Community-based interventions to reduce low income, African American women's risk of sexually transmitted diseases: a randomized controlled trial of three theoretical models.

A community-based sample of disadvantaged African American women (n = 445) was recruited to participate in 1 of 3 theoretically driven experimental interventions based on either the theory of gender and power, social learning theory, or cognitive behavioral theory. Intervention outcomes were compared with a waiting list control condition. From baseline to postintervention, women in the experimental interventions showed differential change on cognitive indices (knowledge and attitudes) and skill acquisition (partner negotiation skills, correct condom application, lubricant selection, and information-provision to social networks) whereas control participants were unchanged. Women in the 3 experimental interventions also completed follow-up assessments for 1 year following the interventions. In all 3 experimental conditions, condom use increased relative to the control group and there were no differences between the experimental interventions. Women who participated in one of the theoretically grounded interventions continued to increase condom use over the following year. Women entering new relationships reported significantly more condom use than did women who remained in ongoing relationships. The findings suggest that intervention models that have proven effective for women who engage in high-risk behavior may be less effective for women in established relationships for whom risk is primarily derived from the extrarelationship behavior of their partners.

Measuring perceived barriers to condom use: psychometric evaluation of the Condom Barriers Scale.

A programmatic series of three studies developed and evaluated the Condom Barriers Scale (CBS), an instrument measuring women s perceived barriers to condom use for prevention of HIV and other sexually transmitted diseases. Following item generation and selection, Study 1 evaluated the CBS in a sample of minority women (N = 178), reduced the number of items, assessed the factor structure, evaluated the internal consistency, and explored the convergent validity of the CBS. In Study 2, the CBS was administered to a cross-validation sample (N = 278). Confirmatory factor analysis and internal consistency were compared against the original sample and construct, criterion, and discriminant validity were assessed. In Study 3 (N = 30), temporal stability of the CBS was evaluated. The resulting instrument appears to have sound psychometric properties and can be used to measure a key construct in the leading theoretical models of health behavior for which a measure with known psychometric properties previously has not been available.

Behavioral and psychosocial consequences of HIV antibody counseling and testing with African American women.

This study compared a sample of low-income African American women in the southeastern United States who had and had not yet undergone HIV counseling and testing on risk-related cognitive mediating variables and self-reported sexual behaviors. Four hundred sixty (N = 460) African American women were recruited from health clinics and community settings in a southern city. Forty-five percent of the women (n = 207) had undergone HIV counseling and testing, whereas 55% (n = 253) had never been tested. Women who were seropositive were excluded from the analyses. After providing informed consent, the women completed a battery of cognitive mediating measures assessing AIDS knowledge, attitudes theoretically relevant to risk reduction, and self-reported sexual behavior. In addition, each participant demonstrated condom application skills using a penile model. Women who had undergone testing were younger, rated HIV disease as more serious, considered AIDS a greater health concern, had more positive attitudes toward HIV prevention, expressed greater intentions to use condoms, and evidenced a greater commitment to self-protective behavior than women who were not yet tested. Women who had undergone HIV antibody testing, however, showed no differences in sexual behavior from women who were never tested. Sexual behavior, including numbers of partners, frequency of unprotected intercourse, and inconsistent condom use, left women in both groups at significant and comparable risk for HIV and sexually transmitted disease infection. HIV counseling and testing alone may not be effective primary prevention strategies for promoting risk reduction among African American women.

Factors influencing condom use among African American women: implications for risk reduction interventions.

Examined factors associated with condom use in a community-based sample of 423 sexually active African American women. Measures were selected to reflect the components in prevailing models of health behavior. Condom users were higher on AIDS health priority, prevention attitudes, stage of change, behavioral intentions, reported more frequent and comfortable sexual communication with partners, perceived greater partner and peer approval for condom use, and reported that peers also used condoms. Women in exclusive relationships evidenced earlier stage of change, lower intentions to use condoms, fewer peers who engaged in preventive behaviors, perceived themselves to have lower risk, and had lower rates of condom use, higher education, and family income. Women in fluid relationships were at particularly high risk, with lower rates of condom use relative to women not in a relationship and greater sexual risk for HIV. Implications for HIV-risk reduction interventions with African American women are discussed.

