A multilevel understanding of HIV/AIDS disease burden among African American women

A resiliency intervention adapted for older women with HIV: Results from a pilot randomized controlled trial in the northeastern US

Aging with HIV often results in psychosocial and health-related challenges for women; however, no resiliency interventions exist for older women with HIV (WWH). WWH aged ≥50 were randomized to 10 group sessions of an adapted resiliency intervention or time-matched supportive psychotherapy. Assessments were conducted at three timepoints. Feasibility and acceptability metrics were defined a priori; differences in resilience, stress coping, anxiety, and depression across timepoints were assessed. Overall, 44 WWH enrolled; participants were 58 years old on average, and 56.4% identified as Black/African American. Among those who attended any sessions, all feasibility metrics were met, and the intervention was acceptable. The interaction of study arm and time was associated with significant decreases in depression and a trend toward significant decreases in anxiety. The intervention was not associated with changes in resilience or stress coping. Adjusting delivery modality may further reduce barriers to attendance, improving feasibility and clinical outcomes.

Hard-to-Reach or Hardly Reached? The "Difficulty" of Engaging Cisgender Black Females in Sexual Health Research

Rather than placing the onus on stigmatized and disenfranchised communities as hard-to-reach in sexual health research, we challenge researchers to recognize and provide outreach to populations who are hardly reached, such as cisgender Black women. We posit that the disparate human immunodeficiency virus (HIV) and sexually transmitted infection (STI) rates experienced by Black women in the USA are due in part to social and structural inequities and lack of researcher outreach within these communities. Social inequities give rise to racial and gender discrimination, which often results in structural barriers that researchers may not acknowledge. Structural barriers include medical mistrust and lack of access to preventative sexual health services, health care, education, and other resources. To achieve health equity, researchers must engage with Black women to understand the unique struggles they face and intervene with non-stigmatizing, culturally appropriate interventions. Interventions must utilize gatekeepers, influencers, community organizations, community advisory boards, and peer support. It is critical that sexual health researchers reach out to those who do not fall under the traditional hard-to-reach category but are hardly reached to counteract the current projection that 1 in 32 Black women will be diagnosed with HIV in their lifetime.

Social-spatial network structures among young urban and suburban persons who inject drugs in a large metropolitan area

BACKGROUND

Recent studies underscore the significance of adopting a syndemics approach to study opioid misuse, overdose, hepatitis C (HCV) and HIV infections, within the broader context of social and environmental contexts in already marginalized communities. Social interactions and spatial contexts are crucial structural factors that remain relatively underexplored. This study examines the intersections of social interactions and spatial contexts around injection drug use. More specifically, we investigate the experiences of different residential groups among young (aged 18-30) people who inject drugs (PWID) regarding their social interactions, travel behaviors, and locations connected to their risk behaviors. By doing so, we aim to achieve a more comprehensive understanding of the multidimensional risk environment, thereby facilitating the development of informed policies.

METHODS

We collected and examined data regarding young PWID's egocentric injection network and geographic activity spaces (i.e., where they reside, inject drugs, purchase drugs, and meet sex partners). Participants were stratified based on the location of all place(s) of residence in the past year i.e., urban, suburban, and transient (both urban and suburban) to i) elucidate geospatial concentration of risk activities within multidimensional risk environments based on kernel density estimates; and ii) examine spatialized social networks for each residential group.

RESULTS

Participants were mostly non-Hispanic white (59%); 42% were urban residents, 28% suburban, and 30% transient. We identified a spatial area with concentrated risky activities for each residential group on the West side of Chicago in Illinois where a large outdoor drug market area is located. The urban group (80%) reported a smaller concentrated area (14 census tracts) compared to the transient (93%) and suburban (91%) with 30 and 51 tracts, respectively. Compared to other areas in Chicago, the identified area had significantly higher neighborhood disadvantages. Significant differences were observed in social network structures and travel behaviors: suburban participants had the most homogenous network in terms of age and residence, transient participants had the largest network (degree) and more non-redundant connections, while the urban group had the shortest travel distance for all types of risk activities.

CONCLUSION

Distinct residential groups exhibit varying patterns of network interaction, travel behaviors, and geographical contexts related to their risk behaviors. Nonetheless, these groups share common concentrated risk activity spaces in a large outdoor urban drug market area, underscoring the significance of accounting for risk spaces and social networks in addressing syndemics within PWID populations.

Using nursing science to advance policy and practice in the context of social and structural determinants of health

BACKGROUND

Social and structural determinants of health play a large role in health inequities.

PURPOSE

To highlight how nursing science can be used to advance policy and practice in the context of social and structural determinants of health.

METHODS

This paper reports on the author's keynote presentation from the 2022 State of The Science Conference on Social and Structural Determinants of Health presented by the Council for the Advancement of Nursing Science. Key concepts are overviewed and defined, followed by examples of two community-engaged research projects with findings that inform practice and policy. The author concludes with individual-, social- and structural-level recommendations as a clarion call for nurses to use research to eliminate health inequities and promote justice for all.

CONCLUSION

What we know is, in part, only as good as what we do with that knowledge. When lives are at stake, gone are the days of knowing something and failing to act on that knowledge.

Individual, Social, and Structural Vulnerability for Black Women in the South: Implications for PrEP

Pre-exposure prophylaxis (PrEP) is an effective biomedical HIV prevention option, yet adoption among Black women, who are disproportionately impacted by HIV, is low. A nuanced understanding of the multi-level factors that contribute to elevated risk is necessary to better contextualize PrEP uptake. Qualitative data from Black women residing in the Southern U.S. who self-screened as HIV-negative, were collected via four focus groups (N = 27) to understand influences on HIV vulnerability and the potential role of PrEP in mitigating risk. Content analysis of transcribed data yielded multiple themes addressing: the pervasiveness of sexual partner sharing; lack of transparency regarding HIV status, disclosure, and testing; and social/cultural influences on HIV risk. Experiences with the health care system and providers were of particular concern. Findings demonstrate support for PrEP in this population and contribute to our understanding of individual, social, and structural factors to better inform PrEP promotion.

