Sexually Transmitted Diseases  >  Research  >  What We Have Learned...1990-1995

What We Have Learned...1990-1995

Previous

Table of Contents

Next

SMALL GROUP FORMATIVE AND INTERVENTION RESEARCH

Research targeting small groups operates on the assumption that some persons require interventions specifically tailored to their circumstances in order for them to adopt or sustain change to healthy behaviors. Small groups can be defined as collections of persons of similar backgrounds and/or risk factors gathered in the same place at the same time (i.e., STD clinic clients, persons in drug treatment, incarcerated populations, students). Formative research on small groups identifies the behavioral, social, and psychological factors influencing the STD/HIV infection risk of persons in the target group. Intervention research develops and evaluates methods to promote healthy behaviors among persons in the targeted small group by addressing their informational and social needs as identified by the formative research. The interventions can take several forms (i.e., persuasive behavior change messages, skills building training, behavioral risk assessment) and be delivered in several ways (i.e., role play, group counseling, interactive discussion).

Project: #22 A Clinic-Based Research and Demonstration Project to Prevent Sexually Transmitted Diseases Among High Risk Blacks and Latinos

Purpose:

To reduce the incidence of STDs among inner-city Blacks and Latinos by producing a culturally sensitive video-based intervention to increase condom use among Black and Latino STD clinic patients and by developing a model to use video-based interventions in STD clinic practice.

Results:

The formative research for the project revealed that people over the age of 25 to 30 are already set in their sexual practices, so the videos were targeted at a younger audience. Formative research of intervention placement within STD clinic flow determined that individual viewing stations in the intake waiting area were not desirable, continuous playing in the intake waiting room was typical, and a separate viewing room at the end of the clinic visit was optimal.

Compared to the control group, participants who only viewed the video demonstrated greater knowledge about condoms and STDs, more positive attitudes about condom use, increased HIV/STD risk perceptions, and greater self-efficacy. Participants in the video-plus interactive group showed still further increases in risk perceptions and self-efficacy, but not in knowledge or attitudes towards condoms. Rates of condom coupon redemption increased consistently by level of intervention across ethnic and gender-specific groups. Latino men and women, particularly Puerto Ricans, exposed to either intervention were the most likely to redeem the coupons. Dominicans were more likely to redeem coupons only after the video-plus interaction intervention. Among Black participants, African Americans showed increases in coupon redemption at both levels of intervention while Caribbean Islanders were more likely to redeem the coupons only after exposure to the more intensive intervention.

Among men, the rate of new STD infection was significantly lower for those in an intervention group compared to those in the control group, but there was no significant difference between the two interventions. Men with multiple sex partners had the highest new infection rate, but also showed the greatest impact of educational intervention. Latinos were somewhat less likely than African Americans to acquire a new infection. Given the overall lower rate of new infections among women, there was not a significant difference in new infection rates among women by treatment group or ethnic group.

Implications:

Interventions to promote condom use will be most effective if they take into account differences in acculturation within members of the same ethnic group and emphasize and individualize the personal risks of unprotected sex. Perhaps videos shown alone are more appropriate for persons who are more embedded in U.S. culture. The 20-minute, interactive, skill-building, small group discussions following video viewing allow participants to discuss personal risk, misperceptions, barriers to condom use, and different styles of condoms. Participants also can practice communicating about condoms through role play. Neither intervention interferes with clinic flow and both are flexible enough to be adopted by clinics with different service models. Public health advisors or health educators could be trained to conduct the small group intervention. The interventions involve minimal time and cost.

Publications:

Solomon MZ, DeJong W. The impact of a clinic-based educational videotape on knowledge and treatment behavior of men with gonorrhea. Sexually Transmitted Diseases 1988;15:127-132.

Solomon MZ, DeJong W. Preventing AIDS and other STDs through condom promotion: a patient education intervention. American Journal of Public Health 1989;79:453-458.

O'Donnell L, San Doval A, Vornfett R, DeJong W. Reducing AIDS and other STDs among inner-city Hispanics: the use of qualitative research in the development of video-based patient education. AIDS Education and Prevention 1994;6(2):140-153.

O'Donnell L, San Doval A, Duran R, O'Donnell CR. STD prevention and the challenge of gender and cultural diversity: knowledge, attitudes, and risk behaviors among Black and Hispanic inner-city STD clinic patients. Sexually Transmitted Diseases 1994;21(3):137-148.

O'Donnell LN, San Doval A, Duran R, O'Donnell C. Video-based sexually transmitted disease patient education: its impact on condom acquisition. American Journal of Public Health 1995;85(6):817-822.

