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Sexually Transmitted Diseases > Research > What
We Have Learned...1990-1995
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 What We Have Learned...1990-1995
ONE-ON-ONE FORMATIVE AND INTERVENTION RESEARCH One-on-one research recognizes that some persons at risk for STD/HIV infection require personalized interventions in order for them to acknowledge their risk, to be encouraged to adopt or maintain healthy behaviors, and to access prevention services. Persons targeted for one-on-one interventions are persons with well defined risk for acquiring or transmitting STD/HIV infection, people who live in a targeted geographic area, and people who belong to a group which is medically and socially underserved (i.e., commercial sex workers, pregnant women, or sexually active youth in high morbidity areas). Formative research on such persons- at-risk identifies barriers and facilitators to accessing medical and social services as well as common behavioral, social, and psychological factors influencing their STD/HIV infection risk. Intervention research develops and evaluates methods to promote healthy behaviors among targeted persons by addressing their informational and social service needs as identified by the formative research. The interventions can take several forms: persuasive behavior change messages, skills building, behavioral risk assessment. And they may be delivered by direct service delivery or referral to services, by individual counseling, and by case management. Project: #36 Development and Integration of Computer Assisted Assessment and Education (CAAE) with Computer Assisted Counseling/Testing (CACT) Purpose: To develop and test computer software which assesses psychosocial and behavioral factors and generates prescriptive recommendations to clients (advice) or customized counseling scripts, which can be used by HIV counselors to maximize effectiveness and efficiency of and decrease random variability or bias in HIV counseling sessions; and to expand software to accommodate simultaneous assessment, and education or counseling of respondents concerning sexually transmitted diseases. Results: Client recommendations were the basis for developing the Computer Assisted Assessment and Counseling Education (CAACE). The CAACE software program has ITS capability and uses the Macintosh® system as the platform. A Microsoft Windows® version is possible for later development. Client characteristics pertinent to his/her educational and counseling needs are determined through various scales measuring depression, attitude or self-esteem, alcohol use, personal values, assertiveness, locus of control, and general feelings. Inquiries on risk behaviors and demographics are included. Appropriate, set client advice scripts are generated at the end of the session. The CAACE software was demonstrated at a University of Illinois sponsored conference for inclusion in a model for elaboration through publication in a 1996 volume of Health Education Quarterly. Implications: Disparity in the training, experience, supervision, and proficiency of HIV counselors causes variations in the content, duration, and delivery of messages in HIV counseling and testing. These variations could greatly compromise the cost-effectiveness and quality of HIV counseling services and could present a serious threat to the validity and reliability of research which employs counseling as an intervention. The application of this software may be appropriate for personal consumers with the adoption of home test kits for HIV. Of course some modifications will be required. In addition, the software can be adapted for off site use in kiosks, video game room settings and the like which are highly traveled areas by high risk populations of adolescents. Publications: M.Jackson, S. McKinnon, K.Hall Computer Assisted Counseling and Testing Initiative (CACTI). Abstract 1994 Division of STD Grantees Meeting, Washington, D.C. Products: Computer Assisted Assessment and Education with Computer Assisted Counseling and Testing: Final Documentation (1994) with four diskettes is available from Mark Jackson, M.D., Director of Student Health Services, University of Maine, Orono, Maine 04469. The hardware requirements for the CAACE program include: 80486-based computer, 33MHZ, 8MB RAM, 15" or larger Super VGA color monitor with Video accelerator card, Sound Blaster or Sound Blaster Pro sound card, and a standard printer. Key Words: STD clinics, STD clinic clients, STD and HIV counselors, scripts, risk assessment, behavioral change, messages, CD ROM, multimedia. Project: #37 Behavioral Risks for HIV/STD and Birth Outcomes Among Pregnant Women Who Abuse Substances: Evidence From Intensive Outreach Through Project Prevent. Purpose: To characterize HIV/STD risk behaviors of substance-abusing, pregnant women upon entry into Project Prevent, an abandoned infants prevention program in Atlanta, GA; to relate these risks to birth outcomes; and to compare risks and outcomes for women who entered the program during pregnancy and women who did not. Results: Project Prevent is a metro-wide, hospital-based service delivery program designed to lessen the in-hospital abandonment of drug- and HIV-affected infants. This model program uses: intensive community outreach for identification and referral of pregnant substance abusers (PRE) and in-hospital identification and referral of mothers who have substance-abuse histories and an infant needing intensive care (POST). During 1994, all 137 enrolling women wee interviewed about HIV/STD risk behaviors, and birth outcome data were obtained from the 90 women who delivered infants during the study period. Previous data from prior enrollees were also analyzed. Overall, approximately 85% of participants reported using crack cocaine during the current pregnancy; 16% reported using heroin; 53% had traded money or drugs for sex; 28% had injected drugs; 21% reported unprotected anal intercourse; 85% reported a history of STDs; and the mean number of sex partners in the past year was 7.6. Fewer than one-fourth thought they were at risk for HIV. Trading sex and having had an STD were strongly