Strength-based interventions for HIV prevention and sexual risk reduction among girls and young women: A resilience-focused systematic review

The "Cycle" of HIV: Limits of Personal Responsibility in HIV Vulnerability Among Transgender Adolescents and Young Women in Lima, Peru

Globally, transgender women (TW) face a high burden of the HIV epidemic. In Peru, HIV prevalence among TW rises at age 25, indicating a need to understand HIV vulnerability as adolescents reach adulthood. The life course of TW is often marked by abuse, discrimination and poverty fueled by transphobic stigma. Approaches to the HIV epidemic among TW and adolescents emphasize problem behaviors such as unprotected sex and substance. However, there has been a call for HIV research and interventions to understand and leverage community strengths. This qualitative study utilized a transgender-oriented, strength-based, intersectional and feminist approach to understand the strengths and protective health behaviors among 17 transgender adolescents and young women (TAYW) age 16-24 in Lima, Peru. Most participants re-located to Lima from the Amazon due to familial rejection, and engaged in obligatory sex work. TAYW demonstrated self-knowledge, motivation for education, efforts to secure employment, strong community networks, legal advocacy, avoiding problem substance use, HIV knowledge and condom use. However, strengths were impeded by multi-level barriers such as familial physical abuse, educational discrimination, and sexual assault which led to increased HIV vulnerability. We created a conceptual model of the "cycle" of HIV to describe the limits of personal responsibility within a vulnerable community denied access to family, education, employment and human rights. We recommend researchers, clinicians and public health workers follow the lead of TAYW at the frontlines of the HIV epidemic, and support beloved communities and enabling environments which may permit protective behaviors to mitigate HIV vulnerability.

Associations of Minority Stressors, Alcohol Use Disorder, Resilience, and HIV Testing Self-Efficacy Among Community-Based Black Men Who Have Sex with Men in a Southern U.S. City: A Causal Mediation and Moderation Analysis

Background: Black men who have sex with men (BMSM) face multiple minority stressors (e.g., homophobia, racism, and presumed HIV status) that may indirectly erode their confidence in pursuing HIV testing uptake through exacerbating alcohol use disorder (AUD). Objectives: Using cross-sectional data from 203 community-based BMSM (71.4% as homosexual with a mean age of 26 years) living in a Southern US city, we conducted a causal mediation and moderation analysis to investigate in/direct pathways linking minority stressors, AUD risk, and self-efficacy of HIV testing, including how resilience may moderate these associations. Results: Our mediation analysis revealed that AUD risk accounted for 32.1% of the total effect of internalized homonegativity (βtotal effect = -0.424; SE=0.071; p<0.001), 28.6% of the total effect of experienced homophobia (βtotal effect = -0.684; SE=0.122; p<0.001), and 15.3% of the total effect of perceived HIV stigma (βtotal effect = -0.361; SE=0.164; p<0.05) on HIV testing self-efficacy. Resilience significantly moderated the associations of experienced homophobia (β = -0.049; SE=0.011; p<0.001), internalized homonegativity (β = -0.065; SE=0.027; p<0.01), and perceived HIV stigma (β = -0.034; SE=0.013; p<0.05) with AUD risk. Resilience also significantly moderated the associations of experienced homophobia (β = -0.073; SE=0.021; p<0.01), internalized homonegativity (β = -0.082; SE=0.012; p<0.001), perceived HIV stigma (β = -0.037; SE=0.039; p<0.05), and AUD risk (β = -0.021; SE=0.015; p<0.05) with HIV testing self-efficacy. Conclusions: Our study provides important implications in identifying multilevel sources for building resilience among BMSM to buffer the effects of minority stress on AUD risk and improve HIV testing outcomes.

Exploring the Longitudinal Influence of Perceived Social Support, HIV Stigma, and Future Orientation on Depressive Symptoms Among People Living with HIV in China

Prior studies demonstrated that perceived social support is negatively associated with behavioral and mental health problems among people living with HIV (PLWH). However, longitudinal data regarding the associations between perceived social support, internalized HIV stigma, future orientation, and depressive symptoms are limited. The current study aimed to investigate the possible indirect relationship between these variables using four-wave follow-up data (6-month intervals) from a sample of 1,098 Chinese PLWH (Mage = 38.63, SD = 9.20, age range: 18-60 years; 63.9% men). All participants were asked to complete an adapted version of Perceived Social Support Scale, Internalized HIV Stigma Scale, Optimism About the Future Scale, and Center of Epidemiological Studies Depression Scale. Results indicated that perceived social support at baseline was negatively related to depressive symptoms at wave 4. Internalized HIV stigma at wave 2 and future orientation at wave 3 indirectly affected the linkage between perceived social support at baseline and depressive symptoms serially over time. This study highlights the essential role of perceived social support in alleviating depressive symptoms among PLWH, and underscores the complex interplay in which internalized HIV stigma and future orientation serially mediated the relationship between perceived social support and depressive symptoms. These findings suggest the need for integrated interventions to enhance social support, address HIV-related stigma, and promote positive future orientation, which could potentially alleviate depressive symptoms and promote mental well-being among PLWH.