O'Donnell L, San Doval A, Duran R, O'Donnell CR. The effectiveness of video-based interventions in promoting condom acquisition among STD clinic patients. Sexually Transmitted Diseases 1995;22(2):97-103.

O'Donnell L, San Doval A, Duran R. O'Donnell CR. Predictors of condom acquisition following an STD clinic visit. accepted for publication by Family Planning Perspectives.

DeJong W, O'Donnell L, San Doval AD, Juhn G. The status of clinic-based STD patient education: the need for a commitment to innovation. Submitted to AIDS Education and Prevention.

San Doval A, Duran R, O'Donnell L, O'Donnell CR. Barriers to condom use in primary and non-primary relationships among Hispanic STD clinic patients. MS prepared for submission.

Products:

The videos, Let's Do Something Different for Black STD clinic clients and Porque Sí for Latino STD clinic clients, are available from the CDC National AIDS Clearinghouse. A sample protocol for integrating video-based education into STD clinics is available from Education Development Center, Inc., 55 Chapel Street, Newton, MA 02158.

Key Words: African Americans, Hispanics, condoms, behavior change- barriers, focus groups, small group discussion, IDUs, attitudes, knowledge, STD clinic clients, skills building, role plays, education, video, Bronx, NY., Boston, MA., Chicago, ILL., condom distribution.

Project: #23 A Formative Evaluation of HIV/AIDS Risk Reduction Programs in Prison Settings

Purpose:

To describe, through formative evaluation, the effectiveness of new and ongoing HIV/AIDS prevention and education projects in prison settings and to gain understanding of the special needs of inmates for the design of appropriate prevention programs.

Results:

The 2-year formative evaluation of the effectiveness of HIV/AIDS prevention and education programs was conducted with four different convenience samples: 1) adolescent males in a boot camp, 2) adolescent boys and girls in a juvenile detention center, 3) adult male felons in a maximum security prison, and 4) commercial sex workers in a city jail. Preliminary descriptive analyses of qualitative and quantitative data derived from 185 structured questionnaires (125 inmates and 60 guards, prison officials and staff) indicated that trained interviewers can obtain good response rates from inmates when data is collected under strictly confidential conditions. Inmates were aware of their personal STD/HIV risk, yet many held various misconceptions about HIV transmission and continued to engage in high risk sexual behaviors. Approximately one-third of the inmates indicated that the STD/HIV education programs offered to them did not relate to the high risk activities that occur in their communities. Many of the inmates surveyed suggested that informational and counseling sessions regarding safe sex should be offered repeatedly or on a continuous basis. Also, most preferred a combination of group and individual sessions led by health or medical personnel.

Preliminary interview data indicated that many of the adolescents were selective condom users. This finding is similar to published data on adults, showing that condoms tend to be used more frequently with non-main sex partners than with main sex partners. Condom availability and partner preference appeared to be the two most important factors which influenced the adoption of consistent condom use by adolescents. Early initiation of sexual activity, alcohol, and drug use did not differ significantly between male and female juvenile offenders. Adolescent girls were as likely as boys to have had sex while drunk and to have ever used drugs. However, significantly more girls than boys reported prior STD treatment and having experienced forced sex. Also, girls were twice as likely as boys to perceive their sex partners as a hindrance to consistent condom use.

Focus groups with additional inmates at each of the four sites are planned. More detailed information will be sought regarding how useful specific aspects of current STD/HIV prevention programs are to meet the needs of these incarcerated populations.

Implications:

HIV prevention programs for incarcerated populations must be optimally effective because significantly higher rates of STD and HIV infection are found among individuals who are detained in prisons compared to the general population. Intervention design must take into account differences in the needs of inmates which are mediated by such factors as age, sex, and sexual experience. Such tailoring of prevention programming must also address the persistent discrepancy between personal awareness of risk status and continued risky behavior. Also, program success will be largely determined by how well interventions directly influence the power differentials between men and women so that women can protect their health by reducing their sexual risk. There will be a continual need to collaborate with inmates in the development of appropriate ideas and methods that may be incorporated into prospective program development. It is clear that no program can be without an effective drug treatment component, inclusive of aggressive follow-up for these vulnerable populations. Finally, additional research is indicated in order to develop a theoretical framework for prevention efforts within the incarceration culture.

Publications:

None

Products:

None

Key Words:

California, Michigan, South Carolina, adolescents, incarcerated populations, formative research, education, commercial sex workers, knowledge, group counseling, focus groups, behavior change-barriers, drug treatment.

