Prevention interventions for human immunodeficiency virus in drug-using women with a history of partner violence

A PrEP Demonstration Project Using eHealth and Community Outreach to Justice-Involved Cisgender Women and Their Risk Networks

Women involved in criminal justice systems (WICJ) are a key population at risk for HIV, and pre-exposure prophylaxis (PrEP) is critical for HIV prevention. This project was designed to evaluate the feasibility and acceptability of delivering PrEP via eHealth to WICJ and members of their risk network (RN). We recruited HIV-negative cisgender WICJ index participants (n = 38) and risk network (RN) members (n = 67) using modified respondent-driven sampling. TDF/FTC was initiated for PrEP in participants meeting clinical criteria and dispensed through eHealth using a community-based, low barrier-to-care outreach model. Key steps in the PrEP care continuum were measured over 12 months. Enrolled participants (n = 105) had high current and lifetime justice-involvement and were predominantly cisgender women and non-Hispanic white with a mean age of 40.9y (SD 9.6). Despite most having primary care providers and medical insurance, PrEP awareness was low, and participants experienced high levels of medical, psychiatric, substance use, social, and economic need. Fifty-two participants (50%) were PrEP-eligible, of whom 24 (46%) initiated PrEP. TDF/FTC was safe and well-tolerated throughout follow-up and 13 individuals chose to remain on PrEP following study conclusion. In this novel PrEP demonstration project for WICJ and RN members, despite high medical, psychiatric, and social comorbidity, PrEP was positively received and effectively delivered using a community outreach model via eHealth.Registered on clinicaltrials.gov under trial registration number NCT03293290.

Structural and syndemic barriers to PrEP adoption among Black women at high risk for HIV: a qualitative exploration

In the USA, Black women are at disproportionately higher risk for HIV compared to women of other races/ethnicities, which can be explained by the Substance Abuse, Violence and AIDS (SAVA) syndemic. Disparities in HIV, substance use and violence are driven by multiple influences, including structural factors (e.g. housing and poverty), which exacerbate social- and individual-level factors leading to more sex partners, engaging in unprotected sex, having sex for money, experiencing forced sex from an intimate partner or increased substance use, all of which increase HIV risk. Pre-exposure prophylaxis (PrEP), a pill that can prevent HIV, is a discreet and underutilised method that Black women experiencing syndemics can use to decrease their risk. This study explored Black women's interest in, and barriers to adopting PrEP over 6 months. Thirty Black women (age M = 32.2) who experienced multiple substance use, violence and HIV-related syndemic factors were interviewed four times over a 6-month period. Results demonstrated that experiencing intimate partner violence, substance use, community violence and other structural factors (poor access to social services, transport and childcare) all acted as barriers to PrEP adoption. Future research should consider multi-level interventions that include methods such as media campaigns, providing PrEP or referrals where women who experience syndemic and structural factors seek help, and implement a PrEP adherence programmes and interventions in support group settings.

"Violence and love and drugs…it all goes hand in hand": A mixed methods analysis of the substance abuse, violence, and HIV/AIDS syndemic among women who use methamphetamine

Background: The synergistic epidemics of substance use, violence, and HIV/AIDS, also known as the SAVA syndemic, disproportionately affects vulnerable women in the United States. Methamphetamine use is closely linked with physical and sexual violence, including intimate partner violence (IPV), which heightens women's vulnerability to HIV. This mixed methods study examined the prevalence and correlates of violence among women who use methamphetamine, (n = 209) enrolled in an HIV intervention study in San Diego, California. Methods: At baseline, 209 women completed an interviewer-administered computer-assisted survey. A sub set of women who reported lifetime IPV (n = 18) also participated in qualitative interviews to contextualize our understanding of patterns of violence over time. Results: In the overall cohort, reports of lifetime (66.0%) and past 2-month (19.6%) IPV were prevalent. Moreover, women reported lifetime physical only (27.3%), sexual only (6.2%), or both forms of violence (50.7%) by multiple perpetrators. Factors independently associated with lifetime IPV were having unprotected sex with a steady partner (odds ratio [OR]: 2.50, 95% confidence interval [CI]: 1.04, 6.00) and being high on methamphetamine during unprotected sex with a steady partner (OR: 2.56, 95% CI: 1.30, 5.09) within the past 2 months. Our qualitative narratives illuminated how IPV in women's steady relationships often reflects a culmination of violent victimization throughout their lifetime which is further exacerbated by methamphetamine use and sexual risk through gendered power dynamics. Conclusions: HIV prevention interventions should address the SAVA syndemic in a holistic manner, including the role of methamphetamine use in the context of women's abusive steady relationships.