associated. PRE and POST women had similar HIV/STD behavioral risk profiles: PRE women had significantly better birth outcomes (higher birth weights, fewer STDs, less drug use) than POST women. Implications: Through the use of paid peer counsellors and intensive outreach, which included a metro wide network of churches, battered women's shelters, homeless shelters, emergency treatment facilities, storefront facilities, and service agency outlets, this project identified and enrolled prenatal women (PRE) at unusually high risk for HIV/STDs. This risk was from unprotected sexual behaviors, presumably associated with crack use, and from drug injection. Despite these admissions of elevated risk, more than three-fourths of women did not perceive their HIV/STD risks. Because the risk profiles of PRE and POST women are so similar, this suggests that the community outreach of the project that identifies PRE women is effectively targeting women at high risk. Those women missed by outreach are, on average, at no higher risk, according to these findings. Prevention programs with priorities similar to those of Project Prevent should strongly consider using its methodology. Publications: Fichtner R, Carson D, Covington S. Project prevent: effectiveness of a peer-based outreach program that targets urban pregnant substance abusers. In: Abstracts, International Conference on AIDS, Berlin, Germany, June 6-11, 1993;1:115. Oral Presentation No. WS-D12-2. Fichtner R. HIV/STD risks among substance-abusing pregnant women identified and not identified by outreach -- Atlanta, Georgia. In: Abstracts, Third Science Symposium...HIV Prevention Research: Current Status and Future Directions, Flagstaff, AZ, August 16-18, 1995; 1:18. Oral Presentation No. D-3. Key Words: Women, Substance abuse, STD, service delivery, infants, HIV infected, crack, cocaine. Project: #38 Evaluation of Multi Media HIV Risk Assessment of Inner City African American Adolescent Women Purpose: To develop an interactive, multi-media risk assessment/risk reduction HIV/AIDS/STD software program targeting African American adolescent women and to evaluate its short-term impact when used with counseling and the impact of its repeated use when coupled with case management. Results: Research funds were awarded in September, 1994. Software with persuasive role model stories is being developed. Prototypes of the software and hardware are being tested. Secure locations for final placement of hardware are being identified. The study will be expanded in 1996 to include members of the target audience receiving services from a local department of health in a small Midwest town. This will be in addition to the test audience from an inner city Chicago neighborhood. Implications: Completion of a behavioral risk assessment and delivery of counseling messages using moving videos of narrators and actors of the same gender and race as the user (of the software) has promise for effective communication with the target audience. The youth participants involved in the creation of the messages and filming were very much interested in the process and are eager to see the final product. The target population is low income, sexually active, African American adolescent women (12-16 years old) living in an inner city Chicago housing project. These young women are at high risk for STD/HIV infections and unintended pregnancies. They have difficulty accessing telephone based sources of information since pay telephones were removed from the housing projects; the telephones were linked to drug sales and service. The current HIV interventions targeting this group are one-time, didactic, and classroom-based, which compete with other pressing demands on the young women's time. Computer-based risk assessments and risk reduction education offer a cost-effective approach to reach the very high risk audience at any time of the day, at the user's convenience. The project will evaluate changes in attitudes, beliefs, perceived norms, and behaviors. This approach will demonstrate the feasibility of using high tech, low cost, and low overhead equipment to serve an otherwise underserved group. Publications: A 1997 issue of Health Education Quarterly will be published describing the proceedings of the December 1994 Conference at the University of Illinois at Urbana-Champaign on interactive behavioral risk assessments and counseling for HIV and STD prevention. Products: Software is currently available through the New York State Department of Health, and other contributors to the project. Other software will be distributed to all interested parties with the appropriate hardware who show interest in participating in the ongoing evaluation of product effectiveness. Several community health centers and schools have shown interest in viewing the materials and instituting them into their preventive educational programs. Key Words: African American, adolescents, inner city, public housing, multi media, CD Rom, video, risk assessments, adolescent, women, Chicago, ILL. Project: #39 Perinatal HIV Reduction and Education Activities (PHREDA) Purpose: To study the HIV risk reduction practices, contraceptive choices, and pregnancy plans of women at high risk of HIV infection and to test the effectiveness of three strategies to prevent women's infections and perinatal HIV transmission (enhancement of services, education and support groups, and community-based information and outreach). Results: Data from multiple sites indicated that more than a quarter of women in drug treatment wanted to have a child in the next year. The majority of women had not planned their last pregnancy, did not wish to become pregnant in the next three years, but had not practiced contraception consistently in the last month. Surgically sterilized women were less likely always to use condoms than unsterilized women, but no less likely to have multiple partners. Condom use with main partners was rare, but was strongly predicted by perceptions that friends were using condoms. Condom use was also predicted by the combination of worry about the effect of AIDS on one's daily life, and a sense of self-efficacy in insisting on a sexual partner's condom