriculture & Technology, Juja, Kenya. .,Washington State University - Global Health, Nairobi, Kenya.
| | - Violet Wanjihia
- Centre for Public Health Research, Kenya Medical Research Institute, Nairobi, Kenya
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19
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Batchelder AW, Choi K, Dale SK, Pierre-Louis C, Sweek EW, Ironson G, Safren SA, O'Cleirigh C. Effects of syndemic psychiatric diagnoses on health indicators in men who have sex with men. Health Psychol 2019; 38:509-517. [PMID: 30973745 DOI: 10.1037/hea0000724] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
OBJECTIVE Syndemic theory posits that co-occurring problems (e.g., substance use, depression, and trauma) synergistically increase HIV risk in men who have sex with men (MSM). However, most investigations have assessed these problems additively using self-report. METHOD In a sample of HIV-negative MSM with trauma histories (n = 290), we test bivariate relationships between four clinical diagnoses (substance use disorder [SUD]); major depressive disorder [MDD], posttraumatic stress disorder [PTSD], and anxiety disorders) and their additive and interactive effects on three health indicators (i.e., high-risk sex, visiting the emergency room [ER], and sexually transmitted infections [STIs]). RESULTS We found significant bivariate relationships between SUD and MDD (χ² = 4.85, p = .028) and between PTSD and MDD (χ² = 35.38, p = .028, p < .001) but did not find a significant relationship between SUD and PTSD (χ² = 3.64, p = .056). Number of diagnoses were associated with episodes of high-risk sex (incidence rate ratio [IRR] = 1.14, 95% CI [1.03, 1.26], p = .009) and visiting the ER (odds ratio = 1.27; 95% CI [1.01, 1.60], p = .040) but not with STIs. No interactions were found between diagnoses and health-related indicators. CONCLUSIONS This is the first study to demonstrate additive effects of clinical diagnoses on risk behavior and health care utilization among MSM with developmental trauma histories. Results indicate the need to prioritize empirically supported treatments for SUD and MDD, in addition to trauma treatment, for this population. (PsycINFO Database Record (c) 2019 APA, all rights reserved).
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20
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Food insecurity and violence in a prospective cohort of women at risk for or living with HIV in the U.S. PLoS One 2019; 14:e0213365. [PMID: 30840700 PMCID: PMC6402690 DOI: 10.1371/journal.pone.0213365] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2018] [Accepted: 02/20/2019] [Indexed: 11/24/2022] Open
Abstract
Background Food insecurity and violence are two major public health issues facing U.S. women. The link between food insecurity and violence has received little attention, particularly regarding the temporal ordering of events. The present study used data from the Women’s Interagency Human Immunodeficiency Virus Study to investigate the longitudinal association of food insecurity and violence in a cohort of women at risk for or living with HIV. Methods Study participants completed six assessments from 2013–16 on food insecurity (operationalized as marginal, low, and very low food security) and violence (sexual or physical, and psychological). We used multi-level logistic regression, controlling for visits (level 1) nested within individuals (level 2), to estimate the association of experiencing violence. Results Among 2,343 women (8,528 visits), we found that victims of sexual or physical violence (odds ratio = 3.10; 95% confidence interval: 1.88, 5.19) and psychological violence (odds ratio = 3.00; 95% confidence interval: 1.67, 5.50) were more likely to report very low food security. The odds of experiencing violence were higher for women with very low food security at both the current and previous visit as compared to only the current visit. HIV status did not modify these associations. Conclusions Food insecurity was strongly associated with violence, and women exposed to persistent food insecurity were even more likely to experience violence. Food programs and policy must consider persistent exposure to food insecurity, and interpersonal harms faced by food insecure women, such as violence.
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21
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Addressing the nexus of risk: Biobehavioral outcomes from a cluster randomized trial of the Women's Health CoOp Plus in Pretoria, South Africa. Drug Alcohol Depend 2019; 195:16-26. [PMID: 30562676 PMCID: PMC6415667 DOI: 10.1016/j.drugalcdep.2018.10.036] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/30/2018] [Revised: 10/22/2018] [Accepted: 10/24/2018] [Indexed: 11/23/2022]
Abstract
BACKGROUND HIV prevalence has increased among South African women who use alcohol and other drugs (AOD). However, HIV prevention and treatment efforts have not focused on this population. This study presents the efficacy of the Women's Health CoOp Plus (WHC+) in a cluster-randomized trial to reduce AOD use, gender-based violence, and sexual risk and to increase linkage to HIV care among women who use AODs, compared with HIV counseling and testing alone. METHODS Black African women (N = 641) were recruited from 14 geographic clusters in Pretoria, South Africa, and underwent either an evidence-based gender-focused HIV prevention intervention that included HIV counseling and testing (WHC+) or HIV counseling and testing alone. Participants were assessed at baseline, 6-months, and 12-months post enrollment. RESULTS At 6-month follow-up, the WHC+ arm (vs. HCT) reported more condom use with a main partner and sexual negotiation, less physical and sexual abuse by a boyfriend, and less frequent heavy drinking (ps < 0.05). At 12-month follow-up, the WHC+ arm reported less emotional abuse (p < 0.05). Among a subsample of women, the WHC+ arm was significantly more likely to have a non-detectable viral load (measured by dried blood spots; p = 0.01). CONCLUSION The findings demonstrate the WHC+'s efficacy to reduce HIV risk among women who use AODs in South Africa. Substance abuse rehabilitation centers and health centers that serve women may be ideal settings to address issues of gender-based violence and sexual risk as women engage in substance use treatment, HIV testing, or HIV care.
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22
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Okafor CN, Christodoulou J, Bantjes J, Qondela T, Stewart J, Shoptaw S, Tomlinson M, Rotherman-Borus MJ. Understanding HIV Risk Behaviors Among Young Men in South Africa: A Syndemic Approach. AIDS Behav 2018; 22:3962-3970. [PMID: 30003507 PMCID: PMC6330132 DOI: 10.1007/s10461-018-2227-x] [Citation(s) in RCA: 26] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Young men in South Africa experience several adverse socio-structural and psychosocial factors that may contribute HIV risk behaviors. This study applied a syndemic framework to explore whether these syndemic factors are interconnected and work in synergy to increase HIV risk behaviors. Five syndemic factors were assessed including: binge drinking, polydrug use, depressive symptoms, violence and food insecurity on two HIV risk behaviors: multiple sex partners and transactional sex. Participants were (N = 1233) young men aged 18-29 years from a township in Cape Town, South Africa. Bivariate logistic regression analysis demonstrated that many of the syndemic factors were related to one another. Pairwise interactions (on an additive scale) among the syndemic factors revealed significant positive interactions between binge drinking and violence on greater odds of reporting multiple sex partners (aOR = 5.10, 95% CI 3.10, 8.29; p = < .001) compared to reporting neither factor. Also, food insecurity and violence (aOR = 2.89, 95% CI 1.63, 5.11; p = < .001) as well as food insecurity and polydrug use (aOR = 2.73, 95% CI 1.54, 4.84; p = < .001) were significantly associated with greater odds of transactional sex compared to reporting neither factor. Our findings highlight a synergistic relationship between some adverse socio-structural and psychosocial factors on HIV risk behaviors. HIV prevention programs that address multiple syndemic factors simultaneously may achieve greater impact on HIV risk reduction.
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Affiliation(s)
- Chukwuemeka N Okafor
- Division of Infectious Diseases, Department of Medicine, David Geffen School of Medicine, University of California, Los Angeles, 10833 Le Conte Ave (Room 37-121CHS), Los Angeles, CA, 90095-1688, USA.