Project: #24 The Atlanta Congenital Syphilis Research Project: Assessing and Improving Provider Compliance

Purpose:

To evaluate compliance by prenatal service providers with congenital syphilis (CS) guidelines by assessing CS outcomes among women who received prenatal care and were delivered of infants in Atlanta, GA, during 1990-1993, a period in which Atlanta had the highest reported incidence rates of infectious syphilis among women of any major U.S. city.

Results:

Data from three sources, including medical records, were consolidated and reconciled so as to maximize the likelihood of identifying the totality of 1990-1993 incident cases of CS among infants who delivered in an inner-city, publicly-funded hospital which reported approximately 95% of all Atlanta cases during the study period. Of the 173 hospital cases identified, 102 (59%) received prenatal care with a median of four prenatal visits. Adverse outcomes among all cases included perinatal mortality (13%), low birth weight (84%), and prematurity (36%). Characteristics among mothers of congenital cases included: prior syphilis history (30%) and cocaine abuse (60%). Among CS cases who were live births, those born to mothers with prenatal care were of greater gestational age and had higher birth weight.

Among the 59% of mothers of CS cases who received prenatal care, 26% had a positive test without subsequent treatment, 20% had late or failed treatment, 16% had late infection, and 13% had no third trimester screening. Forty-one percent of the pregnant women with untreated syphilis had no prenatal care.

Implications:

Improved compliance with congenital syphilis guidelines could potentially prevent 30%-40% of cases. Most women with untreated syphilis access health services at several points during their pregnancies, including prenatal care and emergency clinics, which provide opportunities for preventing congenital syphilis if providers comply with screening and treatment guidelines. Other possible prevention strategies for providers are appropriate follow-up, on-site testing and treatment, community outreach, earlier repeat testing, and partner notification.

Publications:

Warner DL, Rochat RW, Fichtner RR, Toomey KE, Nathan L, Stoll B, Brantley MB (1995). Untreated syphilis in pregnant women: identifying gaps in prenatal care. 123rd Annual meeting of the American Public Health Association, San Diego, CA, October 29-November 2.

Fichtner RR, Warner DL, Rochat RW, Berman SM (1995). Prevention gaps and other factors associated wit congenital syphilis outcomes among urban women in Atlanta, GA,1990-1993. Eleventh meeting of the International Society for STD Research, New Orleans, LA, August 27-30.

Warner DL, Rochat RW, Fichtner RR, Toomey KE, Nathan l (1994). Reasons for congenital syphilis outcome in urban Georgia among women receiving prenatal care, 1990-1993. 122nd Annual American Public Health Association meeting, Washington, DC, October 30-November 3 (#2207).

Division of STD/HIV strategic planning adverse outcomes of pregnancy

chartered group research and program -- recent developments influencing the prevention of adverse outcomes of pregnancy: current trends in CS and prevention strategies (Atlanta site) (1994). Centers for Disease Control and Prevention Division of STD/HIV Prevention Grantee Meeting, Washington, DC,

August 22-26 (#110).

Fichtner RR, Warner DL, Rochat RW, Conlon RT (1994). Compliance with prevention guidelines: congenital syphilis outcomes among urban women in Atlanta, GA, 1990-1993. Tenth International Conference on AIDS, Yokohama, August 7-12.

Products:

None

Key Words:

Syphilis, congenital syphilis, women, pregnant women, substance abuse, crack, cocaine, providers.

Project: #25 Risk Factors for HIV/STD and Intervention Opportunities Among Students Attending Alternative High Schools: The Cities in Schools Project.

Purpose:

To estimate risk factors for HIV/STD in a population of students attending an urban alternative (drop-out prevention) high school; and to develop and pilot test an in-school, risk-reduction intervention for the students that is theory-based and incorporates peer involvement.

Results:

Alternative high schools are increasing in popularity in the U.S. In some urban areas, nearly one in seven students attend these schools, many of which are public/private collaborations. Two such schools were identified in Miami, FL, both of which are affiliated with Cities in Schools, Inc., the largest nonprofit drop-out prevention organization in the U.S. In 1994, all students in these two schools were administered a questionnaire twice: to assess the prevalence of STD/HIV risk behaviors in this population before (baseline) and after a pilot intervention was conducted. Baseline data were compared with findings from the Youth Risk Behavior Survey (YRBS) conducted in public schools in Dade County in 1993.