use. Other findings: Single-site, quantitative analyses showed that HIV positive status did not, in itself, alter an individual's likelihood of bearing additional children. While women decreased their drug-related HIV risk over time, the IV drug use of main partners was not associated with increased condom use. Among women who had little or no prenatal care but who received postpartum, predischarge services designed for women with drug histories, rates for family planning and HIV counseling increased, correct contraceptive use increased, and unprotected sex decreased. Women who received any family planning service (including inexpensive referral services) in their drug treatment center were more likely to use contraception 9 months later than women who received no co-sited family planning service. Two important factors in helping drug-using women maintain contact with family planning services were 1) service provision by staff who had been trained to understand and be sensitive to the special circumstances of this group and 2) ongoing, repeated contact with street outreach workers or designated service providers. Social support from a service provider increased the likelihood of returning for HIV test results. Most minority women reported feeling comfortable asking a male partner to use a condom, and 83% said he would if asked. Small media distribution and outreach efforts brought about increases in condom use and pro-condom norms a full year before similar changes were observed in a comparison neighborhood. Outreach was most effective when more intensive, one- on-one, risk-reduction educational sessions were combined with access to community-specific educational materials. Contrary to the expectation that addressing the entire hierarchy of social service needs of women at high risk would result in behavior change, case management was associated with changes in HIV-risk behavior only when referrals to HIV-specific services such as drug treatment and counseling and testing were made. Multiple site, qualitative data indicated that low levels of condom use were supported by different combinations of 1) the perception that condoms were ineffective in preventing pregnancy or disease, 2) the conviction that partners do not like condoms, 3) the threat of embarrassment while buying condoms or discussing them with a new partner, 4) the feeling that condom use is incompatible with spontaneous or natural sex, 5) the notion that it would be an insult if a partner suggested condom use, and 6) mistaken beliefs about the HIV or pregnancy prevention properties of sterilization, birth control pills, methadone, or illicit drugs. Women at high risk were difficult to enroll and retain in multiple-session, group-based HIV education activities. Providing childcare and incentives for participation to these women were found to be useful and alternative community-based educational strategies were identified. Confidentiality was very important to the women because of the stigma of drug use. Characteristics of relationships with male partners and partner attitudes were central to decisions around condom use and pregnancy. Single-site qualitative observations indicated that women in the peer networks of drug-using women were willing to volunteer as outreach workers. Implications: Provision of sensitive clinical services and coordination of family planning, drug treatment, and HIV services appear to be important for high risk women. Providing at least minimal family planning services in drug treatment centers may increase women's likelihood of contraceptive use and of obtaining HIV antibody counseling and testing. The post-partum hospital stay appears to be a good time to reach women for HIV-related and family planning interventions. It may be advisable for case managers of high risk women to make referrals to services that deal specifically with HIV risk. Staff in family planning clinics should be trained to be sensitive to the medical and emotional needs of drug-using women, and drug-treatment staff should be knowledgeable about HIV-related issues. Dissemination of new HIV information through street outreach and non-stigmatized, community-based settings (e.g., churches, door-to-door) appears promising. HIV-infected women with a history of unplanned pregnancies and inconsistent contraception should be targeted for more intensive counseling and follow-up. Surgically sterilized women may also need additional counseling about condom use, and they should be included in public health messages. For women who use drugs, the HIV transmission risk from sex partners should be emphasized as strongly as drug-related transmission risk. Women appear to place more emphasis on the nature of their emotional relationships with their male partners than on the behavior of the partners; sexual risk from primary partners should be stressed, and male partners should be involved in programs to reduce heterosexual and perinatal transmission of HIV. Attempts to work with networks of women to support a group norm of condom use may be helpful. Emphasizing the impact of HIV on everyday life, providing role models who perceive substantial influence over condom use, and conducting risk-reduction educational groups may increase requests that partners use condoms. Publications: Ajuluchukwu D, Brown LS, Mitchell JL, et al. HIV infection in female intravenous drug abusers (IVDAs) of childbearing age in NYC drug clinics and their demographic profile. DHHS (ADM) NIDA Research Monograph, 105. 1990:346-347. Armstrong KA, et al. HIV-risk behaviors of sterilized and nonsterilized women in drug-treatment programs--Philadelphia, 1989-1991. MMWR 1992;41:149-152. Armstrong, K et al. Barriers to family planning services among patients in drug treatment programs. Family Planning Perspectives 1991;23(6): Armstrong KA. Novel project offers family planning during drug treatment. Contraceptive Technology Update 1991;May:72-78. Berman S, Lindsay M, Hadgu A. Reaching minority women at risk for HIV: the potential for pregestational access by churches and inner-city hospitals. Abstract PO-D13-3746. 