Managing the risk of intimacy: accounts of disclosure and responsiveness among people with HIV and intimate partners of people with HIV.

It is well known that concerns about sexual risk tend to decline among people in intimate relationships where there is established commitment and trust. In the context of relationships at increased risk for HIV transmission, interactions involving disclosure and partner responsiveness are key to maintaining intimacy and physical safety. This paper explores concepts of risk and sexual intimacy articulated by a community sample of 30 people living with HIV and their intimate relationship partners. Data revealed the shifts in intimate relationship dynamics upon the disclosure of an HIV diagnosis, the importance of intimacy in the context of managing one or both partners' HIV care and responses to new advances in HIV prophylaxis. Findings suggest that participants' experiences of self-disclosure and partner responsiveness most often resulted in an increased sense of protectiveness from and for partners. This suggests that health-promoting messaging should be adapted to be more relevant to intimate couple communication and mutual support.

Overlooked Threats to Respondent Driven Sampling Estimators: Peer Recruitment Reality, Degree Measures, and Random Selection Assumption.

Intensive sociometric network data were collected from a typical respondent driven sample (RDS) of 528 people who inject drugs residing in Hartford, Connecticut in 2012-2013. This rich dataset enabled us to analyze a large number of unobserved network nodes and ties for the purpose of assessing common assumptions underlying RDS estimators. Results show that several assumptions central to RDS estimators, such as random selection, enrollment probability proportional to degree, and recruitment occurring over recruiter's network ties, were violated. These problems stem from an overly simplistic conceptualization of peer recruitment processes and dynamics. We found nearly half of participants were recruited via coupon redistribution on the street. Non-uniform patterns occurred in multiple recruitment stages related to both recruiter behavior (choosing and reaching alters, passing coupons, etc.) and recruit behavior (accepting/rejecting coupons, failing to enter study, passing coupons to others). Some factors associated with these patterns were also associated with HIV risk.

Using Participatory System Dynamics Modeling to Examine the Local HIV Test and Treatment Care Continuum in Order to Reduce Community Viral Load.

Achieving community-level goals to eliminate the HIV epidemic requires coordinated efforts through community consortia with a common purpose to examine and critique their own HIV testing and treatment (T&T) care system and build effective tools to guide their efforts to improve it. Participatory system dynamics (SD) modeling offers conceptual, methodological, and analytical tools to engage diverse stakeholders in systems conceptualization and visual mapping of dynamics that undermine community-level health outcomes and identify those that can be leveraged for systems improvement. We recruited and engaged a 25-member multi-stakeholder Task Force, whose members provide or utilize HIV-related services, to participate in SD modeling to examine and address problems of their local HIV T&T service system. Findings from the iterative model building sessions indicated Task Force members' increasingly complex understanding of the local HIV care system and demonstrated their improved capacity to visualize and critique multiple models of the HIV T&T service system and identify areas of potential leverage. Findings also showed members' enhanced communication and consensus in seeking deeper systems understanding and options for solutions. We discuss implications of using these visual SD models for subsequent simulation modeling of the T&T system and for other community applications to improve system effectiveness.

A qualitative analysis of peer recruitment pressures in respondent driven sampling: Are risks above the ethical limit?

BACKGROUND: This paper examines peer recruitment dynamics through respondent driven sampling (RDS) with a sample of injection drug users in Hartford, CT to understand the strategies participants use to recruit peers into a study and the extent to which these strategies may introduce risks above the ethical limit despite safeguards in RDS. METHODS: Out of 526 injection drug users who participated in a mixed-method RDS methodology evaluation study, a nested sample of 61 participants completed an in-depth semi-structured interview at a 2-month follow-up to explore their experiences with the recruitment process. RESULTS: Findings revealed that participants used a variety of strategies to recruit peers, ranging from one-time interactions to more persistent strategies to encourage participation (e.g., selecting peers that can easily be found and contacted later, following up with peers to remind them of their appointment, accompanying peers to the study site, etc.). Some participants described the more persistent strategies as helpful, while some others experienced these strategies as minor peer pressure, creating a feeling of obligation to participate. Narratives revealed that overall, the probability of experiencing study-related risks remains relatively low for most participants; however, a disconcerting finding was that higher study-related risks (e.g., relationship conflict, loss of relationship, physical fights, violence) were seen for recruits who participated but switched coupons or for recruits who decided not to participate in the study and did not return the coupon to the recruiter. CONCLUSIONS: Findings indicate that peer recruitment practices in RDS generally pose minimal risk, but that peer recruitment may occasionally exceed the ethical limit, and that enhanced safeguards for studies using peer recruitment methods are recommended. Suggestions for possible enhancements are described.

Translation of the Risk Avoidance Partnership (RAP) for Implementation in Outpatient Drug Treatment Clinics.

Scientific literature increasingly calls for studies to translate evidence-based interventions into real-world contexts balancing fidelity to the original design and fit to the new setting. The Risk Avoidance Partnership (RAP) is a health promotion intervention originally designed to train active drug users to become Peer Health Advocates. A theoretically driven approach was used to adapt RAP to fit implementation in outpatient methadone treatment clinics and pilot it with clinic patients. Ethnographic observations and process tracking documented the RAP translation and pilot experience, and clinic and community characteristics relevant to program implementation. Clinic administrators, staff, and patients were interviewed on their values, capacities, interest in RAP, perceived challenges of implementing RAP in drug treatment clinics, and experiences during the pilot. Findings indicated that RAP core components can be met when implemented in these settings and RAP can fit with the goals, interests, and other programs of the clinic. Balancing fidelity and fit requires recognition of the mutual impacts RAP and the clinic have on each other, which generate new interactions among staff and require ongoing specification of RAP to keep abreast of clinic and community changes. Collaboration of multiple stakeholders significantly benefited translation and pilot processes.

Participant and staff experiences in a peer-delivered HIV intervention with injection drug users.

We explore ethical issues faced by investigators as they conduct research as part of a peer-delivered HIV/AIDS risk reduction program for injection drug users (IDUs). Staff and participant experiences in peer-delivered interventions among IDUs have come under scrutiny by ethics researchers because of their potential to inadvertently and negatively impact participant rehabilitation due to continued engagement with drug-using networks during the course of outreach. This study explores whether enhanced communication of participant concerns and experiences with clinic and research staff helps to reduce inadvertent malfeasance in peer-delivered drug treatment interventions. Results contribute to the development of patient support infrastructure in peer-delivered risk reduction programs involving IDUs.