Implementing CenteringPregnancy Group Prenatal Care for Minority Women Living with HIV at an Urban University Hospital.

INTRODUCTION: Pregnant women with HIV require sustained education and support throughout pregnancy to achieve healthy perinatal outcomes. To enhance prenatal care for women with HIV, the Prenatal Immunology Service at the University of Miami Miller School of Medicine adapted the Centering Healthcare Institute's CenteringPregnancy curriculum to include HIV content. Nurse-midwives introduced the curriculum in a pilot project to learn if women would enroll in group prenatal care. A retrospective record review was conducted to evaluate perinatal outcomes among women with HIV who received prenatal care in a group setting. METHODS: Data were collected from the electronic health records of women with HIV who received either CenteringPregnancy-HIV group prenatal care or traditional prenatal care between March 2015 and July 2016. Sociodemographic factors, HIV immune markers, and pregnancy and birth outcomes were reviewed. Univariate and bivariate statistics and multiple regression models assessed differences between women in CenteringPregnancy-HIV group prenatal care compared with women with HIV in traditional care. RESULTS: Among women with HIV who received prenatal care during the pilot project, 128 met eligibility criteria for review. Perinatal outcomes were analyzed for 117 women who had a live birth; of these, 14 participated in CenteringPregnancy-HIV group prenatal care, and 103 received traditional care. Demographic profiles were similar in both groups. No significant differences in perinatal outcomes were observed among women in CenteringPregnancy-HIV group prenatal care compared with women with HIV in traditional prenatal care. DISCUSSION: Women with HIV can often feel stigmatized and isolated. Group prenatal care can foster patient engagement, self-management, and social support to improve adherence to antiretroviral and other health regimens that promote healthy outcomes for both woman and newborn. Although results of this pilot study were not statistically significant, they show that CenteringPregnancy-HIV group prenatal care may be an option for women with HIV, but the benefits need further exploration in larger studies.

Social and psychological correlates of unprotected anal intercourse among Hispanic-American women: implications for STI/HIV prevention.

Heterosexual anal intercourse is associated with increased risk for HIV and other sexually transmitted infections. Research on the social and psychological risk factors associated with heterosexual unprotected anal intercourse among Hispanic women in the USA is limited. We examined demographic, mental health, relationship power, sexual self-efficacy, self-esteem, acculturation and HIV knowledge as correlates of unprotected anal intercourse among 514 HIV-negative Hispanic women, 18 to 59 years of age, residing in one urban county in southern Florida. In both unadjusted and adjusted results, the likelihood of engaging in unprotected anal intercourse was associated with food insecurity in the past 30 days (adjusted odds ratio [AOR] = 1.57, 95% confidence interval [CI] 1.03, 2.40) and more interpersonal power attributed to the male partner (AOR = 1.63, 95%CI 1.08, 2.45). Not significant, yet of possible importance, were ever having engaged in exchange sex (AOR = 1.96, 95%CI = 0.97, 3.98) and lower HIV knowledge (AOR = 0.80, 95%CI = 0.63, 1.01). Interventions aimed at reducing heterosexual unprotected anal intercourse risk for HIV infection among Hispanic women may benefit by addressing socioeconomic and interpersonal issues, and assessing HIV knowledge and comprehension.

EXPERIENCE OF FORCED SEX AND SUBSEQUENT SEXUAL, DRUG, AND MENTAL HEALTH OUTCOMES: AFRICAN AMERICAN AND HISPANIC WOMEN IN THE SOUTHEASTERN UNITED STATES.

OBJECTIVES: This cross-sectional study examined African American and Hispanic women's (N = 1,509) self-reports of unwanted forced sex and its association with behavioral and mental health outcomes after the event. METHODS: Twenty percent of the women had experienced forced sex (1st occurrence at age 15 years or younger for 10%, 1st occurrence at older than 15 years of age for 10%). RESULTS: Regardless of when forced sex 1st occurred, women were more likely to have engaged in unprotected vaginal and anal sex, to have had multiple unprotected sex partners, to have sexually transmitted infections, to have reported binge drinking and illicit drug use, and to exhibit distress and have received mental health counseling. CONCLUSIONS: Forced sex may have wide-ranging behavioral and mental health consequences years later.