1993, IXth International Conference on AIDS, Berlin. Berman S, Galavotti C, Musial S. Perinatal HIV prevention: reproductive desires and contraceptive use among women at high risk for infection. Abstract M.D.4091. 1991, VIIth International Conference on AIDS, Florence. Birn AE, Santelli J, Burwell LG. Pediatric AIDS in the United States: epidemiological reality versus government policy. International Journal of Health Services 1990:20:617-630. Republished in Kreiter N, ed. AIDS: The Politics of Survival. 1994, Amityville: Baywood. Carrington BW, Thompson RL, Mitchell JL, et al. The need for family planning services for women delivering with little or no prenatal care. Women & Health 1993;20(1):1-9. Celentano DD, Burwell LG, Davis A, et al. Temporal trends in HIV testing among inner city African Americans. Abstract PO-D01-3403. 1993, IXth International Conference on AIDS, Berlin. Cotton D, Schnell D, Galavotti C, et al. Consistency of condom use with main partner among women at high risk of HIV infection and perinatal transmission. Abstract W.D.4143. 1991, VIIth International Conference on AIDS, Florence. Fordyce M, et al. Childbearing and contraceptive-use plans among women at high risk for HIV infection--selected U.S. sites, 1989-1991. MMWR 1992;41:135-144. Galavotti C, Schnell DJ. Relationship between contraceptive method choice and beliefs about HIV and pregnancy prevention. Sexually Transmitted Diseases 1994;21(1):5-7. Kenen RH, Armstrong K. The why, when and whether of condom use among female and male drug users. Journal of Community Health 1992;17:303- 316. Kline A, Kline E, Oken E. Minority women and sexual choice in the age of AIDS. Social Science and Medicine 1992;34:447-457. Kline A, Strickler J. Perceptions of risk for AIDS among women in drug treatment. Health Psychology 1993;12:313-323. Kline A, Strickler J, Husband S. Determinants of condom use among women in drug treatment. Abstract M.D.4077. 1991, VIIth International Conference on AIDS, Florence. Kline A, Van Landingham M. HIV-infected women and sexual risk reduction: the relevance of existing models of behavior change. AIDS Education and Prevention (in press). Kline A, Van Landingham M. Condom use among HIV seropositive women in New Jersey. Abstract PO-D5211. 1992, VIIIth International Conference on AIDS, Amsterdam. Mantell JE, Karp GB, Gulcur L, et al. The effects of sexual and household decision-making powers on condom use among drug users. Abstract PO-D17-3925. 1993, IXth International Conference on AIDS, Berlin. Mitchell JL. Treating HIV-infected women in chemical dependency programs. AIDS Patient Care 1990;August:36-37. Mitchell JL, Thompson R, Namerow P, et al. A comparison of contraceptive usage by HIV infected and non-infected women one year post delivery. Abstract PO-D5383. 1992, VIIIth International Conference on AIDS, Amsterdam. Nebot M, Celentano DD, Burwell LG, et al. Behavioral risk factors related to AIDS among sexually active inner-city females: a comparison of telephone and face-to-face surveys. Journal of Epidemiology and Community Health 1994;48:412-418. Orr ST, Celentano DD, Santelli J, Burwell L. Depressive symptoms and risk factors for HIV. AIDS Education and Prevention 1994;6(3):230- 236. Santelli JS, Celentano DD, Rozsenich C, et al. Interim outcomes for a community-based program to prevent perinatal HIV transmission: evidence of initial community diffusion. AIDS Education and Prevention (in press). Santelli JS, Davis M, Celentano DD, et al. Combined use of condoms with other methods among inner-city Baltimore women. Family Planning Perspectives (in press). Santelli JS, et al. Surgical sterilization among women and use of condoms--Baltimore, 1989-1990. MMWR 1992;41:568-575. Thompson RL, Carrington B, Gordon R, et al. A model project for the prevention of perinatal AIDS transmission. Abstract M.D.4244. 1991, VIIth International Conference on AIDS, Florence. Tunstall CD, Oliva G, Kegeles S, Darney P. Outreach to women at high risk of perinatal HIV transmission presents new challenges to family planning providers. Abstract M.D.4243. 1991, VIIth International Conference on AIDS, Florence. Products: Kennedy MG, Cotton DA, Galavotti C. What Have We Learned From PHREDA? In preparation. Atlanta, GA: CDC/NCPS/DSTD. Key Words: Women, infants, condoms, service enhancement, education, support groups, outreach-street, prenatal care, family planning, counseling and testing, case management, coordination of services, Newark, Jersey City, N.J., Philadelphia, PA., Baltimore, MD., Tallahassee, FL., Atlanta, GA. Projects: #40 Prenatal Care Utilization Project Purpose: Within two ZIP Code areas of Philadelphia, reduce the incidence of congenital syphilis relative to reported early syphilis morbidity, increase the percentage of women with syphilis who receive prenatal care, and study the linkages between pregnancy testing and prenatal care among low income women. Results: Formative research showed that for pregnant women in the target community there were few structural or institutional barriers (e.g., cost, access, childcare, transportation) for enrolling in prenatal care (PNC). Even women who received late or no PNC reported that they knew where to go, had no difficulty getting appointments, and were satisfied with the treatment they received from providers. However, personal barriers, including negative feelings about pregnancy (e.g., unhappy, depressed, embarrassed, ambivalent about infant), fear of confirming pregnancy, homelessness, and drug or alcohol use often delayed enrollment in PNC and interfered with consistent attendance. Follow-up serologic efforts aimed at women of child-bearing years and male and female adolescents who had syphilis in the previous year located and tested approximately half of the target persons; nearly a quarter of whom were then treated for new or untreated syphilis infections. The case management intervention to facilitate PNC enrollment and participation determined the risk characteristics for enrolled women: no PNC, used crack cocaine in the past 6 months, history of syphilis, exchanged sex for drugs, homelessness, and previously given birth to an infant with congenital syphilis. Of the enrolled women, over one-third reported one risk characteristic and over one-third reported three