"A spade was called a spade … ": Youth and intervention implementers' perceptions of a resilience-based HIV-prevention intervention for youth in South Africa

The youth (15-24 years old) in South Africa remain at high risk of HIV infection despite varied efforts to control the disease. An understanding of the perspectives of relevant stakeholders of HIV-prevention interventions targeting the youth is important to guide research, policy and practice aimed at improving these interventions. This study explores youth and intervention implementers' perceptions of a resilience-based HIV-prevention intervention (You Only Live Once) aimed at reducing risky sexual behaviours among the youth in South Africa. Semi-structured interviews were conducted with 10 young people who participated in the intervention, and four intervention implementers at a not-for-profit organisation in Maluti-a-Phofung Local Municipality, South Africa. Data were analysed using thematic analysis. Three main themes emerged from the data: (1) Acceptability and impact of the intervention; (2) Factors influencing intervention implementation; and (3) Recommendations to improve intervention implementation. These findings provide insights into the acceptability, impact, barriers and facilitators of resilience-based HIV-prevention interventions for the youth in South Africa and similar contexts, and how implementation of these interventions could be enhanced. The findings can help researchers, policy makers and health care practitioners in the field of HIV prevention to improve interventions targeting young people.

Development and Validation of Safe Motherhood-Accessible Resilience Training (SM-ART) Intervention to Improve Perinatal Mental Health

Perinatal mental health issues in women can lead to a variety of health complications for both mother and child. Building resilience can strengthen coping mechanisms for pregnant women to improve their mental health and protect themselves and their children. The study aims to develop and validate the contextual and cultural appropriateness of the Safe Motherhood-Accessible Resilience Training (SM-ART) intervention for pregnant women in Pakistan. A three-phase approach was used to develop and validate an intervention that promotes resilience in pregnant women. Phase I comprised a needs assessment with stakeholders (pregnant women and key informants) to elicit opinions regarding module content. In Phase II, an intervention to build resilience was developed with the help of a literature review and formative assessment findings, and Phase III involved the validation of the intervention by eight mental health experts. The experts assessed the Content Validity Index (CVI) of the SM-ART intervention on a self-developed checklist. The resultant SM-ART intervention consists of six modules with strong to perfect CVI scores for each of the modules. Qualitative responses endorsed the strengths of the intervention as having innovative and engaging activities, contextual and cultural relevance, and a detailed, comprehensive facilitator guide. SM-ART was successfully developed and validated and is now ready for testing to promote the resilience of pregnant women at risk of perinatal mental illness.

Leveraging Resilience-supportive Strategies to Enhance Protective Factors in Young Sexual Minority Men: A Scoping Review of HIV Behavioral Interventions Implemented in High-income Countries

Behavioral HIV interventions focused on strengthening young sexual minority men's (SMM) internal (assets) and external (resources) protective factors are promising, yet their evaluation as resilience-supportive strategies to minimize or negate HIV-related risks remain understudied. The objective of this scoping review was to describe resilience-supportive intervention strategies that have been used to achieve desired HIV behavioral outcomes and to identify how these strategies have been evaluated using a resilience analytic framework. Our scoping review uncovered 271 peer-reviewed articles, of which 38 were eligible for inclusion based on our review criteria. The majority of interventions relied on social support strategies as their primary resilience-supportive strategy. A third of interventions reviewed analyzed their findings from a deficits-focused model, another third used compensatory resilience models, and the remaining interventions employed a hybrid (i.e., deficit and compensatory model) strategy. None of the interventions evaluated their intervention effects using a risk-protective model. From our synthesis regarding the current state of research around resilience-informed interventions, we propose strategies to inform the design of resilience-supportive approaches and make recommendations to move the field forward on how to develop, implement, and measure young SMM's resiliency processes.

