Behavioral HIV Prevention Interventions Among Latinas in the US: A Systematic Review of the Evidence

Compared to White women, Latinas are 4 times more likely to contract HIV. In an effort to determine the overall state of the science meant to address this disparity, we reviewed the current HIV prevention intervention literature for U.S. Latinas. We searched 5 online electronic databases from their inception through July, 2014, for HIV prevention interventions including a majority sample of Latinas. Of 1041 articles identified, 20 studies met inclusion criteria. We documented study designs, participant characteristics, outcomes, theories used, and other intervention characteristics. Overall, HIV knowledge and attitudes were the predominant outcome; a small minority of studies included self-reported condom use or STD incidence. Strategies used to address cultural factors specific to Latinas and HIV included; lay health advisors, using ethnographic narratives, or using the Theory of Gender and Power, however few of the interventions adopted these strategies. This study identified several gaps in the intervention literature that need to be addressed. In addition to including more direct measures of decreased HIV risk (ex. condom use), more systematic use of strategies meant to address gender and cultural factors that may place Latinas at increased risk (e.g., gender inequity, traditional gender role norms such as machismo and marianismo, and relationship power dynamics).

HIV among immigrants living in high-income countries: a realist review of evidence to guide targeted approaches to behavioural HIV prevention

BACKGROUND

Immigrants from developing and middle-income countries are an emerging priority in HIV prevention in high-income countries. This may be explained in part by accelerating international migration and population mobility. However, it may also be due to the vulnerabilities of immigrants including social exclusion along with socioeconomic, cultural and language barriers to HIV prevention. Contemporary thinking on effective HIV prevention stresses the need for targeted approaches that adapt HIV prevention interventions according to the cultural context and population being addressed. This review of evidence sought to generate insights into targeted approaches in this emerging area of HIV prevention.

METHODS

We undertook a realist review to answer the research question: 'How are HIV prevention interventions in high-income countries adapted to suit immigrants' needs?' A key goal was to uncover underlying theories or mechanisms operating in behavioural HIV prevention interventions with immigrants, to uncover explanations as how and why they work (or not) for particular groups in particular contexts, and thus to refine the underlying theories. The realist review mapped seven initial mechanisms underlying culturally appropriate HIV prevention with immigrants. Evidence from intervention studies and qualitative studies found in systematic searches was then used to test and refine these seven mechanisms.

RESULTS

Thirty-four intervention studies and 40 qualitative studies contributed to the analysis and synthesis of evidence. The strongest evidence supported the role of 'consonance' mechanisms, indicating the pivotal need to incorporate cultural values into the intervention content. Moderate evidence was found to support the role of three other mechanisms - 'understanding', 'specificity' and 'embeddedness' - which indicated that using the language of immigrants, usually the 'mother tongue', targeting (in terms of ethnicity) and the use of settings were also critical elements in culturally appropriate HIV prevention. There was mixed evidence for the roles of 'authenticity' and 'framing' mechanisms and only partial evidence to support role of 'endorsement' mechanisms.

CONCLUSIONS

This realist review contributes to the explanatory framework of behavioural HIV prevention among immigrants living in high-income countries and, in particular, builds a greater understanding of the suite of mechanisms that underpin adaptations of interventions by the cultural context and population being targeted.

The efficacy of an HIV risk reduction intervention for Hispanic women

Culturally-specific HIV risk reduction interventions for Hispanic women are needed. SEPA (Salud/Health, Educación/Education, Promoción/Promotion, y/and Autocuidado/Self-care) is a culturally-specific and theoretically-based group intervention for Hispanic women. The SEPA intervention consists of five sessions covering STI and HIV prevention; communication, condom negotiation and condom use; and violence prevention. A randomized trial tested the efficacy of SEPA with 548 adult U.S. Hispanic women (SEPA n = 274; delayed intervention control n = 274) who completed structured interviews at baseline and 3, 6, and 12 months post-baseline. Intent-to-treat analyses indicated that SEPA decreased positive urine samples for Chlamydia; improved condom use, decreased substance abuse and IPV; improved communication with partner, improved HIV-related knowledge, improved intentions to use condoms, decreased barriers to condom use, and increased community prevention attitudes. Culturally-specific interventions have promise for preventing HIV for Hispanic women in the U.S. The effectiveness of SEPA should be tested in a translational community trial.