or more risk characteristics. The obstacles to preventing congenital syphilis discovered by this intervention were enrollment in PNC too late in pregnancy for detection and treatment; unreliable self-reports of disease history, PNC visits, and risk characteristics; and lost linkages within the medical and social services attending to the women. The survey of post-partum women from the target ZIP Code areas showed several significant differences among women who received early PNC, late PNC, and no PNC. Women with early enrollment had fewer pregnancies, fewer live births, and fewer children living at home than women in the other two groups. Although nearly half of the women had pregnancy tests in a medical setting, pregnancy testing was not linked to PNC or to syphilis screening. Women who entered PNC late more often received pregnancy testing, prenatal care, and delivery services from two or three different providers than did women who entered PNC early. Some of the women who accessed several different providers did so to avoid detection of their substance abuse and consequent loss of custody of the infant. A health department telephone number for free at home pregnancy testing was established to make the tests more accessible to women in the target area, but it did not receive any calls. The impact of these collective efforts on syphilis morbidity awaits the compilation of 1995 surveillance data. Implications: Obstacles to preventing congenital syphilis are late or non-enrollment in prenatal care and inconsistent visits once enrolled by at-risk or infected women, maternal risk characteristics, and lost linkages within the medical and social services caring for these women. In areas experiencing congenital syphilis outbreaks, screening women for syphilis at the same time they receive pregnancy tests will detect otherwise missed infections. State communicable disease regulations may need to be modified to redefine the first PNC visit to be the time of a positive pregnancy test. Collaboration among public health and private sector health agencies (e.g., STD control, maternal and child health, and family planning) can create linkages to increase screening, verify treatment, make referrals to other services, and extend outreach to women at highest risk. Publications: Goldberg M, Hendershot EF, Williams JJ. Congenital syphilis surveillance--a retrospective evaluation of serologic follow-up after adequate therapy. Abstract 091. 1994, DSTD/HIVP Grantee Meeting, Washington, DC. Higgins C, Armstrong K, Goldberg M, et al. Results of a formative study to develop an intervention to reduce congenital syphilis in Philadelphia, PA. Abstract 088. 1994, DSTD/HIVP Grantee Meeting, Washington, DC. Higgins C, Armstrong K, Goldberg M, et al. Mothers who deliver congenital syphilis infants: what we can learn from their syphilis histories. Abstract 089. 1994, DSTD/HIVP Grantee Meeting, Washington, DC. Higgins C, Armstrong K, Goldberg M, et al. Inter-agency collaboration to reduce congenital syphilis. Abstract 090. 1994, DSTD/HIVP Grantee Meeting, Washington, DC. Higgins CR, Hendershot EF, Armstrong K, et al. Analysis of a collaboration to reduce congenital syphilis. Abstract 1125-4. 1994, American Public Health Association Annual Meeting, Washington, D.C. Higgins C, Tadlock M, Goldberg M, Santelli J. Community outreach to prevent congenital syphilis: case study of a collaboration. Submitted to Journal of Public Health Management and Practice. Products: None yet. Key Words: Women, infants, condoms, service enhancement, education, support groups, outreach-street, prenatal care, family planning, counseling and testing, case management, coordination of services, accessing services, adolescents, risk behaviors, collaboration, outreach-clinic, syphilis, referral, formative research, Philadelphia, PA. Project: #41 Prevention of HIV Risk Behaviors Among Young Women: Using Community Resources to Explore Alternatives to Prostitution Purpose: For young women (aged 16-25) engaged in or about to engage in prostitution, identify the timing and sequence of their critical life events; determine the availability and perceived availability of social services for young women; identify acceptable and accessed social services; examine receptivity for and factors associated with acceptance of social and health case management services; and ascertain the services needed by young women in social or economic crisis. Results: In Colorado Springs, street walkers were more likely than female STD clinic clients and HIV-test site clients to have used drugs (89% vs 62%), used drugs regularly (82% vs 25%), and injected drugs (46% vs 5%). Street walkers were more likely to be women of color, younger at enrollment, and currently practicing prostitution than women who formerly engaged in prostitution for one year or longer. Women who are commercial sex workers reported engaging in sexual activities at significantly younger ages than comparison women. On average, both street walkers and other commercial sex workers reported using drugs on a regular basis at age 17, about 3 years before they first accepted money or drugs in exchange for sex. Half of the commercial sex workers interviewed said they had injected drugs; 39% reported injecting drugs regularly. Younger commercial sex workers (<18 years old) tended to first inject after entering prostitution, but older commercial sex workers (>18 years old) tended to inject before entering prostitution. In fact, the likelihood of prior injection drug use increased with increasing age. Early initiation of sexual activities and regular drug use during adolescence often precedes entry into prostitution. Half of the study participants named one or more agencies which could assist with basic services. Almost all (98%) had previously used at least one and most (88%) had used four or more. The high rate of depression measured among the participants may have contributed to the low rate of follow through on referrals to or from agencies. Focus group respondents in San Juan, Puerto Rico did not consider prostitution to be "a job" because it was not socially acceptable. They considered the risk of violence to be more serious