- Department of Family Medicine, David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, USA.
| | - Joan Christodoulou
- Department of Psychiatry & Biobehavioral Sciences, Semel Institute, University of California, Los Angeles, Los Angeles, USA
| | - Jason Bantjes
- Department of Psychology, Stellenbosch University, Stellenbosch, South Africa
| | - Tembinkosi Qondela
- Department of Psychology, Stellenbosch University, Stellenbosch, South Africa
| | - Jackie Stewart
- Department of Psychology, Stellenbosch University, Stellenbosch, South Africa
| | - Steve Shoptaw
- Department of Family Medicine, David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, USA
| | - Mark Tomlinson
- Department of Psychology, Stellenbosch University, Stellenbosch, South Africa
| | - Mary Jane Rotherman-Borus
- UCLA Center for HIV Identification, Prevention and Treatment Services, University of California, Los Angeles, 10920 Wilshire Blvd., Suite 350, Los Angeles, CA, 90024, USA
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23
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Psaros C, Milford C, Smit JA, Greener L, Mosery N, Matthews LT, Harrison A, Gordon JR, Mimiaga M, Bangsberg DR, Safren SA. HIV Prevention Among Young Women in South Africa: Understanding Multiple Layers of Risk. ARCHIVES OF SEXUAL BEHAVIOR 2018; 47:1969-1982. [PMID: 29134422 PMCID: PMC5966340 DOI: 10.1007/s10508-017-1056-8] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/04/2014] [Revised: 07/21/2017] [Accepted: 08/09/2017] [Indexed: 06/07/2023]
Abstract
Despite concerted prevention efforts, young South African women remain at the epicenter of the HIV epidemic. Although these women have grown up in a community powerfully affected by HIV, systematic investigation into how this "second generation" of HIV-affected youth navigates HIV risk is lacking. This study qualitatively explored a complex interplay of factors influencing HIV risk among young pregnant women in KwaZulu-Natal, South Africa. We conducted in-depth interviews with 35 pregnant women (22 HIV-uninfected and 13 HIV-infected) aged 18-21, 18 healthcare providers, and focus groups with 19 community stakeholders. Among the young women, HIV knowledge was high, and many reported taking some action to prevent pregnancy or HIV; however, these efforts were not routinely implemented. Themes related to HIV acquisition risk from all participants were organized using a socioecological framework and revolved around individual and developmental experiences (personal experience with HIV, perceived invincibility), family barriers (lack of adult supervision, pressure to leave school), relational barriers (lack of disclosure and partner communication, "burn out" around attempts to discuss condom use with partners, overdependence on partners), community-level barriers (township environment, lack of structured activities), and social barriers (poverty, HIV-related stigma). Some novel concepts emerged from the data, including an understanding of how overdependence on the romantic relationship may develop. Current HIV prevention efforts, including traditional HIV counseling and testing, condom distribution, and biomedical agents for HIV prevention, are unlikely to be effective without a broader, ecological up-to-date understanding of the evolving, intertwined, and complex constellation of factors that drive HIV risk behavior in this high-risk population.
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Affiliation(s)
- Christina Psaros
- Behavioral Medicine Program, Department of Psychiatry, Massachusetts General Hospital, One Bowdoin Square, 7th Floor, Boston, MA, 02114, USA.
- Department of Psychiatry, Harvard Medical School, Boston, MA, USA.
| | - Cecilia Milford
- MatCH Research Unit (Maternal, Adolescent, and Child Health Research Unit), Department of Obstetrics and Gynecology, Faculty of Health Sciences, University of the Witwatersrand, Durban, South Africa
| | - Jennifer A Smit
- MatCH Research Unit (Maternal, Adolescent, and Child Health Research Unit), Department of Obstetrics and Gynecology, Faculty of Health Sciences, University of the Witwatersrand, Durban, South Africa
- School of Health Sciences, College of Health Sciences, University of KwaZulu-Natal, Durban, South Africa
| | - Letitia Greener
- MatCH Research Unit (Maternal, Adolescent, and Child Health Research Unit), Department of Obstetrics and Gynecology, Faculty of Health Sciences, University of the Witwatersrand, Durban, South Africa
| | - Nzwakie Mosery
- MatCH Research Unit (Maternal, Adolescent, and Child Health Research Unit), Department of Obstetrics and Gynecology, Faculty of Health Sciences, University of the Witwatersrand, Durban, South Africa
| | - Lynn T Matthews
- Department of Psychiatry, Harvard Medical School, Boston, MA, USA
- Center for Global Health and Division of Infectious Disease, Massachusetts General Hospital, Boston, MA, USA
| | - Abigail Harrison
- Department of Behavioral and Social Sciences and International Health Institute, Brown University School of Public Health, Providence, RI, USA
| | - Janna R Gordon
- San Diego Joint Doctoral Program in Clinical Psychology, San Diego State University/University of California, San Diego, CA, USA
| | - Matthew Mimiaga
- The Fenway Institute at Fenway Health, Boston, MA, USA
- Department of Behavioral and Social Health Sciences and Epidemiology, School of Public Health, Brown University, Providence, RI, USA
- Department of Psychiatry and Human Behavior, Alpert Medical School, Brown University, Providence, RI, USA
- Institute for Community Health Promotion, Brown University, Providence, RI, USA
- Department of Epidemiology, Harvard T. H. Chan School of Public Health, Boston, MA, USA
| | - David R Bangsberg
- School of Public Health, Oregon Health & Science University-Portland State University, Portland, OR, USA
| | - Steven A Safren
- Department of Psychology, University of Miami, Miami, FL, USA
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Longitudinal Evaluation of Syndemic Risk Dyads in a Cohort of Young Pregnant Couples. J Adolesc Health 2018; 63:189-196. [PMID: 29970332 PMCID: PMC6113066 DOI: 10.1016/j.jadohealth.2018.02.011] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/27/2017] [Revised: 01/19/2018] [Accepted: 02/28/2018] [Indexed: 11/21/2022]
Abstract
PURPOSE The burden of syndemics-which are clusters of overlapping risk factors that adversely impact health-has been previously evaluated among high-risk individuals, yet little is known regarding syndemics within the relationship context. METHODS We evaluated concordant and discordant syndemic profiles among 296 pregnant couples and their actor-partner effects longitudinally from pregnancy to 1-year postpartum. RESULTS Syndemic score and severity were correlated across all time points for men and women. There was a significant difference in syndemic score (βMen-Women = .2736, p = <.0001) and severity (βMen-Women = .4282, p = <.0001) during pregnancy. For actor effects, we found score (βT1-T2 = .273, p = .002; βT2-T3 = .300, p = .005) and severity (βT1-T2 = .253, p = .004; βT2-T3 = .418, p = .001) were significantly associated across all time points for women. For men, only syndemic score predicted subsequent score at later time points (βT1-T2 = .393, p = <.001; βT2-T3 = .421, p = <.001). Severity was not significantly associated across time (βT1-T2 = .043, p = .566; βT2-T3 = .172, p = .066). For partner effects, we found women's syndemic risk to influence men's syndemic risk, while men had no significant effect on women's syndemic risk. CONCLUSIONS Pregnancy provides an opportunity to reduce syndemic burden among men and women. Couples-based prevention programs may serve to reduce syndemic risk for both partners, particularly during the postpartum period.
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Malan M, Spedding M, Sorsdahl K. The prevalence and predictors of intimate partner violence among pregnant women attending a midwife and obstetrics unit in the Western Cape. Glob Ment Health (Camb) 2018; 5:e18. [PMID: 29868238 PMCID: PMC5981656 DOI: 10.1017/gmh.2018.9] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/26/2017] [Revised: 02/01/2018] [Accepted: 02/06/2018] [Indexed: 01/08/2023] Open
Abstract
BACKGROUND Intimate partner violence (IPV) during pregnancy is prevalent across the world, but more so in low- and middle-income countries. It is associated with various adverse outcomes for mothers and infants. This study sought to determine the prevalence and predictors of IPV among pregnant women attending one midwife and obstetrics unit (MOU) in the Western Cape, South Africa. METHODS A convenience sample of 150 pregnant women was recruited to participate in the study. Data were collected using several self-report measures concerning the history of childhood trauma, exposure to community violence, depression and alcohol use. Multivariable logistic models were developed, the first model was based on whether any IPV occurred, the remaining models investigated for physical-, sexual- and emotional abuse. RESULTS Lifetime and 12-month prevalence rates for any IPV were 44%. The 12-month IPV rates were 32% for emotional and controlling behaviours, 29% physical and 20% sexual abuse. The adjusted model predicting physical IPV found women who were at risk for depression were more likely to experience physical IPV [odds ratios (ORs) 4.42, 95% confidence intervals (CIs) 1.88-10.41], and the model predicting sexual IPV found that women who reported experiencing community violence were more likely to report 12-month sexual IPV (OR 3.85, CI 1.14-13.08). CONCLUSION This is the first study, which illustrates high prevalence rates of IPV among pregnant woman at Mitchells Plain MOU. A significant association was found between 12-month IPV and unintended pregnancy. Further prospective studies in different centres are needed to address generalisability and the effect of IPV on maternal and child outcomes.