Relationships Between Patient Race and Residential Race Context With Missed Human Immunodeficiency Virus Care Visits in the United States, 2010-2015

BACKGROUND

Racial inequities exist in retention in human immunodeficiency virus (HIV) care and multilevel analyses are needed to contextualize and address these differences. Leveraging data from a multisite clinical cohort of people with HIV (PWH), we assessed the relationships between patient race and residential characteristics with missed HIV care visits.

METHODS

Medical record and patient-reported outcome (PRO; including mental health and substance-use measures) data were drawn from 7 participating Center for AIDS Research Network of Integrated Clinical Systems (CNICS) sites including N = 20 807 PWH from January 2010 through December 2015. Generalized estimating equations were used to account for nesting within individuals and within census tracts in multivariable models assessing the relationship between race and missed HIV care visits, controlling for individual demographic and health characteristics and census tract characteristics.

RESULTS

Black PWH resided in more disadvantaged census tracts, on average. Black PWH residing in census tracts with higher proportion of Black residents were more likely to miss an HIV care visit. Non-Black PWH were less likely to miss a visit regardless of where they lived. These relationships were attenuated when PRO data were included.

CONCLUSIONS

Residential racial segregation and disadvantage may create inequities between Black PWH and non-Black PWH in retention in HIV care. Multilevel approaches are needed to retain PWH in HIV care, accounting for community, healthcare setting, and individual needs and resources.

Development of a predictive model for identifying women vulnerable to HIV in Chicago

INTRODUCTION

Researchers in the United States have created several models to predict persons most at risk for HIV. Many of these predictive models use data from all persons newly diagnosed with HIV, the majority of whom are men, and specifically men who have sex with men (MSM). Consequently, risk factors identified by these models are biased toward features that apply only to men or capture sexual behaviours of MSM. We sought to create a predictive model for women using cohort data from two major hospitals in Chicago with large opt-out HIV screening programs.

METHODS

We matched 48 newly diagnosed women to 192 HIV-negative women based on number of previous encounters at University of Chicago or Rush University hospitals. We examined data for each woman for the two years prior to either their HIV diagnosis or their last encounter. We assessed risk factors including demographic characteristics and clinical diagnoses taken from patient electronic medical records (EMR) using odds ratios and 95% confidence intervals. We created a multivariable logistic regression model and measured predictive power with the area under the curve (AUC). In the multivariable model, age group, race, and ethnicity were included a priori due to increased risk for HIV among specific demographic groups.

RESULTS

The following clinical diagnoses were significant at the bivariate level and were included in the model: pregnancy (OR 1.96 (1.00, 3.84)), hepatitis C (OR 5.73 (1.24, 26.51)), substance use (OR 3.12 (1.12, 8.65)) and sexually transmitted infections (STIs) chlamydia, gonorrhoea, or syphilis. We also a priori included demographic factors that are associated with HIV. Our final model had an AUC of 0.74 and included healthcare site, age group, race, ethnicity, pregnancy, hepatitis C, substance use, and STI diagnosis.

CONCLUSIONS

Our predictive model showed acceptable discrimination between those who were and were not newly diagnosed with HIV. We identified risk factors such as recent pregnancy, recent hepatitis C diagnosis, and substance use in addition to the traditionally used recent STI diagnosis that can be incorporated by health systems to detect women who are vulnerable to HIV and would benefit from preexposure prophylaxis (PrEP).

Social-spatial network structures among young urban and suburban persons who inject drugs in a large metropolitan area

Background

It is estimated that there are 1.5% US adult population who inject drugs in 2018, with young adults aged 18-39 showing the highest prevalence. PWID are at a high risk of many blood-borne infections. Recent studies have highlight the importance of employing the syndemic approach to study opioid misuse, overdose, HCV and HIV, along with the social and environmental contexts where these interrelated epidemics occur in already marginalized communities. Social interactions and spatial contexts are important structural factors that are understudied.

Methods

Egocentric injection network and geographic activity spaces for young (aged 18-30) PWID and their injection, sexual, and social support network members (i.e., where reside, inject drugs, purchase drugs, and meet sex partners) were examined using baseline data from an ongoing longitudinal study (n=258). Participants were stratified based on the location of all place(s) of residence in the past year i.e., urban, suburban, and transient (both urban and suburban) to i) elucidate geospatial concentration of risk activities within multi-dimensional risk environments based on kernel density estimates; and ii) examine spatialized social networks for each residential group.

Results

Participants were mostly non-Hispanic white (59%); 42% were urban residents, 28% suburban, and 30% transient. We identified a spatial area with concentrated risky activities for each residence group on the West side of Chicago where a large outdoor drug market area is located. The urban group (80%) reported a smaller concentrated area (14 census tracts) compared to the transient (93%) and suburban (91%) with 30 and 51 tracts, respectively. Compared to other areas in Chicago, the identified area had significantly higher neighborhood disadvantages (e.g., higher poverty rate, p <0.001). Significant ( p <0.01 for all) differences were observed in social network structures: suburban had the most homogenous network in terms of age and residence, transient participants had the largest network (degree) and more non-redundant connections.

Conclusion

We identified concentrated risk activity spaces among PWID from urban, suburban, and transient groups in a large outdoor urban drug market area, which highlights the need for considering the role of risk spaces and social networks in addressing the syndemics in PWID populations.

Preliminary effectiveness and implementation outcomes of the IMARA-South Africa sexual health intervention on adolescent girls and young women: A pilot randomized trial