Characteristics of African American Women and Their Partners With Perceived Concurrent Partnerships in 4 Rural Counties in the Southeastern U.S.

BACKGROUND: To the individual with concurrent partners, it is thought that having concurrent partnerships confers no greater risk of acquiring HIV than having multiple consecutive partnerships. However, an individual whose partner has concurrent partnerships (partner's concurrency) is at increased risk for incident HIV infection. We sought to better understand relationships characterized by partner's concurrency among African American women. METHODS: A total of 1013 African American women participated in a cross-sectional survey from 4 rural Southeastern counties. RESULTS: Older age at first sex was associated with lower prevalence of partner's concurrency (prevalence ratio, 0.70; 95% confidence interval, 0.57-0.87), but the participant's age was not associated with partner's concurrency. After adjusting for covariates, ever having experienced intimate partner violence (IPV) and forced sex were most strongly associated with partner's concurrency (prevalence ratios, 1.61 [95% confidence intervals, 1.23-2.11] and 1.65 [1.20-2.26], respectively). Women in mutually monogamous partnerships were the most likely to receive economic support from their partners; women whose partners had concurrent partnerships did not report more economic benefit than did those whose partners were monogamous. CONCLUSIONS: Associations between history of IPV and forced sex with partner's concurrency suggest that women with these experiences may particularly benefit from interventions to reduce partner's concurrency in addition to support for reducing IPV and other sexual risks. To inform these interventions, further research to understand partnerships characterized by partner's concurrency is warranted.

Religiosity, spirituality, and HIV risk behaviors among African American women from four rural counties in the southeastern U.S.

In a cross-sectional survey of 1,013 African American women from rural Alabama and North Carolina, we examined the relationship of (1) organizational religiosity (i.e., religious service attendance), (2) non-organizational religiosity (e.g., reading religious materials), and (3) spirituality with these outcomes: women's reports of their sexual behaviors and perceptions of their partners' risk characteristics. Women with high non-organizational religiosity, compared with low, had fewer sex partners in the past 12 months (adjusted prevalence ratio (aPR): 0.58, 95% confidence interval (CI): 0.42, 0.80) and were less likely to have concurrent partnerships (aPR: 0.47, 95% CI: 0.30, 0.73). Similar results were observed for spirituality, and protective but weaker associations were observed for organizational religiosity. Weak associations were observed between organizational religiosity, non-organizational religiosity, and spirituality with partners' risk characteristics. Further exploration of how religiosity and spirituality are associated with protective sexual behaviors is needed to promote safe sex for African American women.

Prenatal and mental health care among trauma-exposed, HIV-infected, pregnant women in the United States.

Comprehensive prenatal care for HIV-infected women in the United States involves addressing mental health needs. Retrospective quantitative data are presented from HIV-infected pregnant women (n = 45) who reported childhood sexual or physical abuse (66%), abuse in adulthood by a sexual partner (25%), and abuse during pregnancy (10%). Depression and anxiety were the most commonly reported psychological symptoms; more than half of the sample reported symptoms of posttraumatic stress disorder (PTSD), including HIV-related PTSD (PTSD-HIV). There was a strong association between depression and PTSD as well as between anxiety and PTSD-HIV. The majority of infants received zidovudine at birth and continued the recommended regimen. All but one infant were determined to be noninfected. Women improved their CD4(+) T cell counts and HIV RNA viral loads while in prenatal care. Results support the need for targeted prenatal programs to address depression, anxiety, substance use, and trauma in HIV-infected women.

Improving PMTCT uptake in rural South Africa.

INTRODUCTION: Despite the widespread availability of prevention of mother-to-child transmission (PMTCT) programs, many women in sub-Saharan Africa do not participate in PMTCT. This pilot study aimed to utilize partner participation in an intervention to support PMTCT uptake. METHODS: Couples (n » 239) were randomized to receive either a comprehensive couples-based PMTCT intervention or the standard of care. RESULTS: Compared to the standard of care, participants receiving the intervention increased HIV- and PMTCT-related knowledge (F1,474 » 13.94, p » .004) and uptake of PMTCT, as defined by infant medication dosing (74% vs. 46%, w2 » 4.69, p » .03). DISCUSSION: Results indicate that increasing male attendance at antenatal clinic visits maybe "necessary but not sufficient" to increase PMTCT uptake. Increasing HIV knowledge of both partners and encouraging active male participation in the PMTCT process through psychoeducational interventions may be a strategy to increase the uptake of PMTCT in South Africa.