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Affiliation(s)
- M. Malan
- Alan J. Flisher Centre for Public Mental Health, Department of Psychiatry and Mental Health, University of Cape Town, Western Cape, South Africa
| | - M.F. Spedding
- Alan J. Flisher Centre for Public Mental Health, Department of Psychiatry and Mental Health, University of Cape Town, Western Cape, South Africa
| | - K. Sorsdahl
- Alan J. Flisher Centre for Public Mental Health, Department of Psychiatry and Mental Health, University of Cape Town, Western Cape, South Africa
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Gust DA, Gvetadze R, Furtado M, Makanga M, Akelo V, Ondenge K, Nyagol B, McLellan-Lemal E. Factors associated with psychological distress among young women in Kisumu, Kenya. Int J Womens Health 2017; 9:255-264. [PMID: 28496366 PMCID: PMC5422460 DOI: 10.2147/ijwh.s125133] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
BACKGROUND Attention to mental health issues is growing globally. In many countries, including Kenya, however, assessment of psychological distress, especially in rural areas, is limited. METHODS We analyzed data from young women screened for a longitudinal contraceptive ring study in Kisumu, Kenya. Multivariable regression analysis was used to assess factors associated with recent moderate and high psychological distress, as measured by the Kessler (K-6) psychological distress scale. RESULTS Among the 461 women screened, most (58.4%) were categorized as having moderate psychological distress, 20.8% were categorized as having low or no psychological distress, and 20.8% were categorized as having high psychological distress. Moderate psychological distress (vs low/no) was significantly more likely among women who reported a history of forced sex and were concerned about recent food insecurity. High (vs low/no) psychological distress was significantly more likely among women who reported a history of forced sex, who were concerned about recent food insecurity, and who self-reported a sexually transmitted infection. CONCLUSION To reduce psychological distress, a focus on prevention as well as care methods is needed. Girls need a path toward a healthy and productive adulthood with a focus on education, which would help them gain skills to avoid forced sex. Women would benefit from easy access to social services and supports that would help them with basic needs like food security among other things. A holistic or ecological approach to services that would address mental, educational, social, health, and economic issues may have the highest chance of having a long-term positive impact on public health.
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Affiliation(s)
- Deborah A Gust
- Division of HIV/AIDS Prevention, Centers for Disease Control and Prevention
| | - Roman Gvetadze
- Division of HIV/AIDS Prevention, Centers for Disease Control and Prevention
| | | | - Mumbi Makanga
- HIV Research Branch, Kenya Medical Research Institute, Kisumu, Kenya
| | - Victor Akelo
- HIV Research Branch, Kenya Medical Research Institute, Kisumu, Kenya
| | - Kenneth Ondenge
- HIV Research Branch, Kenya Medical Research Institute, Kisumu, Kenya
| | - Beatrice Nyagol
- HIV Research Branch, Kenya Medical Research Institute, Kisumu, Kenya
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Martinez I, Kershaw TS, Lewis JB, Stasko EC, Tobin JN, Ickovics JR. Between Synergy and Travesty: A Sexual Risk Syndemic Among Pregnant Latina Immigrant and Non-immigrant Adolescents. AIDS Behav 2017; 21:858-869. [PMID: 27338951 DOI: 10.1007/s10461-016-1461-3] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
Substance use, intimate partner violence, and depression contribute to sexual risk individually, yet have not been evaluated as a syndemic for adolescents. Using data from 772 pregnant Latina adolescents, we evaluated these factors as a syndemic and tested the moderating role of immigration. Bivariate analyses showed syndemic score (OR = 1.40, p = 0.02) and severity (OR = 1.68, p = 0.006) were predictors for multiple sex partners, and syndemic score predicting STIs (OR = 1.15, p = 0.05). Syndemic severity remained significant in multivariate analyses for multiple sex partners (OR = 1.53, p = 0.04). Moderation analyses showed higher syndemic severity was associated with more condom use among immigrants (OR = 1.75, p = 0.04) and less condom use (OR = 0.07, p = 0.011) among those with separated orientation. Higher syndemic severity also predicted greater odds for multiple partners (OR = 2.40, p = 0.01) among immigrants. This evidence suggests a sexual risk syndemic exists among Latina adolescents. Research should continue exploring this phenomenon, particularly exploring the role immigration plays for sexual health.
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Affiliation(s)
- Isabel Martinez
- Department of Chronic Disease Epidemiology, Yale University School of Public Health and Center for Interdisciplinary Research on AIDS, 135 College St, Suite 200, New Haven, CT, 06510, USA.
| | - Trace S Kershaw
- Department of Chronic Disease Epidemiology, Yale University School of Public Health and Center for Interdisciplinary Research on AIDS, 135 College St, Suite 200, New Haven, CT, 06510, USA
| | - Jessica B Lewis
- Department of Chronic Disease Epidemiology, Yale University School of Public Health and Center for Interdisciplinary Research on AIDS, 135 College St, Suite 200, New Haven, CT, 06510, USA
| | - Emily C Stasko
- Department of Psychology, Drexel University, Philadelphia, PA, USA
| | | | - Jeannette R Ickovics
- Department of Chronic Disease Epidemiology, Yale University School of Public Health and Center for Interdisciplinary Research on AIDS, 135 College St, Suite 200, New Haven, CT, 06510, USA
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Kiene SM, Lule H, Sileo KM, Silmi KP, Wanyenze RK. Depression, alcohol use, and intimate partner violence among outpatients in rural Uganda: vulnerabilities for HIV, STIs and high risk sexual behavior. BMC Infect Dis 2017; 17:88. [PMID: 28103834 PMCID: PMC5248514 DOI: 10.1186/s12879-016-2162-2] [Citation(s) in RCA: 44] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2016] [Accepted: 12/22/2016] [Indexed: 12/27/2022] Open
Abstract
Background Intimate partner violence (IPV), alcohol use, and depression are key vulnerabilities for HIV in Uganda, and taken together may have a synergistic effect on risk. Our objective was to investigate the associations between depression, IPV, and alcohol use and HIV-risk indicators among a sample of outpatients in rural Uganda, and the effect of co-occurrence of these factors on HIV-risk indicators. Methods In a structured interview we collected data on high-risk sexual behavior, depression symptoms, emotional and physical IPV, and alcohol use, as well as a blood sample for HIV and syphilis tests and a urine sample for chlamydia and gonorrhea tests from 325 male and female outpatients receiving provider-initiated HIV testing and counseling (PITC) at a public hospital outpatient clinic in rural Uganda. We used logistic regression and generalized linear modeling to test independent associations between depression, IPV, and alcohol use and HIV-risk indicators, as well as the effect of co-occurrence on HIV-risk indicators. Results Twelve percent of men and 15% of women had two or more of the following conditions: depression, IPV, and alcohol use; another 29% of men and 33% of women had 1 condition. Each condition was independently associated with HIV risk behavior for men and women, and for women, depression was associated with testing positive for HIV or a sexually transmitted infection (STI). Men with one condition (AOR 2.32, 95% CI 1.95–2.77) and two or more conditions (AOR 12.77, 95% CI 7.97–20.47) reported more high risk sex acts compared to those with no potential co-occurring conditions. For men, experiencing two or more conditions increased risky sex more than one alone (χ2 24.68, p < 0.001). Women experiencing one condition (AOR 3.33, 95% CI 137–8.08) and two co-occurring conditions (AOR 5.87, 95% CI 1.99–17.35) were more likely to test positive for HIV or an STI and women with two co-occurring conditions were also at increased risk for risky sex (AOR 2.18, 95% CI 1.64–2.91). We also found preliminary evidence suggesting synergistic effects between depression and emotional IPV and between alcohol use and depression. Conclusions This study demonstrates the co-occurrence of depression, IPV, and alcohol use in men and women in an outpatient setting in rural Uganda. The co-occurrence of these factors was associated with greater HIV risk, highlighting the need for a more holistic approach to HIV prevention and care research and programming.
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Affiliation(s)
- Susan M Kiene
- Division of Epidemiology and Biostatistics, Graduate School of Public Health, San Diego State University, 5500 Campanile Drive (MC-4162), San Diego, CA, 92182, USA.