Effects of group prenatal care on psychosocial risk in pregnancy: results from a randomised controlled trial

Few interventions have succeeded in reducing psychosocial risk among pregnant women. The objective of this study was to determine whether an integrated group prenatal care intervention already shown to improve perinatal and sexual risk outcomes can also improve psychosocial outcomes compared to standard individual care. This randomised controlled trial included pregnant women ages 14-25 from two public hospitals (N = 1047) who were randomly assigned to standard individual care, group prenatal care or integrated group prenatal care intervention (CenteringPregnancy Plus, CP+). Timing and content of visits followed obstetrical guidelines, from 18-week gestation through birth. Each 2-h group prenatal care session included physical assessment, education/skills building and support via facilitated discussion. Using intention-to-treat models, there were no significant differences in psychosocial function; yet, women in the top tertile of psychosocial stress at study entry did benefit from integrated group care. High-stress women randomly assigned to CP+ reported significantly increased self-esteem, decreased stress and social conflict in the third trimester of pregnancy; social conflict and depression were significantly lower 1-year postpartum (all p-values < 0.02). CP+ improved psychosocial outcomes for high-stress women. This 'bundled' intervention has promise for improving psychosocial outcomes, especially for young pregnant women who are traditionally more vulnerable and underserved.

Interventions for encouraging sexual behaviours intended to prevent cervical cancer

BACKGROUND

Human papillomavirus (HPV) is the key risk factor for cervical cancer. Continuing high rates of HPV and other sexually transmitted infections (STIs) in young people demonstrate the need for effective behavioural interventions.

OBJECTIVES

To assess the effectiveness of behavioural interventions for young women to encourage safer sexual behaviours to prevent transmission of STIs (including HPV) and cervical cancer.

SEARCH STRATEGY

Systematic literature searches were performed on the following databases: Cochrane Central Register of Controlled Trials (CENTRAL Issue 4, 2009) Cochrane Gynaecological Cancer Review Group (CGCRG) Specialised Register, MEDLINE, EMBASE, CINAHL, PsychINFO, Social Science Citation Index and Trials Register of Promoting Health Interventions (TRoPHI) up to the end of 2009. All references were screened for inclusion against selection criteria.

SELECTION CRITERIA

Randomised controlled trials (RCTs) of behavioural interventions for young women up to the age of 25 years that included, amongst other things, information provision about the transmission and prevention of STIs. Trials had to measure behavioural outcomes (e.g. condom use) and/or biological outcomes (e.g. incidence of STIs, cervical cancer).

DATA COLLECTION AND ANALYSIS

A narrative synthesis was conducted. Meta-analysis was not considered appropriate due to heterogeneity between the interventions and trial populations.

MAIN RESULTS

A total of 5271 references were screened and of these 23 RCTs met the inclusion criteria. Most were conducted in the USA and in health-care clinics (e.g. family planning).The majority of interventions provided information about STIs and taught safer sex skills (e.g. communication), occasionally supplemented with provision of resources (e.g. free sexual health services). They were heterogeneous in duration, contact time, provider, behavioural aims and outcomes. A variety of STIs were addressed including HIV and chlamydia. None of the trials explicitly mentioned HPV or cervical cancer prevention.Statistically significant effects for behavioural outcomes (e.g. increasing condom use) were common, though not universal and varied according to the type of outcome. There were no statistically significant effects of abstaining from or reducing sexual activity. There were few statistically significant effects on biological (STI) outcomes. Considerable uncertainty exists in the risk of bias due to incomplete or ambiguous reporting.

AUTHORS' CONCLUSIONS

Behavioural interventions for young women which aim to promote sexual behaviours protective of STI transmission can be effective, primarily at encouraging condom use. Future evaluations should include a greater focus on HPV and its link to cervical cancer, with long-term follow-up to assess impact on behaviour change, rates of HPV infection and progression to cervical cancer. Studies should use an RCT design where possible with integral process evaluation and cost-effectiveness analysis where appropriate. Given the predominance of USA studies in this systematic review evaluations conducted in other countries would be particularly useful.