Family-based interventions may help reduce the risk of HIV and other sexually transmitted infections (STI) among adolescent girls and young women (AGYW) in sub-Saharan Africa but few have been tested. We examined the preliminary effectiveness and implementation outcomes of Informed, Motivated, Aware, and Responsible Adolescents and Adults-South Africa (IMARA-SA), an evidence-based intervention for South African AGYW (15-19 years) and their female caregivers. We piloted IMARA-SA in the Western Cape using an individually randomized experimental design and average follow-up at 11 months. Primary outcomes were HIV Testing and Counselling (HTC) uptake, STI incidence (gonorrhea, chlamydia), and pre-exposure prophylaxis (PrEP) uptake. Secondary outcomes were self-reported sexual risk behavior (condom use at last sex, consistency of condom use, substance use during sex, and number of sexual partners) and PrEP adherence. We examined four implementation outcomes: reach, feasibility, acceptability, and fidelity. Data from 59 AGYW (mean = 17.2 years) were analyzed at baseline (n = 29 from IMARA-SA, 30 from a health promotion control group). At follow-up, 51 (86%) completed surveys and 39 (66%) presented for HTC, STI testing, and/or PrEP. Compared to controls, fewer IMARA-SA participants tested positive for an STI (22% versus 38%), more IMARA-SA participants took up PrEP (68% versus 45%), and four of five secondary outcomes favored the IMARA-SA group at follow-up. These differences did not reach statistical significance. HTC uptake at follow-up was 100% in both groups. All AGYW-FC dyads agreed to participate in the study (reach). In the IMARA-SA group, 76% of dyads completed the intervention (feasibility), and over 76% of acceptability ratings from AGYW and their FC had the highest Likert rating. Fidelity of intervention delivery was 95%. IMARA-SA is a promising strategy for reducing HIV/STI risk among South African AGYW. We found strong evidence of reach, feasibility, acceptability, and fidelity. A fully powered randomized controlled trial is warranted. Trial registration: Clinical trials.gov registration number: NCT05504954.

Associations of Social Network- and Individual-Level Factors with HIV Testing, Condom Use, and Interest in PrEP Among Young Black Women

To achieve the 2030 goal of ending the HIV epidemic, we must consider social network- along with individual-level factors related to HIV prevention among young Black women (YBW). This cross-sectional study examined egocentric social network- and individual-level data of 180 YBW aged 18-24. Multivariable logistic regression models were used to study social network characteristics and individual sexual behaviors related to HIV prevention behaviors (e.g., HIV testing, condom use, and interest in preexposure prophylaxis, or PrEP). On average, YBW nominated 11 social network members (SNMs; seven friends, two family members, and one sex partner). About 92% of YBW spoke to at least one SNM about condom use and 58% spoke to at least one SNM about HIV testing. Respondents who spoke to a sex partner about condom use had 70% lower odds of being interested in PrEP, but 2.99 times the odds of reporting condom use during last sex. Odds of being tested for HIV in the prior 3 months were significantly increased by 3.97 times for those who spoke to at least one sex partner about HIV testing. However, odds of being interested in PrEP were significantly decreased by 63% for YBW who were tested for HIV in the prior 3 months. Findings underscore that understanding network- and individual-level factors is crucial in increasing HIV testing, condom use, and interest in PrEP among YBW.

A Systematic Review of Neighborhood-Level Influences on HIV Vulnerability

A better understanding of the social-structural factors that influence HIV vulnerability is crucial to achieve the goal of ending the HIV epidemic by 2030. Given the role of neighborhoods in HIV outcomes, synthesis of findings from such research is key to inform efforts toward HIV eradication. We conducted a systematic review to examine the relationship between neighborhood-level factors (e.g., poverty) and HIV vulnerability (via sexual behaviors and substance use). We searched six electronic databases for studies published from January 1, 2007 through November 30, 2017 (PROSPERO CRD42018084384). We also mapped the studies' geographic distribution to determine whether they aligned with high HIV prevalence areas and/or the "Ending the HIV Epidemic: A Plan for the United States". Fifty-five articles met inclusion criteria. Neighborhood disadvantage, whether measured objectively or subjectively, is one of the most robust correlates of HIV vulnerability. Tests of associations more consistently documented a relationship between neighborhood-level factors and drug use than sexual risk behaviors. There was limited geographic distribution of the studies, with a paucity of research in several counties and states where HIV incidence/prevalence is a concern. Neighborhood influences on HIV vulnerability are the consequence of centuries-old laws, policies and practices that maintain racialized inequities (e.g., racial residential segregation, inequitable urban housing policies). We will not eradicate HIV without multi-level, neighborhood-based approaches to undo these injustices. Our findings inform future research, interventions and policies.

An individually randomized controlled trial of a mother-daughter HIV/STI prevention program for adolescent girls and young women in South Africa: IMARA-SA study protocol

BACKGROUND

South Africa has the world's largest HIV epidemic, but South African adolescent girls and young women (AGYW) acquire HIV at twice the rate of and seroconvert on average 5-7 years earlier than their male peers. Female caregivers (FC) are an untapped resource for HIV/STI prevention in South Africa and offer a novel opportunity to strengthen AGYW prevention efforts. This study will evaluate the effectiveness and cost-effectiveness of an evidence-based mother-daughter HIV/STI prevention program tested in the United States and adapted for South Africa, Informed Motivated Aware and Responsible Adolescents and Adults (IMARA), to decrease STI incident infections and increase HIV testing and counseling (HTC) and PrEP uptake in AGYW.

METHODS

This is a 2-arm individually randomized controlled trial comparing IMARA to a family-based control program matched in time and intensity with 525 15-19-year-old Black South African AGYW and their FC-dyads in Cape Town's informal communities. AGYW will complete baseline, 6-, and 12-month assessments. Following randomization, AGYW-FC dyads will participate in a 2-day group workshop (total 10 h) that includes joint and separate mother and daughter activities. Primary outcomes are AGYW STI incidence, HTC uptake, and PrEP uptake at 6 months. Secondary outcomes are AGYW STI incidence, HTC uptake, and PrEP uptake at 12 months, sexual behavior (e.g., condom use, number of partners), HIV incidence, and ART/PrEP adherence and intervention cost-effectiveness. AGYW who test positive for a STI will receive free treatment at the study site. HIV positive participants will be referred to ART clinics.

DISCUSSION

Primary prevention remains the most viable strategy to stem new STI and HIV transmissions. HIV and STI disparities go beyond individual level factors, and prevention packages that include supportive relationships (e.g., FC) may produce greater reductions in HIV-risk, improve HTC and PrEP uptake, and increase linkage, retention, and adherence to care. Reducing new HIV and STI infections among South African AGYW is global public health priority.

TRIAL REGISTRATION

ClinicalTrials.gov Number NCT04758390 , accepted 02/16/2021.