| | | | - Katelyn M Sileo
- Division of Epidemiology and Biostatistics, Graduate School of Public Health, San Diego State University, 5500 Campanile Drive (MC-4162), San Diego, CA, 92182, USA
| | - Kazi Priyanka Silmi
- Division of Epidemiology and Biostatistics, Graduate School of Public Health, San Diego State University, 5500 Campanile Drive (MC-4162), San Diego, CA, 92182, USA
| | - Rhoda K Wanyenze
- Department of Disease Control and Environmental Health, Makerere University School of Public Health, Kampala, Uganda
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Closson K, Dietrich JJ, Nkala B, Musuku A, Cui Z, Chia J, Gray G, Lachowsky NJ, Hogg RS, Miller CL, Kaida A. Prevalence, type, and correlates of trauma exposure among adolescent men and women in Soweto, South Africa: implications for HIV prevention. BMC Public Health 2016; 16:1191. [PMID: 27884181 PMCID: PMC5123224 DOI: 10.1186/s12889-016-3832-0] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2016] [Accepted: 11/12/2016] [Indexed: 01/24/2023] Open
Abstract
BACKGROUND Youth trauma exposure is associated with syndemic HIV risk. We measured lifetime prevalence, type, and correlates of trauma experience by gender among adolescents living in the HIV hyper-endemic setting of Soweto, South Africa. METHODS Using data from the Botsha Bophelo Adolescent Health Survey (BBAHS), prevalence of "ever" experiencing a traumatic event among adolescents (aged 14-19) was assessed using a modified Traumatic Event Screening Inventory-Child (TESI-C) scale (19 items, study alpha = 0.63). We assessed self-reported number of potentially traumatic events (PTEs) experienced overall and by gender. Gender-stratified multivariable logistic regression models assessed independent correlates of 'high PTE score' (≥7 PTEs). RESULTS Overall, 767/830 (92%) participants were included (58% adolescent women). Nearly all (99.7%) reported experiencing at least one PTE. Median PTE was 7 [Q1,Q3: 5-9], with no gender differences (p = 0.19). Adolescent men reported more violent PTEs (e.g., "seen an act of violence in the community") whereas women reported more non-violent HIV/AIDS-related PTEs (e.g., "family member or someone close died of HIV/AIDS"). High PTE score was independently associated with high food insecurity among adolescent men and women (aOR = 2.63, 95%CI = 1.36-5.09; aOR = 2.57, 95%CI = 1.55-4.26, respectively). For men, high PTE score was also associated with older age (aOR = 1.40/year, 95%CI = 1.21-1.63); and recently moving to Soweto (aOR = 2.78, 95%CI = 1.14-6.76). Among women, high PTE score was associated with depression using the CES-D scale (aOR = 2.00, 95%CI = 1.31-3.03,) and inconsistent condom use vs. no sexual experience (aOR = 2.69, 95%CI = 1.66-4.37). CONCLUSION Nearly all adolescents in this study experienced trauma, with gendered differences in PTE types and correlates, but not prevalence. Exposure to PTEs were distributed along social and gendered axes. Among adolescent women, associations with depression and inconsistent condom use suggest pathways for HIV risk. HIV prevention interventions targeting adolescents must address the syndemics of trauma and HIV through the scale-up of gender-transformative, youth-centred, trauma-informed integrated HIV and mental health services.
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Affiliation(s)
- Kalysha Closson
- Faculty of Health Sciences, Simon Fraser University (SFU), Blusson Hall Rm 10522, 8888 University Drive, Burnaby, BC V5A 1S6 Canada
- British Columbia Centre for Excellence in HIV/AIDS, Vancouver, Canada
| | - Janan Janine Dietrich
- Perinatal HIV Research Unit (PHRU), Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Busi Nkala
- Perinatal HIV Research Unit (PHRU), Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
- Faculty of Humanities, University of the Witwatersrand, Johannesburg, South Africa
| | - Addy Musuku
- Faculty of Health Sciences, Simon Fraser University (SFU), Blusson Hall Rm 10522, 8888 University Drive, Burnaby, BC V5A 1S6 Canada
| | - Zishan Cui
- British Columbia Centre for Excellence in HIV/AIDS, Vancouver, Canada
| | - Jason Chia
- British Columbia Centre for Excellence in HIV/AIDS, Vancouver, Canada
| | - Glenda Gray
- Perinatal HIV Research Unit (PHRU), Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Nathan J. Lachowsky
- British Columbia Centre for Excellence in HIV/AIDS, Vancouver, Canada
- School of Public Health and Social Policy, University of Victoria, Victoria, Canada
| | - Robert S. Hogg
- Faculty of Health Sciences, Simon Fraser University (SFU), Blusson Hall Rm 10522, 8888 University Drive, Burnaby, BC V5A 1S6 Canada
- British Columbia Centre for Excellence in HIV/AIDS, Vancouver, Canada
| | - Cari L. Miller
- Faculty of Health Sciences, Simon Fraser University (SFU), Blusson Hall Rm 10522, 8888 University Drive, Burnaby, BC V5A 1S6 Canada
| | - Angela Kaida
- Faculty of Health Sciences, Simon Fraser University (SFU), Blusson Hall Rm 10522, 8888 University Drive, Burnaby, BC V5A 1S6 Canada
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The Prevalence of and Factors Associated with Alcohol-Related Problems in a Community Sample of African American Women. JOURNAL OF ADDICTION 2016; 2016:7513827. [PMID: 27752388 PMCID: PMC5056303 DOI: 10.1155/2016/7513827] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/07/2016] [Revised: 07/20/2016] [Accepted: 08/11/2016] [Indexed: 11/18/2022]
Abstract
Purpose. This study examines the prevalence of alcohol-related problems, the factors underlying these problems, and whether or not there is evidence of syndemic effects in a community population of southern, urban African American women. Methods. Questionnaire-based interviews were conducted with 817 women, all African American, from 80 targeted census block groups in Atlanta, Georgia. Results. Most of the alcohol users (67.8%) experienced at least one problem as a result of their alcohol (ab)use, with most women experiencing two or more such problems. Eight factors were found to be associated with experiencing more alcohol problems: being aged 30 or older, having had no recent health insurance, lower levels of educational attainment, self-identifying as lesbian or bisexual, experiencing greater amounts of childhood maltreatment, greater impulsivity, perceiving one's local community or neighborhood to be unsafe, and having a larger number of criminally involved friends. Conclusions. Drinking-related problems were prevalent in this population. Numerous factors underlie the extent to which African American women experienced problems resulting from their alcohol use. There is strong evidence of syndemic-type effects influencing drinking problems in this population, and future efforts to reduce the negative impact of alcohol (ab)use ought to consider the adoption of programs using a syndemics' theory approach.
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Peasant C, Sullivan TP, Weiss NH, Martinez I, Meyer JP. Beyond the syndemic: condom negotiation and use among women experiencing partner violence. AIDS Care 2016; 29:516-523. [PMID: 27590004 DOI: 10.1080/09540121.2016.1224296] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
BACKGROUND HIV and sexually transmitted infections (STIs) disproportionately affect women who experience intimate partner violence (IPV). OBJECTIVE The current study (1) applied a syndemic framework to study the collective effects of problematic drug use, hazardous drinking, depression, and posttraumatic stress disorder (PTSD) on fear of condom negotiation, condom negotiation, and condom use and (2) evaluated condom negotiation (controlling for fear of condom negotiation) as a mediator of the association between syndemic severity and condom use among low-income IPV-exposed women. METHODS Participants were 158 women living in the community and experiencing ongoing IPV who completed face-to-face, computer-assisted interviews. RESULTS Almost three-fourths of the participants reported problematic drug use, hazardous drinking, depression, and/or PTSD; many of these factors were correlated, indicating a syndemic. Multivariate logistic and linear regression analyses revealed associations between syndemic severity and fear of condom negotiation (OR = 1.57, p = .02), condom negotiation (β = -8.51, p = .001), and condom use (β = -8.26, p = .01). Meditation analyses identified condom negotiation as a mediator of the association between syndemic severity and condom use (effect = -6.57, SE = 2.01, [95% CI: -10.66, -2.77]). CONCLUSIONS Results fill a critical gap in previous research by identifying condom negotiation as a mechanism through which this syndemic affects condom use. Prevention and intervention programs should consider addressing condom negotiation to reduce sexual risk among this high-risk population. Further, because IPV-exposed women may experience fear related to condom negotiation, it is critical that prevention and intervention efforts for this population offer skills to safely negotiate condom use, increase condom use, and reduce STI and HIV risk.
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Affiliation(s)
- Courtney Peasant
- a Center for Interdisciplinary Research on AIDS , Yale School of Public Health , New Haven , CT , USA
| | - Tami P Sullivan
- b Division of Prevention and Community Research, Department of Psychiatry , Yale University School of Medicine , New Haven , CT , USA
| | - Nicole H Weiss
- b Division of Prevention and Community Research, Department of Psychiatry , Yale University School of Medicine , New Haven , CT , USA
| | - Isabel Martinez
- a Center for Interdisciplinary Research on AIDS , Yale School of Public Health , New Haven , CT , USA
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Klein H, Elifson KW, Sterk CE. How the Interaction of Childhood Sexual Abuse and Gender Relates to HIV Risk Practices among Urban-Dwelling African Americans. ACTA ACUST UNITED AC 2016; 2. [PMID: 30197963 DOI: 10.15744/2454-499x.2.105] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Purpose Previous research has demonstrated that HIV risk practices often differ based on gender and on whether or not people experienced sexual abuse during their formative (i.e., childhood and adolescence) years. The interaction of these two factors, which is the focus of this paper, has received limited attention. Methods Based on a model derived from Social Disorganization Theory and Syndemics Theory, interviews were conducted between 2009 and 2012 with 1,864 African American adults residing in Atlanta, Georgia in 80 strategically-chosen consensus block groups. Results Based on multiple regression and structural equation analyses, the interaction of sexual abuse and gender was found to be a significant predictor of involvement in (un)protected sex. The interaction of sexual abuse and gender also was related to condom use self-efficacy, which was one of the strongest factors underlying (un)protected sex. Conclusion The relationship of sexual abuse history and gender is relevant in the understanding of HIV risk practices. The interaction of these factors with one another and with other relevant influences that shape people's HIV risk profiles is complex. The Syndemics Theory approach used to conceptualize the relationships among relevant variables in this study is an effective way of trying to understand and address HIV risk practices.