Abuse and mental health concerns among HIV-infected Haitian women living in the United States.

This study describes the prevalence of abuse and mental health issues among a cohort of HIV-infected Haitian women living in the United States. We present data on 96 women, ages 19-73 years (M = 47.6, SD = 11.1), who were screened for mental health concerns between 2009 and 2012. Results demonstrated that 12.5% of the women reported a history of abuse. However, posttraumatic stress disorder (PTSD) secondary to HIV was reported by approximately 34% of women. Depression and anxiety were also highly reported, with rates of 49% and 43%, respectively. Women who reported a history of abuse were more likely to report anxiety, PTSD, and PTSD related to HIV symptoms than those without. Our findings suggest that Haitian HIV-infected women may underreport abuse and experience significant depression and anxiety. These preliminary results could be used to develop future studies and to design and implement culturally sensitive interventions for this underserved population.

"A man's gonna do what a man wants to do": African American and Hispanic women's perceptions about heterosexual relationships: a qualitative study.

BACKGROUND: HIV prevention efforts have given limited attention to the relational schemas and scripts of adult heterosexual women. These broader schemas and scripts of romantic and other sexual liaisons, partner selection, relationship dynamics, and power negotiations may help to better understand facilitators and barriers to HIV risk-reduction practices. METHODS: We conducted exploratory qualitative interviews with 60 HIV-uninfected heterosexual African-American women from rural counties in North Carolina and Alabama, and Hispanic women from an urban county in southern Florida. Data were collected for relationship expectations; relationship experiences, and relationship power and decision-making. Interview transcripts underwent computer-assisted thematic analysis. RESULTS: Participants had a median age of 34 years (range 18-59), 34% were married or living as married, 39% earned an annual income of $12,000 or less, 12% held less than a high school education, and 54% were employed. Among the Hispanic women, 95% were foreign born. We identified two overarching relationship themes: contradictions between relationship expectations and desires and life circumstances that negated such ideals, and relationship challenges. Within the contradictions theme, we discovered six subthemes: a good man is hard to find; sex can be currency used to secure desired outcomes; compromises and allowances for cheating, irresponsible, and disrespectful behavior; redefining dating; sex just happens; needing relationship validation. The challenges theme centered on two subthemes: uncertainties and miscommunication, and relationship power negotiation. Gender differences in relationship intentions and desires as well as communication styles, the importance of emotional and financial support, and the potential for relationships to provide disappointment were present in all subthemes. In examining HIV risk perceptions, participants largely held that risk for HIV-infection and the need to take precautions were problems of women who differed from them (i.e., abuse drugs, are promiscuous, exchange sex). CONCLUSION: Underlying women's relational schemas was a belief that relationship priorities differed for men and women. Consequently, expectations and allowances for partner infidelity and negligent behaviors were incorporated into their scripts. Moreover, scripts endorsed women's use of sex as currency in relationship formation and endurance, and did not emphasize HIV risk. Both couple- and gender-specific group-level interventions are needed to deconstruct (breakdown) and reconstruct (rewrite) relationship scripts.

Enhancing acceptability and use of sexual barrier products among HIV concordant and discordant couples.

Strategies to prevent HIV transmission may benefit from addressing both individual and dyadic factors. This study compared the impact of group and individual interventions on the acceptability of sexual barrier products among HIV sero-concordant and discordant couples, and evaluated the contribution of couple members' perceived product acceptability to their sexual barrier use. Participants (n = 216 couples) were multicultural couples in Miami, Florida. Longitudinal multilevel modeling and the actor-partner interdependence model were used for analyses. Product acceptability increased more among female group participants, and acceptability of male condoms increased more among sero-discordant couples in the group. Additionally, acceptability of products associated with prevention of STDS/HIV and pregnancy increased more among sero-concordant couples in the group condition. Both actor and partner product acceptability predicted use. Results support the use of group interventions targeting both partners in relationships in prevention programs designed to enhance sexual barrier use.