Among students reporting ever having sex, respondents from the alternative schools (approx. 33%) were more likely than YRBS respondents to report two or more partners during the preceding 3 months, and were much more likely to have been pregnant or to "have gotten someone pregnant" than YRBS respondents. The prevalence of a report of previous STD or HIV/AIDS diagnosis was 29% in one of the two schools, but only 4% among YRBS respondents; and the prevalence of having injected illegal drugs was 15% in one of the schools compared to 2% in the YRBS. Fewer than one-half of the CIS students who had engaged in sexual intercourse reported use of condoms at last intercourse. Males were at greater risk in this CIS population than females; they initiated sex earlier, were more likely to use alcohol and drugs before having sex, and reported more sex partners. Importantly, this study's longitudinal data indicated that intentions to use condoms was a predictor of future condom-use behavior.

Implications:

Students enrolled in two Miami CIS schools were, in general, much more likely to engage in behaviors that could increase their risk for STD/HIV infections than were their peers in the community public high school system. In many urban centers, the alternative school population is huge and transitory, but opportunities for intervention should be seized. In the pilot intervention in Miami, the use of peers was promising in acquiring student confidence. STD/HIV prevention-service providers, including HIV community planners, should develop intensive, appropriate interventions for these students. This study underscores the relation between academic risks and health risks and the need to integrate academic and health promotion curricula for students at risk for dropping out of school.

Publications:

Centers for Disease Control and Prevention. Sexual behaviors and drug use among youth in dropout-prevention programs -- Miami, 1994. MMWR 1994;43:873-876.

Products:

None

Key Words:

Adolescents, out of school youth, Miami, FL., drop outs, structured groups, alternative high school.

Project: #26 Community Support Group Study

Purpose:

To describe what topics are discussed in a member-directed group for HIV-positive cocaine users and the percentage of time devoted to these topics. To examine whether support group attendance is associated with positive behavioral change.

Results:

Groups had mixed male and female membership. Group members spent the most time discussing drug abstinence issues such as identifying situations which trigger drug use and how to avoid these for a total of 2,230 (22%) of all speaking turns. Safer sex discussion focused almost exclusively on difficulties in informing a sex partner of one's serostatus and received less attention than all other topics with 768 (7%) of speaking turns. The group never discussed sexually transmitted diseases or risk behaviors such as anal sex, even through 36% of the group identified as gay/bisexual. Frequency of group attendance was associated with change in only those behaviors most frequently discussed by group members. Controlling for the level of drug treatment completed, group attendance of four or more meetings as opposed to three or fewer was significantly associated with reduced frequency of drug use, increased months drug free, reduced sex while high, and increased disclosure to all sex partners (p=<.05). Group attendance was not associated with condom use or number of sex partners.

Other Findings:

Recruitment of the drug-using population can be facilitated by introducing them to facilitators and the group process while they are still in drug treatment or in correctional settings (through passes to attend or in-house programs).

Implications:

When support group discussion targets specific behaviors associated with the spread of HIV, even an unstructured support group may assist in reducing those behaviors. The role of facilitator appears critical to the ability of support groups for HIV-infected persons to have a prevention focus. Facilitators need to find creative ways to direct discussion to prevention of risky sexual behavior for these groups whose primary purpose is socio-emotional support. This can be accomplished through training of facilitators either to deliver an intervention focus themselves or to locate guest speakers who can relate to the group members.

Publications:

Greenberg J, Clarke P. Support groups for HIV, HPV, and HSV infections. In Holmes KK, et al. (eds.) Sexually Transmitted Diseases, Third Edition. (in press) McGraw-Hill, New York.

Greenberg J, Johnson W, Fichtner R. Behavioral change among HIV-positive cocaine users attending a community support group in Atlanta, GA. submitted to Journal of Drugs and Society.

Products:

Brief Training for Group Facilitators

Key Words:

Persons in treatment, incarcerated populations, drug treatment, participant recruitment, staff training, risk behaviors, condoms, behavior change, peers, small group discussion, support groups, Atlanta, GA.

Project: #27 Evaluation of Group Counseling for HIV-Positive Drug Users--The Emory Study

Purpose:

To assess the relationship of psychological factors such as sensation seeking and sexual compulsivity to continued risk behavior in HIV-infected men.

Results:

Sexual compulsivity as measured on new scales developed by Kalichman et al. was associated with engaging in unprotected intercourse (anal, vaginal, and/or oral) with two or more partners in a 30-day period. Association was maintained after controlling for age and crack use. HIV-infected drug users can be recruited through drug treatment programs and among incarcerated populations. Recruitment from these sources was successful since participants could be introduced to the group and the facilitator while in an amenable state and were available for all meetings.