HIV risk reduction for incarcerated women: a comparison of brief interventions based on two theoretical models.

Although female inmates are seropositive at rates that exceed those of male inmates, few studies, have evaluated HIV risk reduction interventions for incarcerated women. This demonstration project compared an intervention based on social cognitive theory against a comparison condition based on the theory of gender and power. Incarcerated women (N = 90) were assessed at baseline, postintervention, and again 6 months later. Both interventions produced increased self efficacy, self-esteem, Attitudes Toward Prevention Scale scores, AIDS knowledge, communication skill, and condom application skills that maintained through the 6-month follow-up period. Participants in the intervention based on social cognitive theory showed greater improvement in condom application skills, and women in the program based on the theory of gender and power evidenced greater commitment to change. The results suggests brief interventions in prison settings are feasible and beneficial. However, it is not yet known whether the changes will generalize into the natural environment after the women's release into the community.

Evaluation of the HIV risk reduction intervention for women entering inpatient substance abuse treatment.

OBJECTIVES: Interventions to lower HIV risk behavior among drug users have concentrated on reduction of high risk injection practices. Less attention has been directed to non-injecting drug users and drug-involved women. Female non-injecting drug users (e.g., women who abuse alcohol or crack cocaine) are also at substantial risk for sexual transmission of HIV due to multiple partners, partners who self-inject and share needles, exchange of sex for drugs, coerced sex, high rates of sexually transmitted diseases, and low rates of condom use. This study compared the effectiveness of an educational intervention (EC) against the behavior skills training intervention (BST) in reducing sexual risk behavior among women (N = 117) court-ordered into inpatient drug treatment. METHODS: Participants were assessed at baseline, post intervention, and 2 months after discharge from the drug treatment facility. RESULTS: Women in both conditions reported high rates of sexual risk behavior prior to the intervention. Women in both conditions had more positive attitudes toward HIV prevention and reported greater partner agreement with condom use at the post intervention assessment. However, these changes were not maintained at follow-up for women in the EC condition, whereas women in BST continued to show improvement post discharge. Women in the BST condition showed marked, while women in EC showed little improvement in communication skills and no improvement in condom application skill. At follow-up, women in both conditions had reduced drug use and drug-related high risk sex activities. BST women had increased their condom use while women in EC evidenced a decrease. Condom use increased from 35.7% to 49.5% of vaginal intercourse occasions for BST women and decreased from 28.8% to 15.8% for women in EC. CONCLUSIONS: Results suggest a brief skills training intervention embedded in drug treatment programs can reduce sexual risk for HIV-infection after discharge.

Predictors of African American adolescents' condom use and HIV risk behavior.

This study evaluated predictors of risky and safer behavior in a sample of low-income African American adolescents, assessed their perceptions of the risk associated with their sexual behavior, and examined differences between adolescents who used condoms consistently, inconsistently, or engaged only in unprotected intercourse. African American adolescents (N = 312) completed measures related to AIDS knowledge, frequency of condom use, attitudes toward condoms, and sexual behavior over the preceding 2 months. Multiple regression analyses for the sexually active youths (N = 114) revealed that lower self-efficacy, higher perceived risk, and male gender were associated with high-risk behavior. Positive attitudes toward condoms and younger age had the strongest association with condom use. Consistent condom users were more knowledgeable and held more positive attitudes toward condoms, and nonusers were older. Regardless of their behavior, the adolescents generally did not perceive themselves to be a risk for HIV infection. The findings suggest that precautionary practices (condom use) and high-risk behavior (unprotected sex with multiple partners) may have different correlates. In addition, the data indicate that theoretical models developed with homosexual male populations may also be generalizable to African American adolescents' sexual behavior.