HIV disclosure, sexual negotiation and male involvement in prevention-of-mother-to-child-transmission in South Africa.

HIV-seroconversion during pregnancy is a serious concern throughout South Africa, where an estimated 35 to 40% of pregnant women have HIV/AIDS and drop-out is high at all stages of the prevention-of-mother-to-child-transmission (PMTCT) process. The likelihood of PMTCT success may be linked to partner support, yet male involvement in antenatal care remains low. This qualitative study examined the influence of pregnant couples' expectations, experiences and perceptions on sexual communication and male involvement in PMTCT. A total of 119 couples participated in a comprehensive intervention in 12 antenatal clinics throughout South Africa. Data were collected between December 2010 to June 2011 and analysed using a grounded theory approach. Findings point to the importance of sexual communication as a factor influencing PMTCT male involvement. Analysis of themes lends support to improving communication between couples, encouraging dialogue among men and increasing male involvement in PMTCT to bridge the gap between knowledge and sexual behaviour change.

Reducing sexual risk behavior among high-risk couples in Northern India.

BACKGROUND: With a population of 1.1 billion, India is considered to be a country in which effective prevention interventions could contain the development of a human immunodeficiency virus (HIV) epidemic. Heterosexual transmission accounts for 85 % of the extant HIV infections. PURPOSE: This study sought to assess the feasibility of conducting a group, culturally tailored behavioral intervention and its impact on sexual barrier use, self-efficacy, knowledge, conflict resolution, and coping among high-risk heterosexual couples in Northern India. METHOD: This pilot study was conducted at the Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh, India from February 2008 to January 2009. Thirty sexually active high-risk couples were drawn from a convenience sample of PGIMER patients attending infectious disease and family planning clinics. Couples participated in 1 month of three weekly gender-concordant behavioral intervention groups and were individually administered assessments preintervention and post-intervention. The intervention was tailored to the Northern Indian context and addressed sexual barrier use, human immunodeficiency virus (HIV)/sexually transmitted infection transmission, and cognitive behavioral skill building focusing on sexual negotiation and communication. RESULTS: The participants had a mean age of 32 years (men) and 29 years (women), and the majority had at least 10 years of education. At baseline, the majority reported inconsistent condom use (<100 % of the time; 64 % of women, 59 % of men). Post-intervention, nearly all participants reported consistent condom use (100 % of the time; 100 % of men, 97 % of women). Participants also reported decreased verbal aggression, increased self-efficacy, and increased HIV-related knowledge, and women increased their use of positive coping tactics. CONCLUSIONS: The results highlight the potential to successfully utilize a group intervention to discuss sensitive issues such as sexual risk behavior among both men and women. Strategies to improve condom use and communication without increasing intimate partner violence in high-risk couples may be an important adjunct to preventing the development of a generalized epidemic in India.

Sexual risk, serostatus and intimate partner violence among couples during pregnancy in rural South Africa.

The aim of this study was to describe sexual risk behavior among 239 couples during pregnancy and to examine the relationship of sexual risk behavior with HIV serostatus and intimate partner violence. One-third (31.8 %) of pregnant women and 20.9 % of male partners were HIV positive. HIV risk factors included lack of knowledge of partners' HIV serostatus, unprotected sexual intercourse and multiple sexual partners. Among men, multivariate logistic regression identified awareness of HIV negative partner status, multiple sexual partners and low levels of partner violence and among women Zulu or Swati ethnicity were associated with unprotected intercourse. HIV positive concordance was associated with protected sex and in multilevel analysis of couples HIV positive status and awareness of the partner's HIV positive status were associated with protected sex. High levels of HIV risk behaviour was found among couples during pregnancy calling for HIV risk reduction interventions.

The impact of substance use, sexual trauma, and intimate partner violence on sexual risk intervention outcomes in couples: a randomized trial.