Implications:

Intensive therapeutic interventions are needed for a relatively small number of people who may contribute to the HIV epidemic. Community planning groups need to address interventions for sexual addiction.

Other Findings and Implications:

Recruitment of sufficient numbers for follow-up analysis for this study was not possible within the one-year time period of the award. Factors that affected recruitment included a extensive delay to obtain National Institutes of Health single project assurances for the subcontractors, reluctance of community-based organizations to refer clients for fear of losing them, and the fact that men in these geographic areas (identified as high need areas by the Request For Proposal) reported receiving extensive existing services at baseline.

Financial incentives were clearly related to recruitment. In San Juan, where incentives were provided for interviews and attendance, 64 men were recruited. In Atlanta where incentives were provided for interviews but not attendance, 38 men were recruited, and in Washington, DC where no incentives were provided, 18 men were recruited.

Community agencies involved in the project lacked the ability to recruit skilled interviewers and facilitators who could follow the structured design for the enhancement groups. They also lacked resources for conducting any quality assurance on the comparative designs. Future group studies should allow at least 2-3 years for development and implementation. While such studies can be facilitated through cooperation with community-based organizations, the staffing of such projects should be directly under the supervision of an independent research group.

Publications:

Kalichman S, Greenberg J, Abel G. Psychological characteristics of HIV positive men who engage in high-risk sexual behavior and suggested therapeutic models of intervention. in review by Journal of Health Psychology

CDC, Continued Sexual Risk Behavior Among HIV Seropositive, Drug-using Men- Atlanta, Washington, D.C., San Juan Puerto Rico, 1993; MMWR, Vol.45 No.7, Feb. 23, 1996

Products:

None.

Key Words:

Persons in treatment, incarcerated populations, drug treatment, participant recruitment, staff training, risk behaviors, condoms, behavior change, peers, small group discussion, support groups, Atlanta, GA., Washington, D.C., San Juan, Puerto Rico, staff recruitment.

Projects: #28 Evaluation of the Impact of HIV C&T on Methadone Clients in Drug Treatment Centers

Purpose:

To determine the effect of HIV counseling and testing (C&T) on sex behaviors, drug use behaviors, and treatment drop-out rates on methadone maintenance treatment clients.

Results:

Utilization of HIV C&T services was higher in methadone treatment clinics where HIV and drug treatment services were more integrated. Remaining in drug treatment was associated with a significant reduction in drug infections and sharing of potentially HIV-contaminated injection equipment. Drug users who reported a positive HIV test result reported a small increase in the number of injections; however, for those who attended HIV support groups there was a decrease in drug injection. Reporting an HIV positive test result by the client was associated with a decrease in the number of sex partners without using condoms and a decrease in the number of unprotected sexual contacts. As the amount of HIV counseling increased, the number of unprotected sex partners decreased. Clients who reported a positive HIV test result and those who received drug treatment from clinics which emphasized abstinence were less likely to report always using condoms during sexual intercourse.

Implications:

Methadone maintenance treatment significantly reduces high risk drug use behaviors by clients. HIV C&T should be offered to drug treatment clients and, those who test positive, should be encouraged to attend support groups for HIV-infected persons. All sexually active clients should be encouraged to use condoms, and condoms should be made available without request.

Publications:

Brackbill R, MacGowan R, Rugg D, et al. A prospective study of HIV infection risk behaviors and HIV serostatus among drug users. 1994, 27th Annual Meeting of the Society for Epidemiologic Research, Miami. Journal of Epidemiology (abstract) 1994;139:576.

Brackbill R, MacGowan R, Rugg D. Do methadone treatment clients change their HIV risk behaviors? Abstract PD-0509. 1994, Xth International Conference on AIDS, Yokohama.

Brackbill R, MacGowan R, Johnson W, et al. A prospective assessment of HIV counseling and testing on HIV infection behaviors among drug users. Session 1009. 1994, American Public Health Association Annual Conference, Washington, D.C.

Cole GE, Gorsky R, MacGowan R Collier C. Cost and cost effectiveness of HIV prevention activities in methadone treatment clinics. Abstract PO-C24-3191. 1993, IXth International Conference on AIDS, Berlin.

Collier C, MacGowan R, Fichtner R, et al. Behaviors and demographics associated with reported HIV infection among methadone treatment clients in central Connecticut and Massachusetts. Session 2215. 1993, American Public Health Association Annual Conference. San Francisco.