Profiles of young women's alcohol and cannabis use linked to risk for sexually transmitted infection highlight the importance of multi-level targeted interventions: Findings from the Pittsburgh girls study

Background: Social ecological models designed to understand disparities in sexually transmitted infection (STI) prevalence highlight understudied structural and community risk factors. Guided by a social ecological model, this study identified profiles based on substance use-related STI risk, and examined associations of the profiles with selected indicators of structural-, community-, and individual-level STI risk factors. Methods: Repeated measures latent class analysis was applied to Pittsburgh Girls Study data (n = 2,138; 58% Black, 42% White) at ages 18-20. Profile indicators included: women's and partner's alcohol and cannabis use, women's sexual risk behavior, and self-reported STI. Profile predictors included racial background, structural-, community-, and individual-level risk factors. Results: Two of the five identified profiles had low STI likelihood: "Low Use" of alcohol and cannabis (25.5%; overrepresented by Black women), and "Alcohol Only" (19.1%; overrepresented by White women). Three profiles, all representing co-use of alcohol and cannabis, had higher STI likelihood: "Co-Use: Increasing Alcohol and Occasional Cannabis use" (16.5%; overrepresented by White women), "Co-Use: Occasional Alcohol and Cannabis use" (26.1%; overrepresented by Black women), and "Co-Use: Frequent Cannabis and Occasional Alcohol use" (12.8%; overrepresented by Black women). Structural STI risk (household use of public assistance at wave 1) was associated with "Low Use" and "Co-Use: Frequent Cannabis and Occasional Alcohol use" profiles. STI risk at multiple levels (structural, neighborhood, individual) was associated with the "Co-Use: Frequent Cannabis and Occasional Alcohol use" profile. Conclusions: Co-use of alcohol and cannabis is an important target for STI prevention efforts. Results also highlight structural- and community-level STI risk factors that disproportionately impact Black women, and the importance of multi-level interventions that are targeted to profile of risk to optimize the effectiveness of interventions.

Results from Project GOLD: A pilot randomized controlled trial of a psychoeducational HIV/STI prevention intervention for black youth

Black youth face significant disparities in HIV/sexually transmitted infection (STI) disease burden. Mental illness and emotion regulation are ontributors to HIV/STI risk, yet many HIV/STI prevention interventions do not address these factors. Project GOLD was a pilot randomized controlled trial of a psychoeducational HIV/STI prevention intervention designed to address the role of mental illness and emotion regulation in HIV/STI risk among heterosexually active Black youth aged 14-17 (N = 108). Participants were recruited from outpatient mental health treatment programs and general community settings via community partner referrals, face-to-face encounters, flyers and social media. Assessments were conducted pretest, immediate posttest, and at 3-, 6-, and 12-month follow-up. Although there were no statistically significant differences in behavior change from baseline, there were practically significant effect sizes among HIV condition participants when compared to the general health condition (e.g., fewer sexual partners at 6 months). An increase in theoretical mediators (e.g., condom use negotiation beliefs) was sustained at 12 months. HIV condition participants also reported lower depressive symptom severity, with statistical significance noted at immediate post and at 3 months. The findings highlight the importance and challenges of engaging Black youth in culturally and contextually relevant, developmentally and psychologically appropriate HIV/STI prevention interventions.

A Review of Recent HIV Prevention Interventions and Future Considerations for Nursing Science

ABSTRACT

As our knowledge of HIV evolved over the decades, so have the approaches taken to prevent its transmission. Public health scholars and practitioners have engaged in four key strategies for HIV prevention: behavioral-, technological-, biomedical-, and structural/community-level interventions. We reviewed recent literature in these areas to provide an overview of current advances in HIV prevention science in the United States. Building on classical approaches, current HIV prevention models leverage intimate partners, families, social media, emerging technologies, medication therapy, and policy modifications to effect change. Although much progress has been made, additional work is needed to achieve the national goal of ending the HIV epidemic by 2030. Nurses are in a prime position to advance HIV prevention science in partnership with transdisciplinary experts from other fields (e.g., psychology, informatics, and social work). Future considerations for nursing science include leveraging transdisciplinary collaborations and consider social and structural challenges for individual-level interventions.

IMARA: A mother-daughter group randomized controlled trial to reduce sexually transmitted infections in Black/African-American adolescents

Black/African-American girls are infected with sexually transmitted infections (STIs) at higher rates than their White counterparts. This study tested the efficacy of IMARA, a mother-daughter psychosocial STI/HIV prevention program, on adolescent Black/African-American girls’ incident STIs at 12 months in a 2-arm group randomized controlled trial. Black/African-American girls 14–18 years old and their primary female caregiver were eligible for the study. Girls provided urine samples to test for N. gonorrhoeae, C. trachomatis, and T. vaginalis infection at baseline and 12-months. Mother-daughter dyads were randomly assigned to IMARA (n = 118) or a time-matched health promotion control program (n = 81). Retention at 12-months was 86% with no difference across arms. Both interventions were delivered over two consecutive Saturdays totaling 12 hours. Girls who received IMARA were 43% less likely to contract a new STI in the 12-month post-intervention period compared with those in the health promotion control program (p = .011). A secondary follow-up intent-to-treat analysis provided additional support for the protective effect of IMARA, albeit with a similar magnitude of 37% (p = .014). Findings provide early evidence for IMARA’s efficacy, such that IMARA protected against STIs at 12-months among adolescent Black/African-American girls. Future research should examine the mechanisms associated with reduced STIs.

Prevalence and correlates of transactional sex among women of low socioeconomic status in Portland, OR

BACKGROUND

Women who report transactional sex are at increased risk for HIV and other sexually transmitted infections (STIs). However, in the United States, social, behavioral, and trauma-related vulnerabilities associated with transactional sex are understudied and data on access to biomedical HIV prevention among women who report transactional sex are limited.

METHODS

In 2016, we conducted a population-based, cross-sectional survey of women of low socioeconomic status recruited via respondent-driven sampling in Portland, Oregon. We calculated the prevalence and, assessed the correlates of, transactional sex using generalized linear models accounting for sampling design. We also compared health outcomes, HIV screening, and knowledge and uptake of HIV pre-exposure prophylaxis (PrEP) between women who did and did not report transactional sex.