BACKGROUND: Few HIV prevention interventions focus on sexual risk reduction as mutual process determined by couple members, though risk behaviors are inter-dependent. PURPOSE: This trial examined the impact of substance use, history of sexual trauma, and intimate partner violence on sexual risk associated with participation in a risk reduction intervention. METHODS: HIV seroconcordant and serodiscordant multicultural couples in Miami, Florida (n = 216) were randomized to group (n = 112) or individual (n = 104) couple-based interventions. RESULTS: Group intervention participants increased condom use in couples in which women had a history of sexual trauma [F(2,221) = 3.39, p = 0.036] and by partners of alcohol users. History of sexual trauma was a determinant of conflict resolution, predicting negative communication and intimate partner violence. CONCLUSIONS: Results emphasize the need for group sexual risk reduction interventions targeting sexual trauma, partner violence, and substance use among HIV seroconcordant and serodiscordant couples.

HIV knowledge and sexual risk behavior among pregnant couples in South Africa: the PartnerPlus project.

In sub-Saharan Africa, 60 % of people living with HIV are women and most are of childbearing age. Alarmingly, seroconversion rates during pregnancy are high and increase as pregnancy progresses, highlighting the importance of increasing HIV-knowledge among pregnant women and their partners. This study compared sexual risk behavior, HIV knowledge and condom use pre- to post-partum among South African couples (n = 239 couples) randomly assigned to an intervention or an enhanced standard of care with the PMTCT protocol at rural community health antenatal clinics. Consistent condom use and HIV-related knowledge increased baseline to post-intervention and was maintained at long term follow up post-partum among participants in the intervention condition. HIV knowledge mediated the relationship between the intervention and consistent condom use. Results from this pilot study provide support for the integration of HIV risk reduction interventions for both women and men into existing PMTCT services during and following pregnancy.

HIV knowledge, disclosure and sexual risk among pregnant women and their partners in rural South Africa.

Partner involvement has been deemed fundamental for the prevention of mother-to-child transmission (PMTCT) of HIV, although it remains difficult to achieve. This study aimed to explore the attitudes and behaviours of pregnant women and their partners who participated in a behavioural risk reduction intervention in six community health centres in the Mpumalanga province of South Africa. Qualitative methods only were used in this study. Women and their partners took part in four gender-concordant groups that addressed HIV, PMTCT, disclosure of HIV status and safer sex practices. The results indicate that men value and understand the importance of being involved in women's reproductive health, although some components of the PMTCT programme such as condom use were still met with some resistance. Participants demonstrated high levels of HIV- and sexually transmitted infection-related knowledge. Men lacked knowledge about PMTCT but were interested in acquiring information so that they could support their partners. All groups highlighted the emotional and physical benefits of disclosing one's HIV status. The involvement of men in antenatal care has the potential to prevent women from becoming infected with HIV both during pregnancy and post-partum when they are more vulnerable to infection and have a high risk of transmission to the infant. There is a need for interventions that focus on both increasing male involvement and promoting condom use during pregnancy.

Sexual risk behaviors among African-American and Hispanic women in five counties in the Southeastern United States: 2008-2009.

PURPOSE: We examined sexual risk behaviors and unrecognized HIV infection among heterosexually active African-American and Hispanic women. METHODS: Women not previously diagnosed with HIV infection were recruited in rural counties in North Carolina (African American) and Alabama (African American), and an urban county in southern Florida (Hispanic) using multiple methods. They completed a computer-administered questionnaire and were tested for HIV infection. RESULTS: Between October 2008 and September 2009, 1,527 women (1,013 African American and 514 Hispanic) enrolled in the study. Median age was 35 years (range, 18-59), 33% were married or living as married, 50% had an annual household income of $12,000 or less, and 56% were employed full or part time. Two women (0.13%) tested positive for HIV. In the past 12 months, 19% had been diagnosed with a sexually transmitted infection (other than HIV), 87% engaged in unprotected vaginal intercourse (UVI), and 26% engaged in unprotected anal intercourse (UAI). In multivariate analysis, UAI was significantly (p < .05) more likely among those who reported ever being pregnant, binge drinking in the past 30 days, ever exchanging sex for things needed or wanted, engaging in UVI, or being of Hispanic ethnicity. UAI was also more likely to occur with partners with whom women had a current or past relationship as opposed to casual partners. CONCLUSION: A high percentage of our sample of heterosexually active women of color had recently engaged in sexual risk behaviors, particularly UAI. More research is needed to elucidate the interpersonal dynamics that may promote this high-risk behavior. Educational messages that explicitly address the risks of heterosexual anal intercourse need to be developed for heterosexually active women and their male partners.