Perceptions of Risks and Benefits of Participating in HIV Cure-Related Research Among Diverse Young Adults Living with HIV in the United States: Qualitative Research Findings

In the United States, young adults have the highest rates of new HIV infections, and are less likely to be aware of their infection, be engaged in care, or achieve HIV viral suppression. As biomedical HIV research increasingly focuses on achieving long-term suppression without antiretroviral therapy (ART) and finding an HIV cure, little is known about perceptions of young adults living with HIV (YLWH) regarding HIV cure research. We recruited a diverse sample of 20 YLWH (18-29 years old) to participate in individual semistructured qualitative interviews to explore knowledge and perceptions of HIV cure research, and motivations and barriers to participation. Most participants had little knowledge of HIV cure research. Motivators of HIV cure research participation included altruism, stigma reduction, and the elimination of the clinical burdens of HIV. Barriers included potential physical side effects, psychological distress, the possibility of disclosure as a result of participating, and the amount of time required to participate. Most participants had concerns about analytic treatment interruptions (i.e., ART interruption to assess HIV remission), and indicated that they would want more frequent laboratory testing and protection for their sex partners during this time. Finally, participants suggested that, if other YLWH are considering participation in cure research, they should first learn as much as possible about the research, and then consider the potential personal benefits and the contribution that they could make to science and their communities. As HIV cure research advances, the participation of YLWH will be critical. Our study provides knowledge about how YLWH view HIV cure research. More sociobehavioral research is needed to ensure that those who are most likely to be the decision-makers and beneficiaries of an HIV cure are included at all levels of research.

Predictors of Resilience Among Adolescent Girls and Young Women Who Have Experienced Intimate Partner Violence and Sexual Violence in South Africa

South Africa has some of the highest rates of intimate partner and sexual violence globally, with prevalence ranging from 10% to 21% among adolescent girls and young women (AGYW). Yet, few studies characterize the relationship between violence and resilience. Identifying factors associated with resilience following exposure to violence can guide the development of strength-based interventions that change modifiable protective factors to bolster resilience. Data were derived from a cross-sectional survey of AGYW aged 15 to 24 years in South Africa that took place from 2017 to 2018. This survey was part of a national evaluation of a South African combination HIV intervention for AGYW funded by the Global Fund to Fight AIDS, TB, and Malaria. A sample of 4,399 observations was achieved through a systematic random sampling frame of 35% of households in districts where AGYW were at highest risk for HIV, and where the intervention was implemented. Resilience was assessed using the Connor-Davidson Resilience Scale. Intimate partner and sexual violence were assessed using: (a) an adapted version of a questionnaire from the World Health Organization's 2005 multicountry study on domestic violence against women, and (b) questions on lifetime experience of forced sex/rape. Nearly a third of AGYW (29.6%) reported intimate partner emotional and/or physical and/or sexual violence in the past year. Nearly a quarter of AGYW (23.74%) reported emotional violence, 17.48% reported physical violence, and 6.37% reported sexual violence from intimate partners. Nearly 8% (7.72%) reported forced sex/rape from intimate partners and/or nonpartners. More equitable gender norms, higher social support, and hazardous drinking were positively associated with higher resilience among those who experienced physical or sexual violence. This study addresses a gap in the resilience and violence literature. Future research should focus on the development of resilience-promoting interventions for individuals who have experienced violence.

"I feel like it is asking if he is a stalker … but I also feel like it is asking if he cares": exploring young South African women and men's perceptions of the Sexual Relationship Power Scale

Background

Gender inequity and the subsequent health impacts disproportionately affect communities in the Global South. However, most gender equity measures, such as Pulerwitz’ (2000) Sexual Relationship Power Scale (SRPS), are developed and validated in the Global North and then applied in Global South settings without investigation of context applicability or validity. This study examines the SRPS’ validity evidence, comprehensiveness, and contemporary relevance for young South African women and men.

Methods

Between 2019 and 2021, 38 cognitive interviews (CIs) were conducted among previous participants of a South African youth cohort study ‘AYAZAZI’ (2015–2017) to explore youth’s perceptions of the SRPS. The SRPS measures women’s perceptions of their partner’s controlling behaviours, and men’s perceptions of their own controlling behaviours. Using CIs, participants responded to a 13-item adaptation of the SRPS for use among South African youth (strongly agree-strongly disagree), and then were asked to think-aloud their reasoning for responses, their understanding and perceived relevance of each item, and made overall suggestions for scale adaptations. An item appraisal coding process was applied, whereby Cognitive Coding assessed the types of cognitive problems youth had with understanding the items, and Question Feature Coding assessed which item features caused problems for participant understandings. Finally, youth recommendations for scale adaptations were summarized.