RESULTS

Of 334 women, 13.6% reported transactional sex (95% confidence interval [CI]: 6.8, 20.5%). Women who reported transactional sex were older, more likely to identify as black, to identify as lesbian or bisexual, to experience childhood trauma and recent sexual violence, and to have been homeless. Six percent (95% CI: 1.8, 10.5%) of women with no adverse childhood experiences (ACEs) reported transactional sex compared to 23.8% (95% CI: 13.0, 34.6%) of women who reported eleven ACEs (P <  0.001). Transactional sex was strongly associated with combination methamphetamine and opiate use as well as condomless sex. Women who reported transactional sex were more likely to report being diagnosed with a bacterial STI and hepatitis C; however, HIV screening and pre-exposure prophylaxis knowledge and use were low.

CONCLUSIONS

In a sample of women of low socioeconomic status in Portland, Oregon, transactional sex was characterized by marginalized identities, homelessness, childhood trauma, sexual violence, substance use, and sexual vulnerability to HIV/STI. Multi-level interventions that address these social, behavioral, and trauma-related factors and increase access to biomedical HIV prevention are critical to the sexual health of women who engage in transactional sex.

Strategies for increasing impact, engagement, and accessibility in HIV prevention programs: suggestions from women in urban high HIV burden counties in the Eastern United States (HPTN 064)

BACKGROUND

Merely having the tools to end HIV is insufficient. Effectively ending the epidemic necessitates addressing barriers that impede engagement in biomedical and behavioral prevention and wide scale implementation and utilization of existing interventions. This qualitative study identifies suggestions for increasing access to, engagement in, and impact of HIV prevention among women living in cities in high HIV burden counties in the eastern US.

METHODS

Data analyzed for the current study were collected via a qualitative sub-study within the HIV Prevention Trials Network Study 064 (HPTN 064), a multisite observational cohort study designed to estimate HIV incidence among women residing in communities with elevated HIV prevalence who also reported personal or partner characteristics associated with increased risk of HIV acquisition. Focus group and interview participants in the qualitative sub-study (N = 288) were from four cities in the eastern US.

RESULTS

Thematic analyses revealed four themes describing women's most frequently stated ideas for improving prevention efforts: 1) Promote Multilevel Empowerment, 2) Create Engaging Program Content, 3) Build "Market Demand", and 4) Ensure Accessibility. We conducted additional analyses to identify contradictory patterns in the data, which revealed an additional three themes: 1) Address Structural Risk Factors, 2) Increase Engagement via Pleasure Promotion, 3) Expand Awareness of and Access to Prevention Resources.

CONCLUSIONS

Findings may be useful for enhancing women's engagement in and uptake of behavioral and biomedical HIV prevention resources, improving policy, and addressing multilevel risk factors.

TRIAL REGISTRATION

Clinicaltrials.gov: NCT00995176 , prospectively registered.

Integrating Individual and Contextual Factors to Explain Disparities in HIV/STI Among Heterosexual African American Youth: A Contemporary Literature Review and Social Ecological Model

Heterosexual African American youth face substantial disparities in sexual health consequences such as HIV and STI. Based on the social ecological framework, the current paper provides a comprehensive, narrative review of the past 14 years of literature examining HIV/STI risk, including risky sexual behavior, among heterosexual African American youth and a conceptual model of risk among this population. The review found that individual psychological and biological factors are insufficient to explain the sexual health disparities faced by this group; instead, structural disadvantage, interpersonal risk, and community dysfunction contribute to the disparity in HIV/STI outcomes directly and indirectly through individual psychological factors. The conceptual model presented suggests that for African American youth, (1) HIV/STI risk commonly begins at the structural level and trickles down to the community, social, and individual levels, (2) risk works in a positive feedback system such that downstream effects compound the influence of structural risks, and (3) contextual and individual risk factors must be considered within the advanced stage of the epidemic facing this population. Despite advanced HIV and STI epidemics among heterosexual African American youth, multisystemic interventions that target structural risk factors and their downstream effects are posited to reduce the disparity among this high-risk population.

Implementation of HIV Interventions Into Faith-Based Organizations: Models and Methodological Considerations

BACKGROUND

Implementation of evidence-based interventions aimed at reducing and treating HIV can have a wider spread if funneled through faith-based organizations. However, there is a paucity of frameworks or process models aimed at providing the best practices to implement HIV interventions into faith-based community organizations.

SETTING

Implementation framework and process model for African American faith settings.

RESULTS

Presented here is a systems multilevel implementation framework and implementation process model for integrating HIV interventions into faith-based organizations. We conclude with presentation of key methodological considerations and recommendations and discuss strategies for moving implementation science forward in faith-based organizations.

CONCLUSION

Because of their key role in the African American community, faith-based settings must be engaged in implementing evidence-based HIV interventions. Through use of a multilevel systems framework and process model, the methods and approaches of implementation science can be leveraged to encourage the spread of HIV interventions in the African American community.

Utilizing a Life Course Approach to Examine HIV Risk for Black Adolescent Girls and Young Adult Women in the United States: A Systematic Review of Recent Literature

Objective

Black female youth have been disproportionately burdened by the HIV epidemic. Emerging literature suggests that individual and social-structural factors may uniquely increase HIV risk within this population during key developmental periods, namely adolescence (ages 10-17 years) and emerging adulthood (ages 18-25 years). Few studies, however, have compared drivers of risk within and between these key developmental periods. Therefore, we conducted a systematic review of recent literature to characterize and identify important gaps in our understanding of the individual, psychosocial, and social-structural determinants of HIV risk among Black adolescent girls and emerging adult women.

Design

Using a replicable strategy, we searched electronic databases for articles and abstracts published between October 1, 2017 and September 30, 2019 in which the primary focus was on HIV prevention among Black adolescent girls and emerging adults in the United States.

Results

In total, 21 studies met the inclusion criteria. Most of the studies on Black adolescent girls assessed family functioning, parental monitoring, and parent-adolescent communication as determinants of HIV-related behaviors. However, equivalent studies were lacking for Black emerging adult women. Moreover, few studies assessed neighborhood characteristics, social networks, or other community-level factors as determinants of HIV-related behaviors, which are known drivers of HIV disparities.