PIP: To facilitate identification of factors that place low-income African American adolescents at increased risk of human immunodeficiency virus (HIV), interviews were conducted with 312 youth 12-19 years of age attending a Public Health Service-funded clinic in Mississippi. The analysis was restricted to the 114 sexually active youth in this sample. The full variable set included age, gender, acquired immunodeficiency syndrome (AIDS) knowledge, condom attitude, perceived risk of AIDS, self-efficacy, social provision, church attendance, AIDS Risk Index, and Condom Use Index. Correlations between these variables were small to moderate (0.0 to -0.48). Separate regression analyses revealed significant relationships between the full variable set and the AIDS Risk Index (p 0.0001) and the Condom Use Index (p 0.02). Half of the teens reported unprotected intercourse in the preceding 2 months, yet most perceived themselves at low risk for AIDS. Multivariate analyses of variance revealed that variables most predictive of unprotected sex with multiple partners differed from those associated with condom use. Males who reported lower self-efficacy in avoiding AIDS and perceived themselves at greater risk were most likely to engage in high-risk behaviors. Consistent condom users were younger than intermittent and non-users and had more positive attitudes about condoms and higher AIDS knowledge scores. Interventions aimed at Black teens may need to expand beyond condom promotion to include broader media and community-based educational programs.

Cognitive-behavioral intervention to reduce African American adolescents' risk for HIV infection.

Two hundred forty-six African American adolescents were randomly assigned to an educational program or an 8-week intervention that combined education with behavior skills training including correct condom use, sexual assertion, refusal, information provision, self-management, problem solving, and risk recognition. Skill-trained participants (a) reduced unprotected intercourse, (b) increased condom-protected intercourse, and (c) displayed increased behavioral skills to a greater extent than participants who received information alone. The patterns of change differed by gender. Risk reduction was maintained 1 year later for skill-trained youths. It was found that 31.1% of youths in the education program who were abstinent at baseline had initiated sexual activity 1 year later, whereas only 11.5% of skills training participants were sexually active. The results indicate that youths who were equipped with information and specific skills lowered their risk to a greater degree, maintained risk reduction changes better, and deferred the onset of sexual activity to a greater extent than youths who received information alone.

Comparison of education versus behavioral skills training interventions in lowering sexual HIV-risk behavior of substance-dependent adolescents.

Substance-dependent adolescents (N = 34) in a residential drug treatment facility received either a 6-session behavior skills training HIV-risk reduction intervention or standard HIV education. After the intervention, adolescents who received behavior skills training exhibited increased knowledge about HIV-AIDS, more favorable attitudes toward prevention and condom use, more internal locus of control, increased self-efficacy, increased recognition of HIV risk and decreases in high-risk sexual activity. Self-report data were corroborated by records for the treatment of sexually transmitted diseases. The results from this pilot demonstration effort suggest that skills training based on cognitive-behavioral principles may be effective in lowering high-risk adolescents' vulnerability to HIV infection and warrant evaluation in a controlled comparison with a larger sample.

HIV risk behavior among homeless adults.

Very little information is available regarding HIV risk behavior among homeless adults despite increasing evidence that HIV infection disproportionately affects inner-city residents and disadvantaged populations. In the present study, adults (N = 94) entering a storefront medical clinic for the homeless completed an AIDS risk survey. The results suggest that homeless adults are engaging in sexual and substance-use behaviors that place them at high risk for HIV infection. Sixty-nine percent of the present sample was at risk for HIV infection from either 1) unprotected intercourse with multiple partners, 2) intravenous drug use (IVDU), 3) sex with an IVDU partner, or 4) exchanging unprotected sex for money or drugs. Many persons within the sample evidenced multiple risk factors: 45% reported at least two of the risk factors described above and 26% reported three or more risk factors. The results suggest there is an urgent need to develop and evaluate AIDS-prevention strategies for homeless adults.

Cross-cultural comparison of US and Nigerian adolescents' HIV-related knowledge, attitudes, and risk behaviour: implications for risk reduction interventions.