Gorsky R, MacGowan R, Swanson N, DelGado B. Prevention of HIV infection in drug abusers: a cost analysis. Preventive Medicine 1995;24:3-8.

MacGowan RJ, Rugg DL, Stark KA, et al. HIV test history and voluntary testing among injection drug users in treatment: what influences testing? Abstract Po-C-4825. 1992, VIIIth International Conference on AIDS, Amsterdam.

MacGowan R, Cole G, Scibak J. Drug use and self-reported HIV serostatus of clients entering methadone treatment programs in New England. Session 1109. 1992, American Public Health Association, Washington, D.C.

MacGowan RJ, Cole GE, Rugg DL, Collier C. Changes in drug and sexual behaviors reported by methadone clients in Connecticut and Massachusetts, by knowledge of serostatus, June 1990 - January 1993. Abstract PO-D09-3633. 1993, IXth International Conference on AIDS, Berlin.

MacGowan R, Ransom R, Collier C, Stark K. Changes in injection behaviors of drug users in methadone treatment by duration of treatment, knowledge of serostatus and HIV CT, in New England. Session 2199. 1993, American Public Health Association Annual Conference, San Francisco.

Rugg DL, MacGowan RJ, Stark KA, Swanson NM. Evaluating the CDC program for counseling and testing. Public Health Reports 1991;106(6):708-713.

Rugg DL, MacGowan RJ, Stark KA. Self-reported changes in sexual and drug using behaviors in methadone clients following HIV counseling and testing. Abstract MD-4016. 1991, VIIth International Conference on AIDS, Florence.

Products:

None.

Key Words:

Persons in treatment, drug treatment, behavior change, methadone, Connecticut, Massachusetts.

Project: #29 Evaluation of Risk Among Injection Drug Users in Detoxification Treatment (Proyecto ERAT)

Purpose:

To describe the drug use and sexual behaviors of injection drug users who receive HIV counseling and testing after entering detoxification programs in Puerto Rico.

Results:

Of 390 injection drug users entering drug detoxification centers 29% are seropositive; 85% are male; 77% have been to the U.S.; 51% have been incarcerated; 66% have injected for more than 5 years; 14 of 29 bisexual/homosexual men (48%) versus 66 of 225 (29%) heterosexual men are seropositive; 65 or 174 (37%) who thought they were at risk for HIV infection were seropositive versus 16 of 80 (20%) who did not think they were at risk. Behaviors associated with seropositivity are: years of injecting drugs, injecting with used needles in jail, and having sex with an injection drug user in the last 6 months.

Implications:

HIV counseling and testing services should be made available to injection drug users entering detoxification programs in Puerto Rico. Drug users who are sexually active should be encouraged to engage in safer sex practices. HIV prevention programs should be provided to drug users while they are incarcerated.

Publications:

Martinez R, Colon H, Robles R, et al. Behavioral risk factors and HIV infection of injection drug users at detoxification clinics in Puerto Rico. Abstract POC-4249. 1992, VIIIth International Conference on AIDS, Amsterdam.

Ríos N, MacGowan R, Collier C, et al. A comparison of injection practices of drug users by HIV serostatus before and after detox in Puerto Rico. Session 2199. 1993, American Public Health Association Annual Conference, San Francisco.

Robles R, Colon H, Díaz N, et al. Behavioral risk factors and HIV infection of injection drug users at detoxification clinics in Puerto Rico. International Journal of Epidemiology 1994;23(3):595-601.

Products:

None

Key Words:

Hispanics, counseling and testing, IDUs, methadone, detox.

Project: #30 Hemophilia Behavioral Intervention Evaluation Projects (Adolescents)

Purpose:

To prevent sexual transmission of HIV from infected hemophilic adolescent and young adult males to their sex partners through peer-centered social activities and intensive stage-based individual sessions conducted through nine hemophilia treatment centers and one state hemophilia agencies.

Results:

The majority of sexually active adolescents/young adults report using condoms consistently. Safer sex (condom use, nonpenetrative sex, or abstinence) is more common than disclosure of serostatus to partners. Parental support for disclosure of serostatus is associated with an increased likelihood that adolescents/young adults will disclose their serostatus. Distress about everyday reminders of HIV infection appears to be associated with ineffective coping strategies. (Brown, et al.)

Adolescents and young adults with hemophilia and HIV endorse discussing safer sex and disclosing their HIV seropositivity, yet they report this to be exceedingly difficult and fraught with social and interpersonal risks. (Nuss, et al.).