Conclusions

Our findings highlighted several gaps in the literature, including failure to recognize the ethnic and cultural differences among Black women that may contribute to behavioral differences within this population and insufficient acknowledgment of the role of HIV protective factors (eg, resilience and community assets). Implications and future directions are discussed.

Religiosity, Social Support, and Ethnic Identity: Exploring "Resilience Resources" for African-American Women Experiencing HIV-Related Stigma

INTRODUCTION

African-American women living with HIV report substantial HIV-related stigma and depression. Resilience resources are strength-based resources that may moderate the effects of HIV-related stigma on poor psychosocial outcomes such as depression.

OBJECTIVE

To evaluate whether religiosity, social support, and ethnic identity moderate the effects of HIV-related stigma on depression among African-American women living with HIV.

METHODS

We used baseline data (May 2013-October 2015) from a randomized controlled trial testing the efficacy of an HIV-related stigma-reduction intervention among African-American women living with HIV in Chicago, IL, and Birmingham, AL, who were older than 18 years and currently receiving HIV services. To assess whether religiosity (7-item Religious Beliefs and Behaviors survey), social support (select subscales from the Medical Outcomes Study Social Support Survey), and ethnic identity (Commitment subscale from the Multigroup Ethnic Identity Measure) modified the relationship between HIV-related stigma (Stigma Scale for Chronic Illness) and depression (8-item Patient Health Questionnaire), we conducted 3 separate moderation analyses using linear regression with interactions between HIV-related stigma and each moderator of interest, adjusted for study site, age, time since diagnosis, and education.

RESULTS

Among 226 African-American women living with HIV, greater levels of HIV-related stigma were associated with greater depression in all 3 models (P < 0.05). Only religiosity modified this association (P = 0.04), with a weaker association among women reporting higher levels of religiosity.

CONCLUSIONS

The protective effects of religiosity may be leveraged in interventions for African-American women living with HIV struggling with HIV-related stigma.

Area-level HIV risk and socioeconomic factors associated with willingness to use PrEP among Black people in the U.S. South

Purpose:

In the United States (U.S.), southern states have the highest HIV incidence. Uptake of pre-exposure prophylaxis (PrEP) has been slow among Black people, particularly in the South. We know little about how area-level HIV risk influences one's willingness to use PrEP.

Methods:

169 Black participants across 142 ZIP codes in the South completed the 2016 National Survey on HIV in the Black Community. We performed log-binomial regression to estimate the prevalence risk associated with residing in the upper 25th percentile of increases in new HIV diagnosis (2014–2015) within ZIP code and an individual's willingness to use PrEP, adjusting for individual and area-level covariates.

Results:

Participants were 68% female, mean age of 36 years, and 24% willing to use PrEP. Among the ZIP codes, 23% were within Atlanta, GA. The median increase in new HIV diagnoses was 25 per 100,000 population from 2014 to 2015 (IQR, 14–49). Participants living in ZIP codes within the upper 25th (compared-to-lower 75th) percentile of new HIV diagnoses were more willing to use PrEP (adjusted prevalence ratio (aPR) = 2.02, 95% CI = 1.06–3.86, P = .03). Area-level socioeconomic factors attenuated that association (aPR = 1.63, 95% CI = 0.78–3.39, P = .19).

Conclusions:

Area-level factors may influence PrEP uptake among Black people in the South.

Older African Americans and the HIV Care Continuum: A Systematic Review of the Literature, 2003-2018

Evidence suggests that racial disparities in the HIV care continuum persist in older age groups, particularly among African Americans. The objective of this systematic review was to identify factors that facilitate or hinder older African Americans' engagement in the HIV care continuum. For studies published between 2003 and 2018, we: (1) searched databases using keywords, (2) excluded non-peer-reviewed studies, (3) limited findings to older African Americans and the HIV care continuum, and (4) retrieved and summarized data focused on barriers and facilitators of the HIV care continuum. Among the 1023 studies extracted, 13 were included: diagnosis/testing (n = 1), engagement in care (n = 7), and antiretroviral adherence (n = 5). Barriers included lack of HIV risk awareness, routine testing, and healthcare access, stigma, and multimorbidities. Social support, health/medication literacy, and increased self-efficacy facilitated engagement. A targeted focus on older African Americans is needed to achieve national goals of improving HIV care and treatment outcomes.

Effectively Addressing Human Immunodeficiency Virus Disparities Affecting US Black Women

Black women have disproportionately higher rates of human immunodeficiency virus (HIV) infection, and low percentages being linked to care and becoming virally suppressed, compared with women of other races/ethnicities. To date, few evidence-based HIV prevention and care interventions tailored for black women exist. We highlight three essential factors to consider in designing culturally and gender-appropriate studies to address HIV-related disparities affecting black women: (1) social determinants of HIV risk, (2) determinants of equity, and (3) perceptions of black women's sexuality. Synergy between a strong evidence base and developing strong partnerships could accelerate progress toward HIV-related health equity for black women.

Sexual Health Behavior and Mental Health Among Older African American Women: The Sistahs, Sexuality, and Mental Health Well-Being Project

BACKGROUND

In Los Angeles County, the rates of sexually transmitted infections and diseases among African Americans represent a significant public health disparity. Older African American women are at particular risk as they are more likely to engage in high-risk sexual behaviors and report social isolation and loneliness than their younger counterparts. However, the literature on the relationship between sexual health and mental health in this group is limited. The purpose of this study was to use a community-based participatory research (CBPR) approach to better understand sexual health behaviors and mental health among African American women over 50 years of age who reside in South Los Angeles.

MATERIALS AND METHODS

This project was divided into two phases. Phase I (January-March 2017) of the project consisted of four dialog/focus groups (N = 45) (ages: 50-80; M_age = 67). The purpose of Phase II (April 2017) was to present study results from Phase I to the community via a community-based conference, as well as gather feedback and generate discussion about the next steps for community prevention/intervention.

RESULTS

Women reported that they did not feel comfortable discussing sexual practices with their physician, partners, and friends. Most women identified depression, loneliness, and self-esteem issues as reasons for engaging in high-risk sexual behaviors. During Phase II, potential intervention avenues emerged to address issues such as lack of physician-patient communication, lack of community support, and dialogs about sex.