for them than AIDS. Drug dependency made quitting prostitution difficult. Most commercial sex workers were unemployed, heads of households, and lived with their children. Adolescent women (13-17 years old) entered prostitution after family or academic problems led them to early sexual experience with a boyfriend which resulted in pregnancy, abortion, and economic and emotional despair. They then began exchanging sex for food, clothing, or a fun night out. Drug use tended to follow prostitution. Their strategies for dealing with the fear of HIV infection were knowing their clients and increased condom use. Commercial sex workers' stated needs were jobs, birth control, education, housing, drug treatment, AIDS counseling, social assistance, and medical and mental health treatment. Participants were highly receptive to nutritional services, health care, family planning, temporary employment, vocational training, and legal aid. Major barriers to services were transportation, childcare, long waiting lists for housing, unavailability of drug treatment programs for women, negative perceptions of social services (i.e., taking away custody of children), and perceived discrimination and unethical treatment from service providers. Women who were younger, more educated, married, from rural areas, and with low depressive symptomatology were more likely to accept services than women with opposite characteristics. Case manager-assisted referrals may be more effective with the latter group. Implications: Regular injection drug use among commercial sex workers places them at risk for HIV infection. HIV prevention programs that offer risk-reduction information, HIV counseling and testing services, and condoms and bleach should recognize that these efforts may be insufficient to prevent infections. Women who begin prostitution as teenagers appear to have different patterns of drug use than women who begin prostitution later in their lives. Interventions need to attempt to reach and influence 1) regular drug using adolescents before they enter prostitution and start injecting drugs and 2) young adult women who inject drugs before they enter prostitution. Programs that are not responsive to women's multiplicity of needs and do not consider women's personal characteristics, psychological status, and past experience with such services will limit opportunities to influence behaviors and reduce risk for HIV infection. Given participants' perceived ineffectiveness of social programs, they are unlikely to pursue referrals or benefit from attendance if they do. Commercial sex workers have a better perception of health services than they have of social services. Psychological factors may inhibit the participation of women at risk for HIV in services designed to reduce risk. Psychotherapy delivered early and for a short period of time to such women may decrease anxiety and depression resulting in increased service use and, ultimately, lower risk for HIV. Interventions designed to reduce drug dependency should reduce commercial sex workers' risk for HIV infection. Condom use may prevent HIV transmission to their clients. Publications: Darrow W, Potterat J, Alegría M, et al. HIV prevention for streetwalkers: are condoms enough? Abstract WS-C08-5. 1993. IXth International Conference on AIDS, Berlin. Alegría M, Vera M, Robles R, Burgos M. What have we learned from adolescent prostitutes in the Caribbean that adult prostitutes did not tell us? Abstract WS-C08-2. 1993. IXth International Conference on AIDS, Berlin. Alegría M, Vera M, Robles R, Burgos M. A cry for help: sex-workers perception of the institutional response to their needs in Puerto Rico. Abstract PO-D33-4297. 1993. IXth International Conference on AIDS, Berlin. Vera M, Alegría M, Santos M, Burgos M. Depressive symptoms and HIV risk taking behaviors among adolescent and adult Hispanic sex workers: implications for HIV risk reduction strategies. Abstract PO-D22-4080. 1993. IXth International Conference on AIDS, Berlin. Products: None. Key Words: San Juan, Puerto Rico, Colorado Springs, Co., commercial sex workers, adolescents, Hispanics, focus groups, identify persons at risk, women, infants, condoms, service enhancement, education, support groups, outreach-street, prenatal care, family planning, counseling and testing, case management, coordination of services. Project # 42 Multi-center Study of Enhanced Counseling vs. Current Counseling for Prevention of HIV/STDs. (Project RESPECT) Purpose: These projects were developed to answer the question: "Does HIV counseling work?" Specifically, compared to an HIV/STD education message delivered by a clinician, do multi-session, interactive, face-to-face counseling models based on behavioral science theory and delivered by trained HIV counselors 1) prevent new STDs/HIV? 2) increase condom use with main and other sex partners? 3) reduce non-condom related high risk behaviors? 4) change behavioral determinants (e.g., intentions to use condoms, norms, attitudes, etc.) related to condom use? The study population is HIV-negative, heterosexual STD clinic patients. Results: The study has included two phases. During the first phase, completed in July 1993, the five participating sites completed the following tasks with technical help from CDC and NOVA, Inc: 1) Conducted six pilot studies using various enhanced activities in order to develop an enhanced intervention that was both successful at increasing condom use and operationally feasible for use in STD clinics. 2) Studied baseline characteristics of the study population, including HIV risk factors, prevalence of condom use, and intentions to use condoms in various situations, and from these developed a series of study questionnaires (behavioral and epidemiologic, clinical, and laboratory). 3) Developed strategies for increasing intervention participation, including studies comparing the effectiveness of various monetary and non-monetary incentives in boosting attendance. 4) Participated in developing, then piloted, standard study protocols for approaching intervention and follow-up, a standard procedure manual to use in the randomized trial, and a standard, computerized tracking system for keeping tabs on study progress (Tracking System software developed by NOVA). 