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Affiliation(s)
- H Klein
- Kensington Research Institute, Kensington MD and Rollins School of Public Health, Emory University, Atlanta GA, United States
| | - K W Elifson
- Rollins School of Public Health, Emory University, Atlanta GA, United States
| | - C E Sterk
- Rollins School of Public Health, Emory University, Atlanta GA, United States
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Myers B, Carney T, Wechsberg WM. "Not on the agenda": A qualitative study of influences on health services use among poor young women who use drugs in Cape Town, South Africa. THE INTERNATIONAL JOURNAL OF DRUG POLICY 2016; 30:52-8. [PMID: 26797188 PMCID: PMC4829448 DOI: 10.1016/j.drugpo.2015.12.019] [Citation(s) in RCA: 53] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2015] [Revised: 12/08/2015] [Accepted: 12/17/2015] [Indexed: 11/20/2022]
Abstract
BACKGROUND Poor young women who use alcohol and other drugs (AODs) in Cape Town, South Africa, need access to health services to prevent HIV. Efforts to link young women to services are hampered by limited information on what influences service initiation. We explored perceptions of factors that influence poor AOD-using young women's use of health services. METHODS We conducted four focus groups with young women (aged 16-21) who used AODs and were recruited from two township communities in Cape Town. We also conducted 14 in-depth interviews with health and social welfare service planners and providers. Discussion topics included young women's use of health services and perceived influences on service use. Qualitative data were analysed using a framework approach. RESULTS The findings highlighted structural, contextual, and systemic influences on the use of health services by young women who use AODs. First, young women were absent from the health agenda, which had an impact on the provision of women-specific services. Resource constraints and gender inequality were thought to contribute to this absence. Second, gender inequality and stigma toward young women who used AODs led to their social exclusion from education and employment opportunities and health care. Third, community poverty resulted in the emergence of perverse social capital and social disorder that limited social support for treatment. Fourth, the health care system was unresponsive to the multiple service needs of these young women. CONCLUSION To reach young women who use AODs, interventions need to take cognisance of young women's risk environment and health systems need to adapt to respond better to their needs. For these interventions to be effective, gender must be placed on the policy agenda.
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Affiliation(s)
- Bronwyn Myers
- Alcohol, Tobacco and Other Research Unit, South African Medical Research Council, P.O. Box 19070, Tygerberg, Cape Town 7505, South Africa
- Department of Psychiatry and Mental Health, University of Cape Town, Anzio Road, Observatory, 7900, South Africa
| | - Tara Carney
- Alcohol, Tobacco and Other Research Unit, South African Medical Research Council, P.O. Box 19070, Tygerberg, Cape Town 7505, South Africa
| | - Wendee M. Wechsberg
- RTI International, 3040 E. Cornwallis Road, P.O. Box 12194, Research Triangle Park, NC 27709
- Gillings Global School of Public Health, University of North Carolina, Chapel Hill, North Carolina, USA
- Psychology in the Public Interest, North Carolina State University, Raleigh, North Carolina, USA
- Psychiatry and Behavioral Sciences, Duke University School of Medicine, Durham, North Carolina, USA
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Abstract
In the theory of syndemics, diseases are hypothesized to co-occur in particular temporal or geographical contexts due to harmful social conditions (disease concentration) and to interact at the level of populations and individuals, with mutually enhancing deleterious consequences for HIV risk (disease interaction). Since its original elaboration more than 20 years ago, the epidemiological literature on syndemic problems has followed a questionable trajectory, stemming from the use of a specific type of regression model specification that conveys very little information about the theory of syndemics. In this essay we critically review the dominant approaches to modeling in the literature on syndemics; highlight the stringent assumptions implicit in these models; and describe some meaningful public health implications of the resulting analytical ambiguities. We conclude with specific recommendations for empirical work in this area moving forward.
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Affiliation(s)
- Alexander C Tsai
- MGH Global Health, Massachusetts General Hospital, 125 Nashua Street, Ste. 722, Boston, MA, 02114, USA.
- Harvard Center for Population and Development Studies, Cambridge, MA, USA.
- Mbarara University of Science and Technology, Mbarara, Uganda.
| | - Atheendar S Venkataramani
- MGH Global Health, Massachusetts General Hospital, 125 Nashua Street, Ste. 722, Boston, MA, 02114, USA
- Harvard Center for Population and Development Studies, Cambridge, MA, USA
- Division of General Internal Medicine, Department of Medicine, Massachusetts General Hospital, Boston, MA, USA
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"Outness" as a Moderator of the Association Between Syndemic Conditions and HIV Risk-Taking Behavior Among Men Who Have Sex with Men in Tijuana, Mexico. AIDS Behav 2016; 20:431-8. [PMID: 26324079 DOI: 10.1007/s10461-015-1172-1] [Citation(s) in RCA: 35] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
Multiple psychosocial conditions tend to co-occur and contribute to higher risk for HIV among men who have sex with men (MSM), a phenomenon known as syndemics. Less is known about moderating factors that may attenuate the relation between syndemic conditions and sexual risk-taking. We examined disclosure of same-sex sexual behavior or "outness" as a moderating factor of the syndemic effect. We recruited a sample of MSM (n = 191) using respondent-driven sampling in Tijuana, Mexico. Participants completed a survey of syndemic conditions (i.e., substance use, depression, violence, internalized homophobia, and sexual compulsivity), sexual risk-taking (i.e., condom unprotected anal sex with a stranger in the past 2 months), and the degree to which they are "out" about sex with men. Consistent with previous research, we found that men who report more syndemic conditions show a greater prevalence of sexual risk-taking. As predicted, men who were out to more people showed a weaker association between syndemic conditions and sexual risk-taking, whereas men who were out to fewer people showed the strongest association. This study is the first to provide evidence of "outness" as a moderating factor that attenuates syndemic effects on sexual risk-taking. Building upon previous research, the data suggest that "outness" may be a resilience factor for MSM in Tijuana. HIV prevention intervention implications are discussed.
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Tsai AC, Tomlinson M, Comulada WS, Rotheram-Borus MJ. Food insufficiency, depression, and the modifying role of social support: Evidence from a population-based, prospective cohort of pregnant women in peri-urban South Africa. Soc Sci Med 2016; 151:69-77. [PMID: 26773296 DOI: 10.1016/j.socscimed.2015.12.042] [Citation(s) in RCA: 79] [Impact Index Per Article: 9.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2015] [Revised: 11/03/2015] [Accepted: 12/28/2015] [Indexed: 02/06/2023]
Abstract
RATIONALE Food insecurity has emerged as an important, and potentially modifiable, risk factor for depression. Few studies have brought longitudinal data to bear on investigating this association in sub-Saharan Africa. OBJECTIVE To estimate the association between food insufficiency and depression symptom severity, and to determine the extent to which any observed associations were modified by social support. METHODS AND RESULTS We conducted a secondary analysis of population-based, longitudinal data collected from 1238 pregnant women during a three-year cluster-randomized trial of a home visiting intervention in Cape Town, South Africa. Surveys were conducted at baseline, 6 months, 18 months, and 36 months (85% retention). A validated, single-item food insufficiency measure inquired about the number of days of hunger in the past week. Depression symptom severity was measured using the Xhosa version of the 10-item Edinburgh Postnatal Depression Scale. In multivariable regression models with cluster-correlated robust estimates of variance, lagged food insufficiency had a strong and statistically significant association with depression symptom severity (β = 0.70; 95% CI, 0.46-0.94), suggesting a 6.5% relative difference in depression symptom severity per day of hunger. In stratified analyses, food insufficiency had a statistically significant association with depression only among women with low levels of instrumental support. Using quantile regression, we found that the adverse impacts of food insufficiency were experienced to a greater degree by women in the upper end of the conditional distribution of depression symptom severity. Estimates from fixed-effects regression models and fixed-effects quantile regression models, accounting for unobserved confounding by time-invariant characteristics, were similar. CONCLUSIONS Food insufficiency was associated with depression symptom severity, particularly for women in the upper end of the conditional depression distribution. Instrumental social support buffered women against the adverse impacts of food insufficiency.