CONCLUSIONS

The use of CBPR greatly enhanced our knowledge of the core issues surrounding sexual health and mental health among older African American women.

Sexual culture in low-income older adult housing: norms, behaviours and risks

This paper explores the behaviours and meanings associated with intimacy and sexuality among older adults with diverse partners living in subsidised senior housing. It utilises survey and qualitative data from a mixed methods of ageing/HIV exposure to illustrate gendered views on sexual and intimate behaviours, and attitudes towards transactional/commercial sex. Data suggest that women were cautious about engaging in intimate relationships, while men sought them and the companionship they provided to address loneliness. Reasons for non-intimacy were age and health problems. Generally speaking, both men and women had positive attitudes towards sex. Men took risks by having multiple partners and using condoms irregularly; women believed they could avoid risks by taking time to get to know their partners, but never used condoms. Forty per cent of men who saw sex workers were not regular condom users. They traded risk of gossip, violence and infection for companionship with women seeking money and physical safety. Findings have implications for policies, counselling and interventions for older sexually active adults in institutional and residential settings.

HIV/STI Prevention Among Heterosexually Active Black Adolescents With Mental Illnesses: Focus Group Findings for Intervention Development

Heterosexually active Black adolescents with mental illnesses are at increased risk for sexually transmitted infections (STIs), including HIV. However, few HIV/STI prevention interventions exist for this demographic. We held seven focus groups (N = 33) to elucidate social, cultural, and psychological factors that influence HIV/STI risk-related sexual behaviors in this understudied population. Seven themes emerged: (a) Blackness and media portrayals, (b) Blackness as a source of cultural resilience and pride, (c) psychosocial determinants of condom use, (d) consequences of engaging in sexual activity, (e) attitudes and beliefs toward sexual behaviors, (f) benefits of sexual activity, and (g) coping mechanisms. Participants also supported the feasibility of and interest in HIV/STI prevention programs integrated with mental health treatment. Transportation, potential breaches of confidentiality, and time were noted barriers to participation. Psychoeducational, skills-based programs are needed to address the sequelae of mental illnesses as they relate to the sexual decision-making process in adolescents.

Intersectional stigma among midlife and older Black women living with HIV

HIV-related stigma is a barrier to the prevention and treatment of HIV. For midlife and older Black women, the nature and intensity of HIV-related stigma may be compounded by their multiple marginalised social status based on gender, race, and age. We examined the perceptions and experiences of HIV-related stigma among midlife and older Black women living in Prince George's County, Maryland, USA. Between 2014 and 2015, we conducted semi-structured interviews with a sample of 35 midlife and older Black women living with HIV. Using a modified grounded theory approach, we explored emergent themes related to the manifestation and experience of intersectional stigma and changes in stigma experience over time. Our findings suggest that intersectional stigma is a central feature in midlife and older Black women's lives, with women reporting experiences of intersectional stigma at the interpersonal/familial, community, and institutional/structural levels. Although women acknowledged gradual acceptance of their HIV-positive status over time, they continued to experience negative responses related to gender, race, age, and disease. Our findings indicate that a more robust understanding of the impact of HIV-related stigma requires work to consider the complex manifestations of intersectional stigma among an increasingly aging population of Black women in the USA.

The 21st Century Cures Act Implications for the Reduction of Racial Health Disparities in the US Criminal Justice System: a Public Health Approach

Past drug epidemics have disproportionately criminalized drug addiction among African Americans, leading to disparate health outcomes, increased rates of HIV/AIDS, and mass incarceration. Conversely, the current opioid addiction crisis in the USA focuses primarily on white communities and is being addressed as a public health problem. The 21st Century Cures Act has the potential to reduce racial health disparities in the criminal justice system through the Act's public health approach to addiction and mental health issues. The 21st Century Cures Act is a progressive step in the right direction; however, given the historical context of segregation and the criminalization of drug addiction among African Americans, the goals of health equity are at risk of being compromised. This paper discusses the implications of this landmark legislation and its potential to decrease racial health disparities, highlighting the importance of ensuring that access to treatment and alternatives to incarceration must include communities of color. In this paper, the authors explain the key components of the 21st Century Cures Act that are specific to criminal justice reform, including a key objective, which is treatment over incarceration. We suggest that without proper attention to how, and where, funding mechanisms are distributed, the 21st Century Cures Act has the potential to increase racial health disparities rather than alleviate them.

Place Still Matters: Racial/Ethnic and Geographic Disparities in HIV Transmission and Disease Burden

Neighborhood-level structural interventions are needed to address HIV/AIDS in highly affected areas. To develop these interventions, we need a better understanding of contextual factors that drive the pandemic. We used multinomial logistic regression models to examine the relationship between census tract of current residence and mode of HIV transmission among HIV-positive cases. Compared to the predominantly white high HIV prevalence tract, both the predominantly black high and low HIV prevalence tracts had greater odds of transmission via injection drug use and heterosexual contact than male-to-male sexual contact. After adjusting for current age, gender, race/ethnicity, insurance status, and most recently recorded CD4 count, there was no statistically significant difference in mode of HIV transmission by census tract. However, heterosexual transmission and injection drug use remain key concerns for underserved populations. Blacks were seven times more likely than whites to have heterosexual versus male-to-male sexual contact. Those who had Medicaid or were uninsured (versus private insurance) were 23 and 14 times more likely, respectively, to have injection drug use than male-to-male sexual contact and 10 times more likely to have heterosexual contact than male-to-male sexual contact. These findings can inform larger studies for the development of neighborhood-level structural interventions.

Stakeholder conceptualisation of multi-level HIV and AIDS determinants in a Black epicentre

HIV has reached epidemic proportions among African Americans in the USA but certain urban contexts appear to experience a disproportionate disease burden. Geographic information systems mapping in Philadelphia indicates increased HIV incidence and prevalence in predominantly Black census tracts, with major differences across adjacent communities. What factors shape these geographic HIV disparities among Black Philadelphians? This descriptive study was designed to refine and validate a conceptual model developed to better understand multi-level determinants of HIV-related risk among Black Philadelphians. We used an expanded ecological approach to elicit reflective perceptions from administrators, direct service providers and community members about individual, social and structural factors that interact to protect against or increase the risk for acquiring HIV within their community. Gender equity, social capital and positive cultural mores (e.g., monogamy, abstinence) were seen as the main protective factors. Historical negative contributory influences of racial residential segregation, poverty and incarceration were among the most salient risk factors. This study was a critical next step toward initiating theory-based, multi-level community-based HIV prevention initiatives.

