Understanding factors associated with pregnancy desire, experience and care among female sex workers living with HIV in Santo Domingo, Dominican Republic.

Introduction: Female sex workers (FSWs) are at significantly increased risk for HIV as well as a number of health concerns, however research on living with HIV is severely lacking, particularly in relation to pregnancy and reproductive health. Methods: This study utilizes data from the cross-sectional baseline survey of a longitudinal study named Abriendo Puertas (opening doors) aiming to assess the feasibility of a multi-layered intervention program in Santo Domingo, Dominican Republic (DR). This study aims to assess factors related to pregnancy desire, having been pregnant since diagnosis and having communicated to a health provider about pregnancy among a cohort of FSWs living with HIV in the DR. Results: For the total population, almost all FSWs had children, had been pregnant with a majority having experienced a pregnancy loss. Manuscript one revealed that about 30% of FSWs of reproductive age wanted more children. Significant associations were seen between participants who desire more children and higher HIV related internalized/self stigma, a history of pregnancy loss, lower number of current children, and partner support. Manuscript two revealed that a little more than a third of FSWs have been pregnant since HIV diagnosis. Significant associations were found between having been pregnant since HIV diagnosis and reporting an interruption in anti-retroviral treatment (ART), knowledge of mother-to-child transmission, disclosure of serostatus to a sex partner and a more negative perception of their health provider. Lastly, manuscript 3 illustrated that a little less than half of FSWs who were of reproductive age when diagnosed with HIV have not had a conversation about HIV in pregnancy with any health provider. Significant associations were seen between having had a conversation about HIV and pregnancy with a health provider and a more positive perception of their health provider, no history of drug use and little to no reported alcohol use in the past 30 days. Conclusions: This study highlights the significant need for more research on this understudied population. Health services and conversations with health providers are central for comprehensive and tailored care for this population and for prevention of MTCT. Within this multi-level approach to understanding pregnancy among this high-risk population, health services factors, community level, interpersonal and intrapersonal level factors all play a role in the reproductive health care of this most at risk population

The Role of Masculine Gender Norms in HIV Vulnerability Among Dominican Men Enrolled in a Circumcision Feasibility Trial

Background: Masculine norms influence men’s sexual behaviors. Though this relationship has been extensively theorized, empirical evidence explaining this relationship is limited. This dissertation aims to understand how masculine norms and concern about demonstrating masculinity contribute to men’s HIV vulnerability in the Dominican Republic. Methods: I conducted three studies using qualitative and quantitative data from a feasibility trial of voluntary medical male circumcision for HIV prevention in two Dominican cities. In the first study, I analyzed survey data collected from men 6-12 months post-circumcision (n=293) to examine the association between Gender Role Conflict/Stress (i.e. concern about demonstrating masculine characteristics) and HIV-related sexual behaviors. In the second study, I analyzed data from in-depth interviews with a sub-sample of men in the trial (n=30) to explore how masculine norms shape men’s sexual and violent behaviors. Finally, in study three, I used both data sources to explore the relationships between norms of masculinity, male sexuality, and circumcision. Results: Men’s Gender Role Conflict/Stress was significantly associated with having two or more partners in the past 30 days, inconsistent condom use with non-steady partners, and drinking alcohol at last sex, after controlling for socio-demographic characteristics. In the qualitative interviews, men helped to explain this relationship by showing that masculine norms encouraged them to compete with one another for social status and that demonstrating masculine characteristics within their social networks – such as successful sexual performance or being a provider – was a key way to gain social status. Men were especially concerned about being humiliated because of the implications for losing status, which led to engaging in violence and sexual risk behaviors. Finally, nearly half of men reported feeling more masculine after receiving a circumcision. Their main reason for feeling more masculine was improved sexual performance which allowed them to avoid the humiliation associated with an inability to satisfy sexual partners. Conclusion: Men demonstrate their masculinity through their sexual behaviors and their concern about demonstrating masculine norms to their social network drives men’s HIV-related risk behaviors. HIV prevention efforts should ameliorate the negative effects of competition between men and address men’s concern about demonstrating masculine characteristics.Doctor of Philosoph

Addressing the behavioral and contextual factors that put males, aged 15-18 at risk for exposure to sexually transmitted infections in Georgetown, Guyana