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Affiliation(s)
- Alexander C Tsai
- Massachusetts General Hospital, MGH Global Health, Boston, USA; Harvard Center for Population and Development Studies, Cambridge, USA; Mbarara University of Science and Technology, Mbarara, Uganda.
| | | | - W Scott Comulada
- Center for HIV Identification, Prevention and Treatment Services, University of California at Los Angeles, Los Angeles, USA; Department of Psychiatry and Biobehavioral Sciences, Semel Institute for Neuroscience and Human Behavior, University of California at Los Angeles, Los Angeles, USA
| | - Mary Jane Rotheram-Borus
- Center for HIV Identification, Prevention and Treatment Services, University of California at Los Angeles, Los Angeles, USA; Department of Psychiatry and Biobehavioral Sciences, Semel Institute for Neuroscience and Human Behavior, University of California at Los Angeles, Los Angeles, USA
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Pitpitan EV, Kalichman SC. Reducing HIV Risks in the Places Where People Drink: Prevention Interventions in Alcohol Venues. AIDS Behav 2016; 20 Suppl 1:S119-33. [PMID: 26099244 DOI: 10.1007/s10461-015-1116-9] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
Apart from individual alcohol drinking behavior, the context or places where people drink play a significant role in HIV transmission risk. In this paper, we review the research that has been conducted on alcohol venues to identify the social and structural factors (e.g., social norms, sexual behavior) that are associated with HIV risk in these places, to review HIV prevention interventions based in alcohol venues, and to discuss appropriate methodologies for alcohol venue research. Alcohol venues are defined here as places that sell or serve alcohol for onsite consumption, including bars, bottle stores, nightclubs, wine shops, and informal shebeens. Despite the many established HIV risk factors at play in alcohol venues, limited prevention strategies have been implemented in such places. A total of 11 HIV prevention interventions or programs were identified. HIV prevention interventions in alcohol venues may be conducted at the individual, social, or structural level. However, multilevel interventions that target more than one level appear to lead to the most sustainable behavior change. Strategies to incorporate alcohol venues in biomedical prevention strategies including antiretroviral therapy for alcohol users are also discussed.
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Batchelder AW, Gonzalez JS, Palma A, Schoenbaum E, Lounsbury DW. A Social Ecological Model of Syndemic Risk affecting Women with and At-Risk for HIV in Impoverished Urban Communities. AMERICAN JOURNAL OF COMMUNITY PSYCHOLOGY 2015; 56:229-40. [PMID: 26370203 PMCID: PMC8344336 DOI: 10.1007/s10464-015-9750-y] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/20/2023]
Abstract
Syndemic risk is an ecological construct, defined by co-occurring interdependent socio-environmental, interpersonal and intrapersonal determinants. We posited syndemic risk to be a function of violence, substance use, perceived financial hardship, emotional distress and self-worth among women with and at-risk for HIV in an impoverished urban community. In order to better understand these interrelationships, we developed and validated a system dynamics (SD) model based upon peer-reviewed literature; secondary data analyses of a cohort dataset including women living with and at-risk of HIV in Bronx, NY (N = 620); and input from a Bronx-based community advisory board. Simulated model output revealed divergent levels and patterns of syndemic risk over time across different sample profiles. Outputs generated new insights about how to effectively explore multicomponent multi-level programs in order to strategically develop more effective services for this population. Specifically, the model indicated that effective multi-level interventions might bolster women's resilience by increasing self-worth, which may result in decreased perceived financial hardship and risk of violence. Overall, our stakeholder-informed model depicts how self-worth may be a major driver of vulnerability and a meaningful addition to syndemic theory affecting this population.
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Affiliation(s)
- A W Batchelder
- Osher Center for Integrative Medicine, University of California, San Francisco, 1545 Divisadero Street, 3rd Floor, Box 1726, San Francisco, CA, 94115, USA.
- Ferkauf Graduate School of Psychology, Yeshiva University, New York, NY, USA.
| | - J S Gonzalez
- Ferkauf Graduate School of Psychology, Yeshiva University, New York, NY, USA
- Albert Einstein College of Medicine, Yeshiva University, New York, NY, USA
| | - A Palma
- Albert Einstein College of Medicine, Yeshiva University, New York, NY, USA
- Mailman School of Public Health, Columbia University, New York, NY, USA
| | - E Schoenbaum
- Albert Einstein College of Medicine, Yeshiva University, New York, NY, USA
| | - D W Lounsbury
- Albert Einstein College of Medicine, Yeshiva University, New York, NY, USA
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Pitpitan EV, Strathdee SA, Semple SJ, Chavarin CV, Magis-Rodriguez C, Patterson TL. Buffering Syndemic Effects in a Sexual Risk-Reduction Intervention for Male Clients of Female Sex Workers: Results From a Randomized Controlled Trial. Am J Public Health 2015; 105:1866-71. [PMID: 25713953 PMCID: PMC4529804 DOI: 10.2105/ajph.2014.302366] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/24/2014] [Indexed: 11/04/2022]
Abstract
OBJECTIVES We sought to test the efficacy of a sexual risk intervention for male clients of female sex workers (FSWs) and examine whether efficacy was moderated by syndemic risk. METHODS From 2010 to 2014, we conducted a 2-arm randomized controlled trial (60-minute, theory-based, safer sex intervention versus a didactic time-equivalent attention control) that included 400 male clients of FSWs on the US-Mexico border with follow-up at 4, 8, and 12 months. We measured 5 syndemic risk factors, including substance use and depression. Primary outcomes were sexually transmitted infections incidence and total unprotected sex with FSWs. RESULTS Although participants in both groups became safer, there was no significant difference in behavior change between groups. However, baseline syndemic risk moderated intervention efficacy. At baseline, there was a positive association between syndemic risk and unprotected sex. Then at 12 months, longitudinal analyses showed the association depended on intervention participation (B = -0.71; 95% confidence interval [CI] = -1.22, -0.20; P = .007). Among control participants there still existed this modest association (B = 0.36; 95% CI = -0.49, 1.22; P = .09); among intervention participants there was a significant negative association (B = -0.35; 95% CI = -0.63, -0.06; P = .02). CONCLUSION A brief intervention might attenuate syndemic risks among clients of FSWs. Other populations experiencing syndemic problems may also benefit from such programs.
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Affiliation(s)
- Eileen V Pitpitan
- Eileen V. Pitpitan, Steffanie A. Strathdee, Shirley J. Semple, and Claudia V. Chavarin are with the Division of Global Public Health, Department of Medicine, University of California San Diego. Carlos Magis-Rodriguez is with the Centro Nacional para la Prevención y Control del VIH/SIDA (CENSIDA; National Center for HIV/AIDS Prevention and Control), Ministry of Health, Mexico. Thomas L. Patterson is with the Department of Psychiatry, University of California San Diego
| | - Steffanie A Strathdee
- Eileen V. Pitpitan, Steffanie A. Strathdee, Shirley J. Semple, and Claudia V. Chavarin are with the Division of Global Public Health, Department of Medicine, University of California San Diego. Carlos Magis-Rodriguez is with the Centro Nacional para la Prevención y Control del VIH/SIDA (CENSIDA; National Center for HIV/AIDS Prevention and Control), Ministry of Health, Mexico. Thomas L. Patterson is with the Department of Psychiatry, University of California San Diego
| | - Shirley J Semple
- Eileen V. Pitpitan, Steffanie A. Strathdee, Shirley J. Semple, and Claudia V. Chavarin are with the Division of Global Public Health, Department of Medicine, University of California San Diego. Carlos Magis-Rodriguez is with the Centro Nacional para la Prevención y Control del VIH/SIDA (CENSIDA; National Center for HIV/AIDS Prevention and Control), Ministry of Health, Mexico. Thomas L. Patterson is with the Department of Psychiatry, University of California San Diego
| | - Claudia V Chavarin
- Eileen V. Pitpitan, Steffanie A. Strathdee, Shirley J. Semple, and Claudia V. Chavarin are with the Division of Global Public Health, Department of Medicine, University of California San Diego. Carlos Magis-Rodriguez is with the Centro Nacional para la Prevención y Control del VIH/SIDA (CENSIDA; National Center for HIV/AIDS Prevention and Control), Ministry of Health, Mexico. Thomas L. Patterson is with the Department of Psychiatry, University of California San Diego
| | - Carlos Magis-Rodriguez
- Eileen V. Pitpitan, Steffanie A. Strathdee, Shirley J. Semple, and Claudia V. Chavarin are with the Division of Global Public Health, Department of Medicine, University of California San Diego. Carlos Magis-Rodriguez is with the Centro Nacional para la Prevención y Control del VIH/SIDA (CENSIDA; National Center for HIV/AIDS Prevention and Control), Ministry of Health, Mexico. Thomas L. Patterson is with the Department of Psychiatry, University of California San Diego
| | - Thomas L Patterson
- Eileen V. Pitpitan, Steffanie A. Strathdee, Shirley J. Semple, and Claudia V. Chavarin are with the Division of Global Public Health, Department of Medicine, University of California San Diego. Carlos Magis-Rodriguez is with the Centro Nacional para la Prevención y Control del VIH/SIDA (CENSIDA; National Center for HIV/AIDS Prevention and Control), Ministry of Health, Mexico. Thomas L. Patterson is with the Department of Psychiatry, University of California San Diego
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Theoretical Foundations of Research Focused on HIV Prevention Among Substance-Involved Women: A Review of Observational and Intervention Studies. J Acquir Immune Defic Syndr 2015; 69 Suppl 2:S146-54. [PMID: 25978481 DOI: 10.1097/qai.0000000000000658] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Abstract
Although substance use continues to be a significant component of HIV risk among women worldwide, to date, relatively little attention has been paid in research, services, or policy to substance-involved women (SIW). HIV acquisition for SIW stems from transmission risks directly related to substance use and risks associated with sexual activity in which power to negotiate risk and safety are influenced by dynamics of male partnerships, sex work, and criminalization (of both drug use and sex work), among other factors. As such, HIV risk for SIW resides as much in the environment—physical, social, cultural, economic, and political—in which drug use occurs as it does from transmission-related behaviors of individual women. To reduce HIV infections among SIW, it is important to specify the interaction of individual- and environmental-level factors, including, but not limited to those related to women's own substance use, that can and ought to be changed. This involves theorizing about the interplay of gender, substance use, and HIV risk, and incorporating that theoretical understanding into intervention design and evaluation. A review of the published literature focused on HIV prevention among SIW revealed a general lack of theoretical and conceptual foundation specific to the gender-related and environmental drivers of HIV in this population. Greater theoretical linkages to intersectionality and syndemic approaches are recommended to better identify and target relevant mechanisms by which the interplay of gender dynamics and substance use potentiate the likelihood of HIV acquisition and transmission among SIW.