Implications:

This stage-based intervention approach may have implications for the development of intervention strategies with other populations of HIV-infected young people.

Publications:

Nuss R, Smith PS, Cotton D, Kisker T. Communication about safer sex and serostatus disclosure in HIV-positive adolescents with hemophilia, Hemophilia (1995), 1, 126-130.

Brown LK, Schultz JR, Gragg RA. HIV-infected adolescents with hemophilia: adaptation and coping, Pediatrics (in press).

Products:

(none at this time)

Key Words:

Hemophilia, adolescents, safer sex.

Project: #31 Hemophilia Behavioral Intervention Evaluation Projects (Adults)

Purpose:

To prevent sexual transmission of HIV from infected hemophilic men to their sex partners by facilitating behavior change for talking to partners about safer sex and consistently practicing safer sex. The intervention is conducted through five hemophilia treatment centers and one state hemophilia foundation.

Results:

Preliminary findings show a disparity in perception and beliefs between partners with respect to condom use. Emotional barriers to relationship development impede many single men's ability to negotiate and use condoms with their partners.

Implications:

This stage-based intervention approach may have implications for the development of intervention strategies with other populations of HIV-infected adults. In addition, this project addresses many issues specific to HIV-discordant couples which may have relevance for HIV-discordant couples in other settings.

Publications:

None

Products:

(none at this time - plans are in place for the development within the next year of an intervention training manual and videotape for use in other populations)

Key Words:

Hemophilia, adults, safe sex.

Project: #32 Peace Corps STD/HIV Intervention Design Project

Purpose:

To describe HIV risk behaviors in Peace Corps Volunteers (PCV) and to examine correlates of sexual risk behaviors.

Results:

During 1991, cross-sectional data were collected by self-administered questionnaire from more than 1200 randomly selected PCV stationed in 28 countries. Sixty-one percent of the 1080 PCV answering questions about sexual behavior reported having at least one sex partner during their Peace Corps service, 39% had a host-country national partner, and 29% had an expatriate partner who was not a PCV. Overall, less than a third (32%) of unmarried PCVs used condoms during each episode of sexual intercourse. Condoms were used more frequently with non-steady partners and (for male PCV only) with host-country national partners. Among male PCV, condom use was associated with lower alcohol use and the belief that HIV was a problem in the host country. Female PCV reporting more condom use were younger and had fewer partners than those reporting less use. Number of partners was associated with greater time in-country, more frequent alcohol use, being under 40 years of age, and country of assignment.

Implications:

Less than a third of PCV are using condoms consistently, an alarming finding given the involvement of some PCV with sex partners from areas where HIV seroprevalence is very high. Peace Corps must insure that PCV are 1) educated about local seroprevalence and cultural differences in sexual negotiation and practice, 2) enabled to reduce their sexual risk through access to high quality condoms, including the female condom; and 3) supported in their sexual risk reduction, through counseling, outreach, and other strategies tailored to the special needs of young Americans living in developing countries.

Publications:

Moore J, Beeker C, Harrison J, Eng T, Doll L. HIV risk behavior among Peace Corps Volunteers. AIDS 1995;9:795-799.

Products:

Moore J and Beeker C. 1993. Final Report: Prevention of STD and HIV infection among Peace Corps Volunteers--Research and recommendations. National Centers for Disease Control and Prevention, Atlanta GA.

Key Words:

Risk behaviors, HIV prevalence, Peace Corps, condoms.

Project: #33 The Prevention of HIV in Women and Infants

Demonstration Projects (WIDP)

Purpose:

To prevent the acquisition and transmission of HIV in women and to prevent the perinatal transmission of HIV to infants.

Results:

One component of the project is the production of role model stories in small media (pamphlets, brochures) to encourage women to use condoms all the time with their sex partners. The stories have cognitive and behavioral content messages specific to a stage on the Stages of Change continuum. Each story is ethnically specific, low-literacy, and uses the language of and actual quotes from women in the community. The Projects produce three role model stories a month and to date have produced 160 stories (including 4 about women using the female condom and a few about men and couples). The materials are distributed through outreach, peer volunteer networks, and drop sites. Preliminary results are currently being analyzed.

Implications:

For social norms to develop and have the opportunity to influence individual's behavior, it is critical to develop the participation of a broad range of community members with different roles, statuses, and involvement in the community so that the norm becomes integral to the community. Behavior changes, such as condom use, are adopted incrementally and cannot be intervened upon or measured by an "all or nothing" standard. Issues of motherhood and childbearing influence condom use for both disease prevention and pregnancy planning--particularly suitability of situation, responsibilities of motherhood, consequences of childbearing on other relationships, enhancement of self-esteem, and the psychological significance of the mother-child relationship.