PROBLEM STATEMENT: Globally, 70% of more than three million new curable sexually transmitted infections (STI) are among 15-24 year olds, with young people in developing countries bearing the highest burden. Chlamydia Trachomatis prevalence, for example, is 15.4% and 20.5% in young women and men attending STD clinics in the U.S. However, Caribbean STI data for young men are particularly scarce and inconsistent and cases are under-reported due to poor health seeking behavior. In Guyana, 42% of the STI cases from 2010 -2014 occurred in young people, aged 15- 24. Moreover, few programs and policies focus specifically on the sexual and reproductive health (SRH) needs of young men. This dissertation explores the contextual and behavioral factors that cause young men’s vulnerability to STI and proposes recommendations for the national response in Guyana. METHODS: Research methods included: 9 focus group discussions (FGDs) with young men, aged 15-18, mothers and fathers and 25 in-depth interviews with representatives from government, community, faith-based and donor organizations. Interviews and FGDs were audiotaped, transcribed, and analyzed for major themes among and across each stakeholder group. Analysis was guided by a socio-ecologic framework and resulted in program and policy recommendations to address vulnerability to STI and augment protective factors against STI in young men in Guyana. RESULTS: Salient overarching themes include: Poverty and Disenfranchisement “Yes, this is a Man”: Early Sex, Fast Money, and Risk”, “The Empty Room: Young Men without Male Roles Models”, “Sex in a violent society”, “Stigma, Discrimination, and Shame: Road blocks to young men’s sexual health” and Young men’s Sexual and Reproductive Health: Young men’s Sexual and Reproductive Health: It all depends on family, religion, education, music and media (or not). Participants highlighted a lack of SRH awareness and health care seeking resulting from insufficient male SRH promotion and services. Parental engagement, school attendance, supportive peers, religious commitment and internet use for SRH information were described as protective factors. CONTRIBUTION: A socio-ecological model helped to comprehensively identify and organize broad social determinants of SRH and high risk sexual behaviors for young men. The resulting program and policy recommendations are proposed for implementation in Georgetown, Guyana.2018-11-08T00:00:00

HIV among immigrants living in high-income countries: a realist review of evidence to guide targeted approaches to behavioural HIV prevention

Immigrants from developing and middle-income countries are an emerging priority in HIV prevention in high-income countries. This may be explained in part by accelerating international migration and population mobility. However, it may also be due to the vulnerabilities of immigrants including social exclusion along with socioeconomic, cultural and language barriers to HIV prevention. Contemporary thinking on effective HIV prevention stresses the need for targeted approaches that adapt HIV prevention interventions according to the cultural context and population being addressed. This review of evidence sought to generate insights into targeted approaches in this emerging area of HIV prevention

"This is Tobago"Social and Cultural 'Influencers' of HIV Infections in Tobago

INTRO: In Tobago, HIV rates continue to increase (prevalence rate =5%). Women and youth are increasingly being infected, and heterosexual transmission accounts for most HIV infections. If these trends continue, Tobago's economic and social structure will be in jeopardy. This study has public health significance because it identifies and makes recommendations for incorporating relevant social and cultural factors into HIV prevention programs in Tobago. METHODS: Qualitative methods (participant observations, ethnographic and in-depth interviews) were utilized to unearth (a) pre- and post-HIV infection experiences of People Living With HIV/AIDS (PLWHAs), (b) relevant cultural and social 'influencer' of HIV/AIDS rates, (c) how these factors influence community norms and individual behavior, and (d) appropriate methods/model for incorporating relevant factors into HIV/AIDS prevention programs. PLWHAs, health professionals, community members and leaders were interviewed. RESULTS: 14 PLWHAs, 10 health professionals, 15 community leaders and 25 community members were interviewed. Participant observations occurred in homes, businesses, entertainment events, HIV-related organizations and health facilities. 206 PLWHAs are currently being treated in Tobago (HIV-related medications free to Trinidad and Tobago citizens). Infidelity, sex-in-exchange for resources, abuse and economic need increased PLWHAs' HIV risk. Lack of confidentiality is an issue, and stigma and discrimination are prevalent. There is lack of information about the causes, prevention and treatment of HIV in the general population. Sex is not openly discussed, however youth sexual behavior is common. Serial monogamy coupled with multiple sexual partnering increases general community risk. Consistent and correct condom use is not common, and purchasing or requesting condom use is difficult for women, youth, and married individuals. HIV testing is not common, and pre- and post-test counseling is inadequate. Current HIV prevention programs focus on abstaining, being faithful and using condoms, which do not take into account the complexities surrounding sexual decision making. There is a need for comprehensive HIV prevention programs. RECOMMENDATIONS: A client-centered, risk-reduction model of HIV prevention is recommended. Using the socio-cultural theory of learning, this study highlights the zone of proximal development, the knowledge-in-waiting, knowledge-in-use, agents of change, needed resources, and social environment needed to improve HIV prevention strategies in Tobago

Giving Voices to the Voiceless: Language Barriers & Health Access Issues of Black Immigrants of African Descent

Takes an initial step toward identifying language and cultural issues that impede access to health care among immigrants of African descent in California

IIMA in HealthCare Management: Abstract of Publications (2000-2010)

The Indian Institute of Management, Ahmedabad (IIMA), was established in 1961 as an autonomous institution by the Government of India in collaboration with the Government of Gujarat and Indian industry. IIMA’s involvement in the health sector started with the establishment of the Public Systems Group in 1975. In the initial period, our research focused on the management of primary healthcare services and family planning. We expanded our research activities to include the management of secondary healthcare services in the 80s and to tertiary healthcare services in the 90s. Currently our research interests focus on the governance and management issues in the areas on Rural Health, Urban Health, Public Health and Hospital Management. In June 2004, IIMA Board approved the setting up of a Centre for Management Health Services (CMHS) in recognition of IIMA’s contributions to the health sector in the past and the felt need to strengthen the management of health sector in the context of socio-economic developments of our country. The overall objectives of CMHS are to address the managerial challenges in the delivery of health services to respond to the needs of different segments of our population efficiently and effectively, build institutions of excellence in the health sector, and influence health policies and wider environments. All our research projects are externally funded and we have developed research collaborations with 15-20 international universities in USA, UK, Europe, and Asia. CMHS has also established strong linkages with the Ministry of Health and Family Welfare at the national and state government levels, particularly in the states of Gujarat, Maharashtra, Rajasthan, Madhya Pradesh, Chattisgarh, Orissa, and Bihar. This working paper is a compilation of the abstracts of all our publications in the last 10 years, which include 40 referred journal articles, 54 Working Papers, 19 Chapters in Books and 18 Case Studies.