5) Participated in developing, then piloted, standard protocols for each of the three interventions along with a corresponding manual of scripts. All study counselors and clinicians also participated in a series of standard training courses conducted by Nancy Rosenshine of NOVA, Inc., to assure that staff from all sites usedintervention protocols in a correct and similar manner. 6) Participated in developing, then piloted, a set of observation forms detailing key components for each intervention. These forms are being used by supervisory staff at each site and CDC to assure that each intervention is conducted in a similar way among counselors and across sites. 7) Piloted a set of standard questionnaires to be used during the intervention. For the intervention, all study interviewers participated in a series of standard training courses conducted to assure that staff from all sites enrolled and interviewed participants in a correct and similar manner. During phase I the research team set up a common system for data collection and retrieval. Phase 2, the randomized trial, was started in July 1993. During the trial, participants were assigned to one of 4 study arms, including each of the three interventions (with interval follow-up) and a fourth arm that received the HIV Education intervention and no study-related follow-up. The plan is to use the 4th arm to measure a possible effect related to repeated follow-up, rather than to the intervention itself. To assess this, syphilis and gonorrhea incidence will be compared between those assigned to arm 4 and those who had symptomatic visits in arm 3. In March 1995, the five sites completed enrollment. In total, 5800 participants (approximate equal representation of men and women) were enrolled. Of these, 82% completed their entire assigned intervention. Among those assigned to arms 1,2, or 3, overall follow-up is approximately 70%. Three month follow-up and 6-month follow-up visits have been completed (68% and 73% follow-up, respectively), 9-month follow-up will be completed April 15 (currently 62%), and 12-month follow-up will be completed July 15th (currently 69%). Analyses of baseline data are currently underway. Implications: HIV prevention counseling is currently the cornerstone of CDC's HIV prevention strategies, and accounts for a substantial part of the prevention budget. Results from this study will answer questions about whether various clinic-based, HIV prevention counseling models are successful in changing condom use behaviors with main and other sex partners, and preventing new STDs/HIV, and how successful. Among the intervention models being evaluated is one that CDC currently recommends for use among STD clinic patients. Further, the study is designed to answer questions about the costs and cost-benefit of the various interventions. The data collected will also contribute to our understanding in a number of areas, for example, the relationships between various behavioral determinants, subsequent behaviors, and STDs; the effect of specific STDs to incident disease among patients enrolled at STD clinics (e.g., the role of asymptomatic chlamydia in men); and how gender differences may affect condom use and other behaviors (see abstracts for additional projects). Finally, Project RESPECT serves as an example of a successfully conducted evaluation of a one-on-one, clinic-based HIV prevention intervention. Publications: F, Malotte CK, Fishbein M, Douglas J, Rogers J, Erwin-Johnson C, Bolan G, Project RESPECT Study Group Explanatory model for condom use in a sample of STD clinic patients: males versus females with main versus occasional partners. Rhodes . XIth Meeting of the International Society for STD Research (ISSTDR), New Orleans, LA, August 27-30, 1995. (#241) Malotte CK, Rhodes F, Fishbein M, Hoxworth T, Iatesta M, Erwin - Johnson C, Kent C, Project RESPECT Study Group. Relationship of condom-use stage of change to behavioral beliefs, perceived social norms, self-efficacy, and self-concept in a sample of STD clinic patients. XIth Meeting of the International Society for STD Research (ISSTDR), New Orleans, LA, August 27-30, 1995. (#242) Kent CK, Lambert S, Alter M, Woodruff B, Douglas J, Iatesta M, Lentz A, Hoyt L, Bolan G, Project RESPECT Study Group. Hepatitis C Virus infection among patients attending clinics for sexually transmitted diseases. XIth Meeting of the International Society for STD Research (ISSTDR), New Orleans, LA, August 27-30, 1995. (#191) Graziano SL, Kamb ML, Peterman TA, Zaidi A, Coleman K, Douglas J, Erwin-Johnson C, Hoyt L, Rogers J, Project RESPECT Study Group. Clinic-based interventions: Who comes back? XIth Meeting of the International Society for STD Research (ISSTDR), New Orleans, LA, August 27-30, 1995. (#84) Douglas JM, McGill WL, Bundy R, Spitalny K, Zenilman J, Graziano S, Kamb M, Project RESPECT Study Group. STD incidence among patients enrolled in a randomized trial of HIV counseling: preliminary results. XIth Meeting of the International Society for STD Research (ISSTDR), New Orleans, LA, August 27-30, 1995. (#58) Kamb ML, Miller KG, Iatesta M, Malotte CK, LeDrew C, Lentz A, Graziano S, Fishbein M, Project RESPECT Study Group. A randomized trial comparing HIV counseling interventions: enrollment results . Xth International Conference on AIDS/Vth STD World Congress. Yokohama, Japan, August 7-12, 1994. (#PCO534) Graziano S, Berringer L, Douglas JM, Napolitano EC, Bolan G, Sweet D, Kamb ML, Peterman TA, Fishbein M, Project RESPECT Study Group. Will STD clinic patients enroll in multiple session HIV/STD prevention counseling? Xth Meeting of the International Society for STD Research (ISSTDR), Helsinki, Finland, August 29-September 1, 1993. (#135) M Kamb, R MacGowan, F Rhodes, C Kent, T Hoxworth, D Sweet, K Spitalny, Project RESPECT Study Group. Developing an HIV prevention intervention for a randomized trial. IXth International Conference on AIDS/IVth STD World Congress. Berlin, Germany, June 6-11, 1993. (WS- C21-1). Kamb ML, Dillon BA, Fishbein M, Willis K, Project RESPECT Study Group Quality assurance of HIV prevention counseling in a