The many faces of translational research: a tale of two studies.

Translational research can take many forms: bench to bedside, across cultural groups, across geographical boundaries, among others. This case study will share how we addressed all three "translational" issues using two evidence-based studies (USA, Zambia) to illustrate these "roads less traveled." Our implementation and dissemination efforts were anchored by the "train the trainer" strategy, and the Glasgow RE-AIM model provided programmatic guideposts and direction. Keeping all stakeholders (scientific, community, political) involved in the implementation and dissemination process was an essential, perhaps determining factor in the success of the translation process.

Sexual barrier acceptability among multiethnic HIV-positive and at-risk women.

BACKGROUND: Sexual behavior interventions have been found to reduce sexual risk among HIV-seropositive and high-risk HIV-seronegative women. METHODS: This study examined the influence of ethnicity and HIV serostatus on sexual barrier acceptability and use at short-term and long-term follow-up among African American and Hispanic (n=457) women participating in a gender and culturally tailored sexual risk reduction intervention. We hypothesized that sexual barrier acceptability and use would differ between ethnic groups but that this difference would dissipate after intervention participation. We further postulated that HIV-seropositive women would report greater acceptability and use of sexual barriers than seronegative women at baseline and that after participation in the intervention, acceptability and use would increase for both serostatus groups. RESULTS: We enrolled 317 African American and 140 Hispanic women, 273 (60%) seropositive and 184 (40%)seronegative. Ethnic differences in the frequency of male and female condom use existed at baseline but were not found at 12-month follow-up. Male condom acceptability was higher among African American women than Hispanic women at baseline and 12-month follow-up. Seropositive women reported higher levels of consistent male condom use, but both ethnic and serostatus groups reported high levels (positive, 40%; negative, 52%) of inconsistent condom use. Most women had little experience with female condoms or lubricating gels and suppositories at baseline. No differences between ethnicities were identified in lubricant use. CONCLUSIONS: Results support the use of a culturally tailored intervention among these populations to increase sexual barrier use and reduce sexual risk.

Enhancing the health of women living with HIV: the SMART/EST Women's Project.

THE PRINCIPAL OBJECTIVE OF THESE MULTISITE STUDIES (FLORIDA, NEW YORK, NEW JERSEY: epicenters for human immunodeficiency virus [HIV] among women) was to develop and implement effective combinations of behavioral interventions to optimize the health status of the most neglected and understudied population affected by the acquired immunodeficiency syndrome (AIDS) epidemic in the United States: poor women of color living with HIV. The two studies enrolled nearly 900 women randomly assigned to "high intensity" (cognitive-behavioral stress management training combined with expressive-supportive therapy [CBSM]+ group) or "low intensity" (individual psychoeducational program) treatment conditions over a period of 9 years. The initial study of the stress management and relaxation training/expressive-supportive therapy (SMART/EST) Women's Project (SWP I) focused on reducing depression and anxiety, as well as improving self-efficacy and overall quality of life for women with case-defined AIDS. Findings from this study demonstrated the utility of CBSM+ in reducing distress (depression, anxiety) and denial, while improving social support, self-efficacy, coping skills, and quality of life. The second study (SWP II), which included all women living with HIV, extended these findings by demonstrating that exposure to CBSM+ significantly improved the ability of the participants to take advantage of a health behavior change program encouraging the adoption and maintenance of healthier lifestyle behaviors (high levels of medication adherence, appropriate nutritional intake and physical activity, safer sexual practices, and reduced alcohol use/abuse) essential for optimal health in the context of living with HIV. SWP II also determined that the intervention program was equally beneficial to less-acculturated segments of the affected population (ie, non-English speaking HIV+ women) through the creation of culturally and linguistically sensitive Spanish and Creole versions of the program. A third study (SWP III) is currently underway to "translate" this evidence-based treatment program into Community Health Centers in Miami, New York City, and metropolitan New Jersey.