HIV Risk-Reduction Prevention Interventions Targeting African American Adolescent Women

African American young women are overwhelmingly disproportionately burdened by HIV/AIDS in the United States today. The purpose of the current systematic review was to identify the characteristics of efficacious HIV risk-reduction prevention interventions targeting African American adolescent women in order to inform future intervention development and expansion. We searched PubMed, PsychInfo, and ProQuest databases for journal articles and dissertations published between 2000 and 2015 reporting the impacts of HIV risk-reduction prevention interventions in the U.S. targeting African American adolescent women under age 25. Twenty articles assessing the efficacy of 12 interventions were eligible for inclusion. Selected interventions represented a total of 5,556 African American adolescent women and primarily drew from self-efficacy and self-empowerment-based theoretical frameworks. One intervention targeted girls under age 13; eight included participants ages 13-17; ten targeted adolescents aged 18-24 years; and five interventions included women over age 24 among their participants. Most interventions consisted of in-person knowledge and skills-based group or individual sessions led by trained African American female health professionals. Three were delivered via personal electronic devices. All programs intervened directly at the individual-level; some additionally targeted mothers, friends, or sexual partners. Overall, efficacious interventions among this population promote gender and ethnic pride, HIV risk-reduction self-efficacy, and skills building. They target multiple socio-ecological levels and tailor content to the specific age range, developmental period, and baseline behavioral characteristics of participants. However, demonstrated sustainability of program impacts to date are limited and should be addressed for program enhancements and expansions.

Structural inequalities drive late HIV diagnosis: The role of black racial concentration, income inequality, socioeconomic deprivation, and HIV testing

In the United States, research is limited on the mechanisms that link socioeconomic and structural factors to HIV diagnosis outcomes. We tested whether neighborhood income inequality, socioeconomic deprivation, and black racial concentration were associated with gender-specific rates of HIV in the advanced stages of AIDS (i.e., late HIV diagnosis). We then examined whether HIV testing prevalence and accessibility mediated any of the associations above. Neighborhoods with highest (relative to lowest) black racial concentration had higher relative risk of late HIV diagnosis among men (RR=1.86; 95%CI=1.15, 3.00) and women (RR=5.37; 95%CI=3.16, 10.43) independent of income inequality and socioeconomic deprivation. HIV testing prevalence and accessibility did not significantly mediate the associations above. Research should focus on mechanisms that link black racial concentration to HIV diagnosis outcomes.

Addressing Unmet Sexual Health Needs among Black Adolescents with Mental Illnesses

Despite advances in HIV epidemiologic and prevention research, adolescents with mental illnesses remain a historically underserved group with respect to human immunodeficiency virus (HIV)/sexually transmitted infection (STI) prevention resources. Black adolescents with mental illnesses in particular are a relatively underserved, hidden population in the field of sexual health. Strategies and guidelines are needed to account for underlying psychopathology among Black adolescents with mental illnesses in ways that current models have yet to address. In this paper, we propose several actionable mechanisms to better integrate HIV/STI and mental health related services and activities for sexual health promotion.

The Role of Sexual Health Professionals in Developing a Shared Concept of Risky Sexual Behavior as it Relates to HIV Transmission

"Risky sexual behavior" accounts for the majority of new HIV infections regardless of gender, age, geographic location, or ethnicity. The phrase, however, refers to a relatively nebulous concept that hampers development of effective sexual health communication strategies. The purpose of this paper was to propose development of a shared conceptual understanding of "risky sexual behavior." We reviewed multidisciplinary HIV/AIDS literature to identify definitions of risky sexual behavior. Both the linguistic components and the social mechanisms that contribute to the concept of risky sexual behaviors were noted. Risky sexual behavior was often defined in a subjective manner in the literature, even in the scientific research. We urge a paradigm shift to focus on explicit behaviors and the social context of those behaviors in determining HIV risk. We also propose a new definition that reduces individual biases and promotes a broader discussion of the degree of sexual risk across a diversity of behavioral contexts. Sexual health professionals can strengthen practice and research initiatives by operating from a concise working definition of risky sexual behavior that is broadly transferable and expands beyond a traditional focus on identity-based groups.

Multilevel drivers of human immunodeficiency virus/acquired immune deficiency syndrome among Black Philadelphians: exploration using community ethnography and geographic information systems

BACKGROUND

Unequal human immunodeficiency virus (HIV)/acquired immune deficiency syndrome (AIDS) distribution is influenced by certain social and structural contexts that facilitate HIV transmission and concentrate HIV in disease epicenters. Thus, one of the first steps in designing effective community-level HIV/AIDS initiatives is to disentangle the influence of individual, social, and structural factors on HIV risk. Combining ethnographic methodology with geographic information systems mapping can allow for a complex exploration of multilevel factors within communities that facilitate HIV transmission in highly affected areas.

OBJECTIVES

We present the formative comparative community-based case study findings of an investigation of individual-, social-, and structural-level factors that contribute to the HIV/AIDS epidemic among Black Philadelphians.

METHODS

Communities were defined using census tracts. The methodology included ethnographic and geographic information systems mapping, observation, informal conversations with residents and business owners, and secondary analyses of census tract-level data in four Philadelphia neighborhoods.

RESULTS

Factors such as overcrowding, disadvantage, permeability in community boundaries, and availability and accessibility of health-related resources varied significantly. Furthermore, HIV/AIDS trended with social and structural inequities above and beyond the community's racial composition.

DISCUSSION

This study was a first step to disentangle relationships between community-level factors and potential risk for HIV in an HIV epicenter. The findings also highlight stark sociodemographic differences within and across racial groups and further substantiate the need for comprehensive, community-level HIV prevention interventions. These findings from targeted U.S. urban communities have potential applicability for examining the distribution of HIV/AIDS in broader national and international geosocial contexts.