Attitudes towards AIDS prevention, AIDS-related knowledge, and sexual behaviour of Nigerian adolescents and their African-American counterparts in two geographic regions of the United States were compared to assess cross-cultural similarities and differences between the adolescents. This study was conducted as the first in a programmatic sequence of activities leading toward the adaptation of a risk reduction intervention that was developed in the US for implementation with Nigerian youths. Subjects (n = 511) completed self-report measures of AIDS-related knowledge, attitudes towards condoms, attitudes towards AIDS prevention, sexual behaviour over the past two months, self- and response efficacy, and perceived vulnerability. Between-group comparisons revealed that US adolescents were more knowledgeable, held more favourable attitudes towards prevention and toward condoms, reported more sex partners, engaged in higher frequencies of unprotected vaginal intercourse, and became sexually active at later age than Nigerian adolescents. The findings are discussed with respect to their implications for translating risk reduction interventions developed in the US for African-American adolescents for later cross-cultural implementation with adolescents in developing countries where such risk reduction efforts are urgently needed.

Barriers to condom use and barrier method preferences among low-income African-American women.

Low-income African-American women (N = 178) entering health clinics completed surveys assessing perceived barriers to condom use for themselves personally and for African-American women generally. Following the survey, each woman received a demonstration of five barrier contraceptive methods and then rated her preference among those methods. The women perceived relatively few personal barriers to use of the male condom but perceived significantly greater barriers for other African-American women (all p < .0001). The male condom was first choice of the largest percentage of women (45%) and last choice of the smallest percentage of women (11%). The male condom was preferred for its convenience, availability, and safety, although the necessity for active cooperation by the male partner was considered a hindrance to using the method. Only 23% of women ranked the female condom as first choice and 35% ranked the female condom as last choice. Reasons for selecting the female condom included preference for a female-controlled method, safety, and protection. However, the female condom was perceived to be uncomfortable, to require the partner's acquiescence, and to interfere with sexual experience. Differences in the women's perceptions of barriers to condom use for themselves and for other African-American women are consistent with Weinstein's theory of optimistic bias. Preferences among barrier methods indicate that further research and product development are needed to develop barrier methods that are female-controlled, do not require the awareness of the male partner, and are safe, comfortable, and convenient.

PIP: A survey conducted among 178 low-income African-American women (mean age, 33.1 years) recruited from health clinics in Mississippi (US) identified a need to increase condom use in this population. Although 22% of subjects reported 2 or more sexual partners in the preceding 12 months and only 12% were consistent condom users, 50% believed they were at low personal risk for human immunodeficiency virus (HIV) and just 10% considered their HIV risk to be high. On the other hand, 93% of respondents had used the male condom at some point and 44% kept their own supply on hand. Notable was a pattern of consistent difference between the subjects' personal attitudes about male condoms and their perceptions of the beliefs of other Black women. For example, while 15% of subjects felt that asking their male partner to use a condom could generate anger, 39.2% anticipated that other Black women's partners would react with anger to this suggestion. Frequent condom users reported fewer negative attitudes about the male condom than nonusers or infrequent users. When presented with 5 barrier method options, 45% preferred the male condom, 23% the female condom, 20% vaginal contraceptive film, 11% the Today sponge, and 2% the Protectaid sponge. High protection, safety, and familiarity were the most frequently cited reasons for selecting the male condom. When women were asked to select their least favorite barrier method, 35% identified the female condom. Although the female condom gives women control over their reproductive health, the method was perceived as too large and visible.

Cognitive-behavioral group intervention to assist substance-dependent adolescents in lowering HIV infection risk.

Substance dependent adolescents (N = 19), court referred into a residential drug treatment facility received a five-session HIV risk-reduction intervention that provided risk education, social competency skills (sexual assertion, partner negotiation, and communication skills), technical skills (condom use), and problem-solving training. Before and after the intervention, subjects completed measures of AIDS risk knowledge, health locus of control, social support, attitudes toward HIV prevention, attitudes toward condoms, self-efficacy, and perceptions of risk in addition to role-play assessments of behavioral skill resisting high-risk coercions. Postintervention, subjects exhibited increased knowledge about HIV/AIDS, more favorable attitudes toward prevention, greater internal and lower external locus of control scores, more favorable attitudes toward condom use, increased self-efficacy, and greater recognition of HIV vulnerability. Following intervention, the percentage of participants reporting sexual activity in high-risk contexts decreased, substantiating the intervention's effectiveness. Self-report data were corroborated by sexually transmitted disease treatment records. This uncontrolled demonstration effort suggests that skills training based on cognitive-behavioral principles may be a promising intervention strategy to lower vulnerable adolescents' risk of HIV infection.