HIV Knowledge, Attitudes, and Sexual Risk Behaviors among Women from Trinidad

Currently, the Caribbean has the second highest new cases of HIV infection, only after Sub-Saharan Africa. Women are becoming disproportionally more at risk for HIV/AIDS, mainly through heterosexual contact. The purpose of this dissertation study was to evaluate HIV knowledge, attitudes, and sexual risk behaviors among Trinidadian women. A sample of 113 participants was recruited for this study. The Theory of Planned Behavior (TPB) and Purnell Model of Cultural Competence were used to guide this study. Data were gathered using the HIV Knowledge Questionnaire (HIV-KQ-18), Condom Attitude Scale (CAS), Safe Sex Behavior Questionnaire (SSBQ), and a demographic questionnaire. Data were analyzed using statistical analysis software package (SPSS) version 22. Descriptive and Frequencies, Pearson product-moment correlation coefficient (r), one-way between groups ANOVA, and Multiple Regression analyses were implemented to assess HIV knowledge, attitudes about condom use, religious beliefs, level of education, and substance use among Trinidadian women. The results of this study indicated that level of education and race/ethnic backgrounds were associated with HIV knowledge among Trinidadian women. Religious beliefs had a negative correlation with attitudes about condom use. Also, there was a positive correlation between attitudes about condom use and safer sexual behaviors. The empirical knowledge obtained from this study can be used to provide a baseline for healthcare providers and policy makers to develop culturally aware, gender-relevant interventions to decrease the rate of HIV infection among Trinidadian women

Exploring the Role of Social Support, Ethnic Identity, and Psychological Empowerment on Drug Use and Sexual Risk Behavior Among Black & Hispanic Female Adolescents

Adolescent females of color, particularly Black and Hispanic adolescents, are often viewed as a homogenous group with adolescent boys of color, thus ignoring unique gender-racial specific risk and protective factors to drug use and HIV/AIDS that may be present. Such an absence can lead to flawed outcomes in HIV, STIs (sexually transmitted infections), and substance abuse prevention work that may continue to marginalize girls of color. Using empowerment theory and intersectionality as a framework, this study examines the extent to which ethnic identity, social support, and psychological empowerment is on drug use and sexual risk behavior. The study uses a sample of (N = 830) female adolescents who identify as being Black only or Non-White Hispanic only. All participants resided in a northeastern urban community in New Jersey. A majority of the participants (90%) were between the ages of 15–17 years of age. Confirmatory factor analysis was employed to test the factor structure of the scale used to measure psychological empowerment and structural equation modeling was used to test the hypothesized model of the mediating role of drug use on sexual risk behavior. Findings revealed that 30-day drug use significantly mediated the relationship between social support, ethnic identity, and psychological empowerment on sexual risk behavior. By highlighting the strengths of Black and Hispanic girls, researchers can attempt to learn from those who are not engaging in risky behaviors as a way to incorporate a strengths-based view in prevention

Body Image Experiences of Racial/Ethnic Minority Heterosexual Males Living with HIV/AIDS: An Interpretative Phenomenological Analysis

People living with HIV or as AIDS defined (PLWHA) may experience significant physical and metabolic alterations (i.e., lipodystrophy syndrome) as a side effect of HIV medications (i.e., Highly Active Antiretroviral Therapy) leading to profound transformations in body image (Collins et al., 2000). Despite the significant percentage of racial/ethnic minority heterosexual men living with HIV or as AIDS defined (REHMHA) both in the United States and globally and the known adverse effects of HAART on the body, the body image experiences of REHMHA have been unaccounted for in quantitative or qualitative research. The present study conducted in-depth semi-structured interviews with 21 REHMHA using open-ended questions and prompts conceptualized according to three domains thought to be important to body image—the perceptual, the behavioral, and the subjective (Thompson, 1990). In addition, the participants filled out a demographic questionnaire, body image questionnaire, and Perception of Lipodystrophy Scale (PLS). Ninety-five percent of participants reported perceived lipodystrophic alterations on the PLS with fat accumulation in the abdomen and face. Analysis of semi-structured interviews was conducted using interpretative phenomenological analysis (IPA). IPA revealed three super-ordinate themes or main areas of concern to REHMHA’s understanding of body image— “describing the valued and devalued body;” “losing and gaining control” and “navigating social dimensions of visibility and invisibility.” The results suggest that intrapersonal, interpersonal, and social experience of HIV or AIDS defined status and HAART-related physical transformations are important aspects of how REHMHA understand and explore their body images