Publications:

Cotton D, Person B. Using the community mobilization framework as a foundation for implementing community interventions in your community. Abstract 193. 1994, DSTD/HIVP Grantee Meeting, Washington, DC.

Bond L. A new approach to an old problem: applying the transtheoretical model of behavior change to HIV/STD prevention outreach. Abstract 024. 1994, DSTD/HIVP Grantee Meeting, Washington, DC.

Enguidanos S, Iarrobino P. Designing community-tailored intervention material. Abstract 022. 1994, DSTD/HIVP Grantee Meeting, Washington, DC.

Products:

A Model of Community Mobilization for the Prevention of HIV in Women and Infants

Key Words:

Women, infants, perinatal, role model stories, small media, community level intervention, prostitutes, commercial sex workers, IDUs, high risk women, sex partners of IDUs, HIV positive.

Project: #34 STD Clinic Flow and Utilization

Purpose:

To determine the level of overburdening in STD clinics in metropolitan areas with high STD morbidity, the factors leading to overburdening, and the impact of overburdening on client care.

Results:

Overburdening was calculated by dividing the number of clients seen by the number of persons applying for service. Budget cuts did not seem to be a factor as demonstrated by the five clinics which were able to provide budget data. All had increases in funding during the study year. Across the seven clinics studied, there was little variation with regard to hours of registration and operation, cost of services, type of HIV services offered (confidential or anonymous), the gender and ethnicity of clients seen and range of STD services provided. However, two correlations were discovered; the length of client waiting time was directly correlated with the clinic's level of overburdening; and, low levels of overburdening were correlated with high levels of clinical staffing. Apparently, two phenomena are operating simultaneously to produce the latter result: overburdening, which results in clients being turned away, and under utilization, caused by clients being turned away. Interview and observation revealed common features among all clinics, as well as marked contrasts among clinics within the highly overburdened group. Analysis revealed that clinic processes combining both walk-in and appointment systems seem to maximize clinic efficiency, and that clinics where nursing staff conduct STD examinations experience less overburdening than those that do not.

Implications:

Public STD clinics require better operating strategies during a period of continued funding contractions and health care reform. Strategies that incorporate scheduling flexibility and extended use of human resources are likely to be most effective. Some possible strategies of alleviating overburdening include: 1) evening and weekend hours for clients who cannot be seen during the day; 2) sufficiently staffed satellite clinics placed in high morbidity locations; 3) computerized office systems; 4) staff development training for front desk personnel to encourage positive experiences for clients; 5) ongoing training for clinical and program staff in how to work with "difficult" populations; 6) maximize use of mid-level clinicians such as nurse examiners; 7) provide mechanisms at the leadership level for closer rapport between clinical and program staff; and 8) assist sites to develop their monitoring and evaluation capabilities.

Publications:

Hare ML, Conlon R, Butler MO. Evaluating patient utilization of public STD clinics. Abstract 1125-7. 1994, American Public Health Association Annual Meeting, Washington, D.C.

Products:

Hare ML, Butler MO, Hersey JC, et al. Final Report: Contract #200-88- 0642 for Task 11 on Evaluation of STD Clinic Flow and Utilization. 1993. Battelle Memorial Institute, Arlington, VA.

Key Words:

STD clinics, turn aways, overburdened, nurse practitioner, providers, ethnography.

Project: #35 Women In Group Support (WINGS)

Purpose:

To determine 1) what strategies are successful for recruiting and retaining high risk women in support groups; 2) whether structured, support groups are effective in reducing risk behaviors in high risk women; 3) whether drop-in groups following a series of 6 structured sessions increase the effectiveness of the intervention; 4) if women will attend drop-in groups without monetary compensation.

Results:

Participant recruitment began in October, 1994 and continues at this time. No results are available at this time.

Implications:

This study is expected to generate information on personal concerns of high risk women and female group dynamics which lead to positive behavior change that can be applied by agencies serving women at high risk.

Publications:

None.

Products:

A sample Quality Assurance Form for Group Interventions is available from Judith Greenberg, Division of STD Prevention, NCHSTP, CDC, Mailstop E-44, 1600 Clifton Road, Atlanta, GA 30333.

Key Words:

STD clinics, STD clinic clients, health care providers, accessing services, staff training, nurse practitioners, service enhancements, service delivery, waiting times, clinic turn aways.

Previous

Table of Contents

Next