Results

Overall, 21 women and 17 men aged 21–30 participated in CIs in Durban and Soweto, South Africa. Cognitive Coding revealed 1. Comprehension issues, and 2. Judgements related to items’ applicability to lived experiences and identities (e.g., being unmarried). Question Feature Coding revealed items’ 1. Lack of clarity or vagueness in wording and 2. Logical problems in assumptions leading to multiple interpretations (e.g., item ‘my partner always need to know where I am’ interpreted as both controlling and caring behaviour). Multiple, overlapping issues revealed how many items failed to “fit” within the present-day living realities of South African youth. Youth recommended several item adaptations and additions, including strength-based items, to existing measures of gender equity and relationship power.

Conclusion

Given identified issues, several adaptations including revising items to be more inclusive, contemporary, context specific, relational, and strength-based are needed to validly measure gender equity and power dynamics within the relationships of South African youth.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12889-022-13686-9.

Using the science of positive psychology in the formative evaluation of social justice interventions: A case example

The pursuit of culturally responsive approaches for designing and evaluating programs to promote social justice has become of the utmost importance to the evaluation community in the past decade. A strengths-focused evaluation approach has great promise for empowering individuals, groups, communities, and organizations, and identifying program strengths to build upon in addition to illuminating program deficits. However, there is a dearth of literature on using a strengths approach to evaluate interventions and programs to promote social justice. Drawing from the two disciplines of positive psychology and evaluation, this article illustrates a strengths-focused approach to formative evaluation using a case example of a halfway house for previously incarcerated women. The findings exemplify the positive psychological phenomena that emerge as a result of focusing the evaluation on program strengths. The case demonstrates that the application of a strengths-focused approach to evaluating social justice interventions can be empowering for institutions and the communities they serve.

Perceived HIV Invulnerability and PrEP Knowledge and Attitudes among Black Sexual Minority Women

Black women have disproportionate rates of HIV compared to women of all other racial groups. The purpose of this analysis was to investigate perceived HIV risk, HIV and STI testing behaviors, and PrEP knowledge and attitudes among Black sexual minority women (SMW) and examine differences based on their history of male sex partners. Secondary data analysis was conducted using data from the Generations Study. This analysis used a sample of N=149 participants who identified as Black cisgender women. Results showed Black SMW with a history of male sex partners reported a higher perceived risk of contracting HIV and significantly more frequent HIV and STI testing than those without a history of male sex partners. Overall, most of the sample was not familiar with PrEP, but one-third had favorable attitudes towards it, and half felt like they did not know enough about PrEP to form an opinion. Implications for culturally relevant public health campaigns and comprehensive sexuality education that integrate PrEP are included.

Considerations for Increasing Racial, Ethnic, Gender, and Sexual Diversity in HIV Cure-Related Research with Analytical Treatment Interruptions: A Qualitative Inquiry

Despite disproportionate incidence and prevalence of HIV among transgender individuals, cisgender women, and racial and ethnic minority groups, all remain underrepresented in HIV cure research. As HIV cure trials are scaled up, there is emerging research on ways to mitigate risks of HIV acquisition for sexual partners of analytical treatment interruption (ATI) trial participants. As such, it is imperative that HIV cure researchers consider the implications of implementing ATIs in populations that are disproportionately affected by HIV, but largely underrepresented in trials to date. In this qualitative study, we sought to derive triangulated perspectives on the social and ethical implications regarding ATIs and partner protection strategies during ATIs among under-represented populations. We conducted 21 in-depth interviews with 5 types of informants: bioethicists, community members [people living with HIV (PLWH) and their advocates], biomedical HIV cure researchers, sociobehavioral scientists, and HIV care providers. We analyzed the data using conventional content analysis and reduced the data to important considerations for implementing ATI trials in diverse communities and settings. Our study revealed the following key themes: (1) attention must be paid to gender and power dynamics in ATI trials; (2) ATI trials should be designed and implemented through the lenses of intersectionality and equity frameworks; (3) ATI trials may have both positive and negative effects on stigma for PLWH and their partners; and (4) partnership dynamics should be considered when designing ATI protocols. Our study generated actionable considerations that could be implemented in ATI trials to promote their acceptability to communities that have been underrepresented in HIV cure research to date. Research teams must invest in robust community and stakeholder engagement to define best practices. Paying attention to representation and equity will also promote better and more equitable implementation of HIV cure strategies once these become ready for rollout.

Current Resources for Evidence-Based Practice, July 2020

An extensive review of new resources to support the provision of evidence-based care for women and infants. The current column includes a discussion of whether it is ethical not to offer doula care to all women, and commentaries on reviews focused on folic acid and autism spectrum disorder, and timing of influenza vaccination during pregnancy.