Mood, Meth, Condom Use, and Gender: Latent Growth Curve Modeling Results from a Randomized Trial

Methamphetamine use poses increased risk for HIV and other sexually transmitted infections. There is robust evidence that methamphetamine use increases sexual risk behavior, like condomless sex, primarily among men who have sex with men but also among heterosexual women and men. Gender differences have been found among women and men who use meth, and there is a high degree of interconnectedness between meth use, depression, and condomless sex. The aims of the current study are to evaluate the efficacy of a theory-based, tri-focal intervention designed to reduce depression, meth use, and condomless sex among women and men, and to examine gender as a moderator of efficacy. A total of 432 HIV-negative women and men who use meth participated in a two-arm randomized controlled trial and completed baseline and follow-up assessments at 4, 8, and 12 months. We used latent growth curve modeling techniques to analyze the data. Results showed that while all participants exhibited reductions in depression, meth use, and condomless sex, the intervention and comparison groups did not differ in changes over time. However, we did find a significant gender moderation effect, such that among men, those in the intervention arm reported greater reductions in meth use relative to those in the comparison group; reduced meth use was associated with reduced condomless sex, but not depression. In contrast, women in the intervention condition did not differ from women in the comparison condition in changes in any of the three outcome variables. Interventions targeting heterosexual women and men who use meth must be gender-specific, and take into account the unique vulnerabilities and experiences of women, including the perceived positive aspects of using meth, gendered power dynamics, higher depression, and violence.

"When you get old like this … you don't run those risks anymore": influence of age on sexual risk behaviors and condom use attitudes among methamphetamine-using heterosexual women with a history of partner violence

BACKGROUND

Drug use and partner violence affect older women, yet few studies highlight age-specific HIV risks and prevention strategies. This study compares sexual risk behaviors, condom use attitudes, and HIV knowledge between midlife/older women (ages 45+) and younger women (ages 18-44) reporting methamphetamine use and partner violence in San Diego, California.

METHODS

Our mixed methods study used themes from a qualitative substudy (n = 18) to inform logistic regression analysis of baseline data from an HIV behavioral intervention trial (n = 154).

FINDINGS

Age-related qualitative themes included physiologic determinants, HIV knowledge, and "dodging the bullet," referring to a lifetime of uncertainty surrounding HIV serostatus after engaging in unsafe drug and sex practices. Midlife/older age was associated with never being married (24.2% vs. 51.2; p = .03), having less than a high school education/GED (12.1% vs. 34.7%; p = .04), lower condom use self-efficacy (2.87 vs. 3.19; p = .03), lower positive outcome expectancies (1.9 vs. 2.1; p = .04), and lower HIV knowledge (85.3% vs. 89.7%; p = .04); however, sexual risk behaviors were not associated with age group. In the multivariate analysis, midlife/older age remained independently associated with lower condom use self-efficacy (adjusted odds ratio, 0.49; 95% CI, 0.27-0.87) and lower HIV knowledge (adjusted odds ratio, 0.96; 95% CI, 0.93-0.99).

CONCLUSIONS

Midlife/older methamphetamine-using women with experiences of partner violence present similar sexual risk profiles, but possess different HIV-related knowledge and attitudes toward prevention methods compared with their younger counterparts. Clinicians and public health practitioners can have a positive impact on this overlooked population by assessing HIV risks during routine screenings, encouraging HIV testing, and providing age-appropriate HIV prevention education.

Women's perspectives on female-initiated barrier methods for the prevention of HIV in the context of methamphetamine use and partner violence

BACKGROUND

Female-initiated barrier methods for the prevention of HIV may be an effective alternative for drug-using women who are unable to negotiate safe sex, often as a result of physical and/or sexual partner violence.

METHODS

Utilizing a SAVA (substance abuse, violence, and AIDS) syndemic framework, we qualitatively examined perspectives on female condoms and vaginal microbicides among 18 women with histories of methamphetamine abuse and partner violence in San Diego, California.

FINDINGS

Most women were not interested in female condoms owing to perceived discomfort, difficulty of insertion, time-intensive effort, and unappealing appearance. Alternatively, most women viewed vaginal microbicides as a useful method. Positive aspects included convenience, ability to disguise as a lubricant, and a sense of control and empowerment. Concerns included possible side effects, timing of application, and unfavorable characteristics of the gel. Acceptability of female-initiated barrier methods was context dependent (i.e., partner type, level of drug use and violence that characterized the sexual relationship).

CONCLUSIONS

Findings indicate that efforts are needed to address barriers identified for vaginal microbicides to increase its uptake in future HIV prevention trials and marketing of future Food and Drug Administration-approved products. Strategies should address gender-based inequalities (e.g., partner violence) experienced by drug-using women and promote female empowerment. Education on female-initiated barrier methods is also needed for women who use drugs, as well as health care providers and other professionals providing sexual health care and contraception to women with histories of drug use and partner violence.

Prevalence and correlates of female condom use and interest among injection drug-using female sex workers in two Mexico-US border cities

Little is known about female condom use among female sex workers who inject drugs (FSW-IDUs) in Northern Mexico, where HIV/STI prevalence is high. We examined the prevalence and correlates of female condom use and interest in female condom use among FSW-IDUs aged >18 years in Tijuana and Ciudad Juárez, Mexico enrolled in a behavioral intervention designed to reduce high-risk sexual and injection behaviors. Of 621 FSW-IDUs, 8 % reported ever using female condoms, and 67.2 % expressed interest in trying female condoms. Factors independently associated with female condom use were having had a client become angry at the suggestion of using condoms and having engaged in unprotected vaginal sex with non-regular clients. Factors independently associated with interest in using female condoms were lifetime physical abuse and lifetime sexual abuse. Increasing the availability of female condoms and providing education on their use in the context of drug use and violence is recommended.