A lifetime of low-risk behaviors among HIV-positive Latinas in Los Angeles

The objective is to assess the differences in lifetime and current transmission risk behaviors of HIV-positive and HIV-negative Latinas. In 2005-2006, 214 HIV-positive Latinas were recruited from systems of care and 111 HIV-negative Latina-matched controls were interviewed in Los Angeles, CA regarding lifetime and recent sexual and drug-taking risk behaviors. Multivariate OLS regression and logistic regression models were used to assess differences in lifetime and current transmission risk. There was no significant difference between the two groups with respect to lifetime exposure through injection drug use. HIV-positive Latinas reported significantly more lifetime sexual partners than HIV-negative Latinas. Rates of current sexual activity were not significantly different across the two groups. HIV-positive Latinas were less likely to report recent unprotected sex relative to HIV-negative Latinas. In Los Angeles, HIV-positive and HIV-negative Latinas were very similar with respect to transmission risk. The challenges these findings pose to prevention efforts that target Latinas and suggestions for new interventions are discussed.

Addressing barriers to cultural competence

Although the need for cultural competence in healthcare is well established, the integration of cultural competence approaches in most healthcare settings is not yet a reality. A review of the literature reveals several factors in clinical settings that pose barriers for health providers. The purpose of this article is to explore the barriers to cultural competence faced by nurses and to examine the role of staff development in addressing these barriers.

A randomized clinical trial of an HIV-risk-reduction intervention among low-income Latina women

BACKGROUND

HIV infection has increased within the Latina community more than in any other ethnic or racial group within the United States. Latinas comprise only 13% of the U.S. population, yet they account for 20% of the cumulative reported cases of AIDS.

OBJECTIVES

The purpose of the study was to evaluate a randomized culturally tailored intervention to prevent high-HIV-risk sexual behaviors for Latina women residing in urban areas.

METHODS

Mexican and Puerto Rican women (18-44 years of age; N = 657) who were sexually active during the previous 3 months were recruited and randomized into intervention and control groups. The intervention, facilitated by bilingual, bicultural, trained Latina women, consisted of culturally tailored sessions on understanding their bodies, HIV/AIDS and sexually transmitted diseases, condoms (myths and use), negotiating safer sex practices, violence prevention, and partner communication. Bivariate and multivariate analyses assessed changes from baseline.

RESULTS

The intervention improved HIV knowledge, partner communication, risk-reduction behavioral intentions, and condom use, and decreased perceived barriers to condom use.

DISCUSSION

The efficacy of a culturally-sensitive intervention to reduce HIV/AIDS-risk behaviors in Latina women was demonstrated in the current study.

Evaluation of the Dutch AIDS information helpline: an investigation of information needs and satisfaction of callers

AIDS telephone hotlines have an important function in AIDS education, HIV prevention and counselling. In this study, consults of the Dutch AIDS information helpline were evaluated to determine the AIDS information needs of the callers and callers' satisfaction with the telephone-delivered information and consultation. Immediately after their telephone consult, callers (N = 309) were redirected to co-workers of an independent telephone survey. They participated in an interview on content and evaluation of the telephone consult. This study shows that most telephone calls concerned questions about personal risk of HIV transmission, HIV transmission in general and HIV testing. Callers were very satisfied with the services of the helpline. Furthermore, helpline employees' counselling and conversation skills were evaluated very positively. These results are discussed within the scope of the professional organization of the Dutch AIDS information helpline.

Cultural Landscapes and Cultural Brokers of Sexual and Reproductive Health in U.S. Latino and Latin American Populations

A literature review synthesizing 19 recent journal articles related to sexual and reproductive health education in U.S. Latino and Latin American populations. Emphasis is on the role of culture and qualitative research methodologies and listening to the voice of communities. Part 1 deals with the cultural landscape: social influence on behavior by male partners, family, and community. Part 2 describes the roles played by lay health providers and promoters (parteras, promotoras, poetas) as cultural brokers influencing sexual and reproductive health behavior.