Outcome of cognitive-behavioral and support group brief therapies for depressed, HIV-infected persons.

OBJECTIVE: Although many studies have documented patterns of emotional distress in persons with HIV disease, there have been few controlled evaluations of therapy outcomes with these individuals. This research evaluated the effects of brief cognitive-behavioral or social support group therapy with this population. METHOD: Sixty-eight depressed men with HIV infection were randomly assigned to one of three conditions: eight-session cognitive-behavioral groups, eight-session social support groups, or a comparison condition. Before and after intervention and at 3-month follow-up, all participants were individually assessed by using measures of symptoms of distress as well as substance use and sexual practices. RESULTS: Relative to the comparison group, both the cognitive-behavioral and social support group therapies produced reductions in depression, hostility, and somatization. The social support intervention also produced reductions in overall psychiatric symptoms and tended to reduce maladaptive interpersonal sensitivity, anxiety, and frequency of unprotected receptive anal intercourse, while the cognitive-behavioral intervention resulted in less frequent illicit drug use during the follow-up period. Tests for clinical significance of change particularly underscored benefits of the social support group intervention both at postintervention and at long-term follow-up. CONCLUSIONS: Brief group therapy for depressed persons with HIV infection produced reductions in symptoms of distress. The two forms of therapy resulted in shared and unique improvements in functioning, although social support groups focused on emotional coping presented greater evidence of clinically significant change. As more persons contract HIV infection and live longer with HIV disease, further research is needed to evaluate outcomes of mental health services with these individuals.

Factors associated with severity of depression and high-risk sexual behavior among persons diagnosed with human immunodeficiency virus (HIV) infection.

Whereas some people appear to cope after learning that they have human immunodeficiency virus (HIV) infection, others experience depression and suicidal ideation. In this study, 142 persons with HIV infection were administered the Center for Epidemiological Studies Depression Scale (CES-D). High levels of depression were predicted by lower perceived social support, attributions that health was influenced more by chance, high-risk sexual behavior practices, and greater number of HIV illness symptoms and greater duration of time knowing of one's own positive serostatus. Ongoing high-risk sexual behavior practices were predicted by higher levels of recreational drug use and of depression. These findings highlight the need for improved mental health services for persons with HIV conditions.

Community AIDS/HIV risk reduction: the effects of endorsements by popular people in three cities.

OBJECTIVES: It is critical to extend community-level acquired immunodeficiency syndrome (AIDS) prevention efforts beyond education alone and to develop models that better encourage behavioral changes. Gay men in small cities are vulnerable to human immunodeficiency virus (HIV) infection due to continued high rates of risk behavior. This research introduced an intervention that trained popular people to serve as behavioral change endorsers to peers sequentially across three different cities. METHODS: Populationwide surveys were conducted of all men patronizing gay clubs in each city to establish risk behavior base rates. After a small cadre of popular "trendsetters" were identified, they received training in approaches for peer education and then contracted to communicate risk reduction recommendations and endorsements to friends. Surveys were repeated at regular intervals in all cities, with the same intervention introduced in lagged fashion across each community. RESULTS: Intervention consistently produced systematic reductions in the population's high-risk behavior (unprotected anal intercourse) of 15% to 29% from baseline levels, with the same pattern of effects sequentially replicated in all three cities. CONCLUSIONS: This constitutes the first controlled, multiple-city test of an HIV prevention model targeting communities. The results support the utility of norm-changing approaches to reduce HIV risk behavior.

AIDS/HIV risk behavior among the chronic mentally ill.