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Tsai AC, Burns BFO. Syndemics of psychosocial problems and HIV risk: A systematic review of empirical tests of the disease interaction concept. Soc Sci Med 2015; 139:26-35. [PMID: 26150065 DOI: 10.1016/j.socscimed.2015.06.024] [Citation(s) in RCA: 153] [Impact Index Per Article: 17.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2015] [Revised: 06/11/2015] [Accepted: 06/22/2015] [Indexed: 01/13/2023]
Abstract
In the theory of syndemics, diseases co-occur in particular temporal or geographical contexts due to harmful social conditions (disease concentration) and interact at the level of populations and individuals, with mutually enhancing deleterious consequences for health (disease interaction). This theory has widespread adherents in the field, but the extent to which there is empirical support for the concept of disease interaction remains unclear. In January 2015 we systematically searched 7 bibliographic databases and tracked citations to highly cited publications associated with the theory of syndemics. Of the 783 records, we ultimately included 34 published journal articles, 5 dissertations, and 1 conference abstract. Most studies were based on a cross-sectional design (32 [80%]), were conducted in the U.S. (32 [80%]), and focused on men who have sex with men (21 [53%]). The most frequently studied psychosocial problems were related to mental health (33 [83%]), substance abuse (36 [90%]), and violence (27 [68%]); while the most frequently studied outcome variables were HIV transmission risk behaviors (29 [73%]) or HIV infection (9 [23%]). To test the disease interaction concept, 11 (28%) studies used some variation of a product term, with less than half of these (5/11 [45%]) providing sufficient information to interpret interaction both on an additive and on a multiplicative scale. The most frequently used specification (31 [78%]) to test the disease interaction concept was the sum score corresponding to the total count of psychosocial problems. Although the count variable approach does not test hypotheses about interactions between psychosocial problems, these studies were much more likely than others (14/31 [45%] vs. 0/9 [0%]; χ2 = 6.25, P = 0.01) to incorporate language about "synergy" or "interaction" that was inconsistent with the statistical models used. Therefore, more evidence is needed to assess the extent to which diseases interact, either at the level of populations or individuals, to amplify HIV risk.
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Affiliation(s)
- Alexander C Tsai
- Center for Global Health, Massachusetts General Hospital, Boston, MA, United States; Harvard Center for Population and Development Studies, Cambridge, MA, United States; Mbarara University of Science and Technology, Mbarara, Uganda.
| | - Bridget F O Burns
- Center for Global Health, Massachusetts General Hospital, Boston, MA, United States
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Traumatic stress and the mediating role of alcohol use on HIV-related sexual risk behavior: results from a longitudinal cohort of South African women who attend alcohol-serving venues. J Acquir Immune Defic Syndr 2015; 68:322-8. [PMID: 25394191 DOI: 10.1097/qai.0000000000000433] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/24/2023]
Abstract
BACKGROUND In South Africa, alcohol contributes to the HIV epidemic, in part, by influencing sexual behaviors. For some, high levels of alcohol consumption may be driven by previous traumatic experiences that result in traumatic stress. The purpose of this study was to quantify the longitudinal association between traumatic stress and unprotected sex among women who attend drinking venues and to assess whether this association was explained by mediation through alcohol use. METHODS Data were collected in 4 waves over a year from a prospective cohort of 560 women who regularly attended alcohol-serving venues in a Cape Town township. Longitudinal mixed models examined (1) the relationship between traumatic stress and counts of unprotected sex and (2) whether alcohol use mediated the association between traumatic stress and unprotected sex. RESULTS Most women reported elevated traumatic stress (80%) and hazardous alcohol use (88%) at least once during the study period. In models adjusted for covariates, traumatic stress was associated with unprotected sex (b = 0.28, SE = 0.06, t = 4.82, P < 0.001). In addition, traumatic stress was associated with alcohol use (b = 0.27, SE = 0.02, t = 14.25, P < 0.001) and was also associated with unprotected sex (b = 0.20, SE = 0.06, t = 3.27, P < 0.01) while controlling for alcohol use (b = 0.28, SE = 0.07, t = 4.25, P < 0.001). The test for the mediated effect established that alcohol use was a significant mediator, accounting for 27% of the total effect of traumatic stress on unprotected sex. CONCLUSIONS These results highlight the need to address traumatic stress among female venue patrons as an important precursor of HIV risk due to alcohol use.
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Mizuno Y, Purcell DW, Knowlton AR, Wilkinson JD, Gourevitch MN, Knight KR. Syndemic vulnerability, sexual and injection risk behaviors, and HIV continuum of care outcomes in HIV-positive injection drug users. AIDS Behav 2015; 19:684-93. [PMID: 25249392 DOI: 10.1007/s10461-014-0890-0] [Citation(s) in RCA: 47] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
Limited investigations have been conducted on syndemics and HIV continuum of care outcomes. Using baseline data from a multi-site, randomized controlled study of HIV-positive injection drug users (n = 1,052), we examined whether psychosocial factors co-occurred, and whether these factors were additively associated with behavioral and HIV continuum of care outcomes. Experiencing one type of psychosocial problem was significantly (p < 0.05) associated with an increased odds of experiencing another type of problem. Persons with 3 or more psychosocial problems were significantly more likely to report sexual and injection risk behaviors and were less likely to be adherent to HIV medications. Persons with 4 or more problems were less likely to be virally suppressed. Reporting any problems was associated with not currently taking HIV medications. Our findings highlight the association of syndemics not only with risk behaviors, but also with outcomes related to the continuum of care for HIV-positive persons.
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Affiliation(s)
- Yuko Mizuno
- Division of HIV/AIDS Prevention, National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention, Centers for Disease Control and Prevention, 1600 Clifton Road, NE Mail Stop E37, Atlanta, GA, 30333, USA,
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Eaton LA, Cain DN, Pitpitan EV, Carey KB, Carey MP, Mehlomakulu V, Simbayi LC, Mwaba K, Kalichman SC. Exploring the relationships among food insecurity, alcohol use, and sexual risk taking among men and women living in South African townships. J Prim Prev 2015; 35:255-65. [PMID: 24806889 DOI: 10.1007/s10935-014-0346-3] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
South African townships have among the highest rates of HIV infection in the world. Considerable research on understanding the high rates of HIV transmission in this country has identified alcohol use as a critical factor in driving the HIV epidemic. Although the relationship between alcohol use and sexual risk-taking is well documented, less is known about how other factors, such as food insecurity, might be important in understanding alcohol's role in sexual risk-taking. Furthermore, prior research has highlighted how patterns of alcohol use and sexual risk-taking tend to vary by gender. We examined how food insecurity is related to both alcohol use and sexual risk-taking. We administered anonymous community surveys to men (n = 1,137) and women (n = 458) residing within four contiguous Black African townships outside of Cape Town, South Africa. In multivariate linear regression, we found that food insecurity was related to having higher numbers of male sex partners and condom-protected sex acts among women only. These relationships, however, were fully mediated by women's alcohol use. Among men, we found that food insecurity was negatively related to unprotected sex; that is, men with greater food security reported more unprotected sex acts. Unlike the results found among women, this relationship was not mediated by alcohol use. Food insecurity appears to be an important factor in understanding patterns of sexual risk-taking in regards to gender and alcohol use, and may serve as an important point of intervention for reducing HIV transmission rates.