multi-center randomized controlled trial. . In Press: Public Health Reports. March 1996. Quinn TC, Welsh L, Lentz A, Crotchfelt K, Zenilman J, Newhall J, Gaydos C, Project RESPECT Study Group. Diagnosis of chlamydia trachomatis infection in urine samples from women and men by Amplicor polymerase chain reaction. (Submitted 12/95 J. Clin Inf Dis). Hoxworth T, Fishbein M, Douglas J, Project RESPECT Study Group. Gender differences in condom use behavior, perceptions of social support and self efficacy. XIth Meeting of the International Society for STD Research (ISSTDR), New Orleans, LA, August 27-30, 1995. (#244) Finelli L, Iatesta M, Rogers J, Napolitano E, Spitalny KC, Fishbein M, Project RESPECT Study Group. Differences in measures of self-image among HIV-infected and uninfected enrollees, Project RESPECT -- Newark, 1995. XIth Meeting of the International Society for STD Research (ISSTDR), New Orleans, LA, August 27-30, 1995. (#249) Malotte CK, Hoyt L, Graziano S, Lentz A, Rogers J, Miller K, Kent C. Lessons learned by staff during an STD clinic-based randomized trial (Workshop). Conducted at the CDC Division of STD/HIV Prevention Grantees Meeting. Washington D.D., August 22-24, 1994. (Log #231) Products: Protocol Manual for conducting operations of the multi-site randomized trial. Intervention Protocols for the three, clinic-based, one-on-one HIV prevention interventions; Enhanced HIV Counseling, HIV Prevention Counseling, and HIV Education. Each intervention includes several components (e.g., card came aimed at risk perception; condom skills building exercise, etc.). Fact Sheets about correct condom use, common misperceptions about STDs and STD symptoms. Observation and Feedback Instruments to provide a structured, objective approach to quality assurance for each of the three interventions. Process Evaluation tools to assess counselors and participants perception of how well the interventions were conducted and achieved their objectives. Data Collection Instruments (17 separate instruments) collecting behavioral data at baseline, after intervention, and at follow-up; clinical information at baseline and follow-up; laboratory information and tests at baseline and follow-up. Each instrument has an Instruction Manual to facilitate training and correct, consistent use across sites. Software programs, comprised of double entry data programs for sites to input data from the 17 data collection instruments, and quality assurance programs to check missing data and data validity. Tracking System, a computerized program to facilitate study sites' monitoring of enrollment and follow-up. For example, at appropriate dates before return appointments, the system prints letters reminding patients of their appointments. Programs to facilitate site data analysis are included. Key Words: Counseling and testing, multi-session, interactive, face-to-face counseling models, intentions to use condoms, STD clinic clients, condom use, stages of change. Project #43 Evaluation of Factors, Including Perceived and Actual Risk, that Influence HIV-Testing Behaviors Among STD Clinic Clients. Purpose: To evaluate the relationships of self-perceived and assessed (actual) risk for HIV infection, and other potentially relevant factors with: (1) receiving HIV pretest counselling, (2) having blood drawn for HIV testing, (3) returning for HIV test results and post-test counselling, and (4) HIV serostatus. Results: Data from more than 51,000 client visits to Illinois STD clinics from 1991 to 1993 were examined. All clinics offered HIV counselling and testing (CT) services. Overall, 22.7% of clients perceived themselves to be at risk of having HIV infection, while 28.7% were assessed at-risk of having HIV infection on the basis of (1) responses to a face-to-face questionnaire (asking about sex and drug behaviors) administered before HIV testing was offered; or (2) being concurrently diagnosed with genital ulcer disease. More than two-thirds of clients correctly perceived their assessed risk for HIV. Individuals who perceived they were at-risk of having HIV were more likely that those without perceived risk to complete each stage of CT. Assessed risk was not significantly associated with returning for test results. Those with either perceived risk or assessed risk were more likely to be seropositive than those with no perceived or assessed risk. African Americans were much less likely to return for test results (25%) than either Hispanics (43%) or Whites (56%), yet perceived risk was most strongly associated with return rates for African Americans. Implications: Perceived risk of having HIV infection is a better indicator of whether STD clinic patients will fully utilize CT services than is assessed risk. While 40% of STD clinic clients with perceived risk complete all stages of CT, only 28% of clients with assessed risk do so. Unfortunately, assessed risk is a better predictor HIV serostatus that is perceived risk. Counsellors and other prevention workers should work with at-risk individuals (especially African American men who are at-risk) to increase their perceived risk of HIV infection. In addition, rapid HIV-testing methods should target those clients who, from this analysis, are least likely to return for test results and most likely to be HIV-infected. Publications: Fichtner R, Rabins C, Schnell D, Fishbein M, Anderson J, Holtgrave D. Perceived vs. actual risk: factors influencing STD clinic clients to obtain HIV pretest counselling. In: Abstracts, Meeting of the International Society for STD Research, Helsinki, Finland, August 29- September 1, 1993;1:134. Oral Presentation No. 134. Fichtner R, Wolitski R, Johnson W, Rabins C, Fishbein M. Influence of perceived and assessed risk on STD clinic clients' acceptance of HIV testing, return for test results, and HIV serostatus. Psychology, Health, and Medicine (1996), 1, 83-98. Key Words: Counseling and testing, STD clinic clients, perceived risk.
Page last modified: May 19, 2009 Page last reviewed: May 19, 2009 Historical Document Content Source: Division of STD Prevention, National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention |
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