OBJECTIVE: There is growing concern that chronic mentally ill adults living in the community have a high risk for HIV infection. The purpose of this study was to identify risk knowledge, high-risk behaviors, and risk-related encounters of chronic psychiatric outpatients. METHOD: Detailed information on high-risk behaviors and risk-related situations during the past 12 months was collected from 60 outpatients appearing for regular visits at inner-city community mental health clinics. RESULTS: Of the 60 outpatients, 37 (62%) had been sexually active during the past year, and 42% of the men and 19% of the women reported multiple sexual contacts and infrequent use of condoms during intercourse. Assessments of the patients' knowledge of AIDS risks revealed substantial deficits in their practical understanding of AIDS and risk reduction measures. Although use of intravenous drugs was uncommon in this group, many subjects reported histories of 1) trading sex for money, drugs, or a place to stay, 2) coercion to engage in unwanted sex, 3) causal sexual encounters, and 4) sexual activity after use of drugs or intoxicants. Twenty percent of the subjects had met their sexual partners on the streets, in parks, or in other public places. One-third had been treated for sexually transmitted diseases other than AIDS. CONCLUSIONS: These findings underscore the need for AIDS risk assessment, counseling, and prevention programs for the chronic mentally ill.

Situational factors associated with AIDS risk behavior lapses and coping strategies used by gay men who successfully avoid lapses.

While most gay men have reduced behavior practices at high risk for HIV infection, there is growing evidence that many also lapse to unsafe sex. This study examined situational factors related to risk behavior lapses as well as coping strategies used by men who successfully resist lapse urges. A convenience sample of 470 men patronizing gay bars or attending social organization meetings in four cities was surveyed. Forty-five percent of men were classified as "lapsers" (those who had had unprotected anal intercourse in the previous 6 months) and 24% were classified as "resisters" (those who successfully resisted urges to engage in this behavior). All provided information concerning the importance of factors related to the most recent occurrence of either unsafe sex or resisting unsafe urges. Most episodes of unsafe sex occurred outside monogamous relationships and with partners of unknown HIV serostatus, although simply inquiring about partner serostatus was relatively common. Lapsers rated affectionate feelings and wishing to please a partner as well as spontaneity of unsafe sex as the most important situational factors surrounding high-risk behavior. Resisters of unsafe sex urges reported active cognitive self-guidance, experience in safe sex, and recall of both AIDS fears and safety benefits as their most important coping strategies. Gay men who continue high-risk behavior may be overrelying on partner reports of negative serostatus. Lapse prevention approaches tailored to situations that create increased risk vulnerability must be developed. Teaching skills already used by men who successfully resist unsafe sex urges might be one approach.

HIV risk behavior reduction following intervention with key opinion leaders of population: an experimental analysis.

BACKGROUND AND PURPOSE: Peer norms influence the adoption of behavior changes to reduce risk for HIV (human immunodeficiency virus) infection. By experimentally intervening at a community level to modify risk behavior norms, it may be possible to promote generalized reductions in HIV risk practices within a population. METHODS: We trained persons reliably identified as popular opinion leaders among gay men in a small city to serve as behavior change endorsers to their peers. The opinion leaders acquired social skills for making these endorsements and complied in talking frequently with friends and acquaintances. Before and after intervention, we conducted surveys of men patronizing gay clubs in the intervention city and in two matched comparison cities. RESULTS: In the intervention city, the proportion of men who engaged in any unprotected anal intercourse in a two-month period decreased from 36.9 percent to 27.5 percent (-25 percent from baseline), with a reduction from 27.1 percent to 19.0 percent (-30 percent from baseline) for unprotected receptive anal intercourse. Relative to baseline levels, there was a 16 percent increase in condom use during anal intercourse and an 18 percent decrease in the proportion of men with more than one sexual partner. Little or no change was observed among men in the comparison cities over the same period of time. CONCLUSIONS: Interventions that employ peer leaders to endorse change may produce or accelerate population behavior changes to lessen risk for HIV infection.