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Affiliation(s)
- Lisa A Eaton
- Center for Health, Intervention and Prevention, University of Connecticut, Storrs, CT, USA,
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Dyer TP, Regan R, Pacek LR, Acheampong A, Khan MR. Psychosocial vulnerability and HIV-related sexual risk among men who have sex with men and women in the United States. ARCHIVES OF SEXUAL BEHAVIOR 2015; 44:429-41. [PMID: 25183549 PMCID: PMC4324087 DOI: 10.1007/s10508-014-0346-7] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/13/2013] [Revised: 01/31/2014] [Accepted: 01/31/2014] [Indexed: 05/12/2023]
Abstract
In the U.S., HIV is concentrated among men who have sex with men (MSM), some of whom have had female partners (MSMW). MSMW are disproportionately impacted by psychosocial vulnerabilities, like depression and substance use that increase sexually transmitted infection (STI) and HIV risk. Research on psychosocial vulnerability and HIV-related sexual risk among MSMW is warranted to reduce infection transmission among MSM and to prevent bridging to female partners. We analyzed data from Wave IV (2007-2008) of the National Longitudinal Study of Adolescent Health to assess psychosocial vulnerability and HIV risk-taking among MSMW. Using lifetime and past year sexual activity, we classified men as ever having sex with: women only (MSW), men only (MSMO) or MSMW, with further refined categorization of MSMW with male only partners in the past 12 months, only female partners in the past 12 months, and both male and female partners in the past 12 months (N = 6,945). We compared psychosocial vulnerability characteristics and HIV-related risk behaviors among the five categories of men. MSMW were more likely to report depression, suicidality, substance use, and incarceration than MSW and MSMO. Compared to MSW, MSMW with current female partners had greater odds of unprotected sex, exchange sex, and STI. MSMW with male partners in the past year had greater odds of multiple or concurrent partners in the past year. HIV risk and psychosocial vulnerability factors are elevated among MSMW, a priority population for HIV risk reduction. HIV risk reduction interventions should address this and heterogeneity of sexual partnerships among MSMW.
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Affiliation(s)
- Typhanye P Dyer
- Department of Epidemiology and Biostatistics, University of Maryland, 2234FF School of Public Health, College Park, MD, 20742, USA,
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O’Connor MJ, Rotheram-Borus MJ, Tomlinson M, Bill C, LeRoux IM, Stewart J. Screening for fetal alcohol spectrum disorders by nonmedical community workers. JOURNAL OF POPULATION THERAPEUTICS AND CLINICAL PHARMACOLOGY = JOURNAL DE LA THERAPEUTIQUE DES POPULATIONS ET DE LA PHARMACOLOGIE CLINIQUE 2014; 21:e442-52. [PMID: 25658901 PMCID: PMC4526235] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Subscribe] [Scholar Register] [Indexed: 06/04/2023]
Abstract
BACKGROUND South Africa has the highest prevalence of Fetal Alcohol Spectrum Disorders (FASD) in the world yet many women have no access to clinic care or to physicians in their communities. The shortage of physicians trained in the diagnosis of FASD is even more severe. Thus there is a need to train community workers to assist in the delivery of health care. OBJECTIVES This study reports on the effectiveness of training community workers to screen for a possible diagnosis of a FASD. METHODS Community workers in Cape Town, South Africa were trained to screen for FASD in 139, 18-month-old toddlers with prenatal alcohol exposure (PAE). Children were assessed according to the salient characteristics of individuals with PAE using height, weight, head circumference (OFC), philtrum, and lip measurements according to criteria set forth by the Institute of Medicine. Screen-positive children were referred for diagnostic assessment to a pediatrician reliably trained in the diagnosis of FASD. RESULTS Of the screen-positive children, 93% received an FASD diagnosis suggesting that the screening procedure was highly sensitive. Diagnoses included 15% with fetal alcohol syndrome (FAS), 23% with Partial FAS, and 62% with Alcohol Related Neurodevelopmental Disorder (ARND, provisional). CONCLUSION The use of community workers to screen for FASD represents a promising approach to effective diagnosis of children affected by PAE in areas lacking adequate medical resources.
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Affiliation(s)
- Mary J. O’Connor
- Department of Psychiatry and Biobehavioral Sciences, David Geffen School of Medicine, University of California at Los Angeles
| | - Mary Jane Rotheram-Borus
- Department of Psychiatry and Biobehavioral Sciences, David Geffen School of Medicine, University of California at Los Angeles
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Choudhry V, Östergren PO, Ambresin AE, Kyagaba E, Agardh A. Giving or receiving something for sex: a cross-sectional study of transactional sex among Ugandan university students. PLoS One 2014; 9:e112431. [PMID: 25386901 PMCID: PMC4227706 DOI: 10.1371/journal.pone.0112431] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2014] [Accepted: 10/03/2014] [Indexed: 11/19/2022] Open
Abstract
OBJECTIVE This study sought to determine the prevalence of transactional sex among university students in Uganda and to assess the possible relationship between transactional sex and sexual coercion, physical violence, mental health, and alcohol use. METHODS In 2010, 1954 undergraduate students at a Ugandan university responded to a self-administered questionnaire that assessed mental health, substance use, physical violence and sexual behaviors including sexual coercion and transactional sex. The prevalence of transactional sex was assessed and logistic regression analysis was performed to measure the associations between various risk factors and reporting transactional sex. RESULTS Approximately 25% of the study sample reported having taken part in transactional sex, with more women reporting having accepted money, gifts or some compensation for sex, while more men reporting having paid, given a gift or otherwise compensated for sex. Sexual coercion in men and women was significantly associated with having accepted money, gifts or some compensation for sex. Men who were victims of physical violence in the last 12 months had higher probability of having accepted money, gifts or some compensation for sex than other men. Women who were victims of sexual coercion reported greater likelihood of having paid, given a gift or otherwise compensated for sex. Respondents who had been victims of physical violence in last 12 months, engaged in heavy episodic drinking and had poor mental health status were more likely to have paid, given a gift or otherwise compensated for sex. CONCLUSIONS University students in Uganda are at high risk of transactional sex. Young men and women may be equally vulnerable to the risks and consequences of transactional sex and should be included in program initiatives to prevent transactional sex. The role of sexual coercion, physical violence, mental health, and alcohol use should be considered when designing interventions for countering transactional sex.
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Affiliation(s)
- Vikas Choudhry
- Division of Social Medicine and Global Health, Department of Clinical Sciences, Faculty of Medicine, Lund University, Malmö, Sweden
- * E-mail:
| | - Per-Olof Östergren
- Division of Social Medicine and Global Health, Department of Clinical Sciences, Faculty of Medicine, Lund University, Malmö, Sweden
| | - Anne-Emmanuelle Ambresin
- Multidisciplinary unit for Adolescent Health, Department of Pediatrics, Lausanne University Hospital- CHUV, Lausanne, Switzerland
| | - Emmanuel Kyagaba
- Department of Dean of Students, Mbarara University of Science and Technology, Mbarara, Uganda
| | - Anette Agardh
- Division of Social Medicine and Global Health, Department of Clinical Sciences, Faculty of Medicine, Lund University, Malmö, Sweden
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Thurston IB, Dietrich J, Bogart LM, Otwombe KN, Sikkema KJ, Nkala B, Gray GE. Correlates of sexual risk among sexual minority and heterosexual South African youths. Am J Public Health 2014; 104:1265-9. [PMID: 24832149 DOI: 10.2105/ajph.2013.301865] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
We explored psychosocial correlates of sexual risk among heterosexual and sexual minority youths (SMYs) in Johannesburg, South Africa. Young people 16 to 18 years old (n = 822) were administered surveys assessing demographic characteristics, sexual behaviors, mental health, and parent-child communication. Adjusted multivariate regressions examining correlates of sexual risk revealed that SMYs had more sexual partners than heterosexual youths (B = 3.90; SE = 0.95; P < .001) and were more likely to engage in sex trading (OR = 3.11; CI = 1.12-8.62; P < .05). South African SMYs are at increased risk relative to their heterosexual peers.
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Affiliation(s)
- Idia B Thurston
- Idia B. Thurston is with the Department of Psychology, University of Memphis, Memphis, TN. Janan Dietrich, Kennedy N. Otwombe, Busiswe Nkala, and Glenda E. Gray are with the Perinatal HIV Research Unit, University of the Witwatersrand, Chris Hani Baragwanath Hospital, Johannesburg, South Africa. Laura M. Bogart is with Boston Children's Hospital and the Harvard Medical School, Boston, MA. Kathleen J. Sikkema is with the Department of Psychology and Neuroscience, Duke University, Durham, NC
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Cognitive Behavioral Therapy for HIV-Negative Heterosexual Meth Users: The FASTLANE II Intervention. COGNITIVE AND BEHAVIORAL PRACTICE 2014. [DOI: 10.1016/j.cbpra.2013.09.004] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
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