Factors That Influence HIV Risk among Hispanic Female Immigrants and Their Implications for HIV Prevention Interventions

Hispanics are the fastest growing minority group in North Carolina with increasing incidence of HIV infection. Gender roles, cultural expectations, and acculturation of women may explain some of Hispanic women's risks. The perspectives of Hispanic female immigrants and community-based providers were sought to identify services they offer, understand HIV risk factors, and support the adaptation of a best-evidence HIV behavioural intervention for Hispanic women. Two sets of focus groups were conducted to explicate risks and the opportunities to reach women or couples and the feasibility to conduct HIV prevention in an acceptable manner. Salient findings were that Hispanic female immigrants lacked accurate HIV/AIDS and STI knowledge and that traditional gender roles shaped issues surrounding sexual behaviour and HIV risks, as well as condom use, partner communication, and multiple sexual partnerships. Intervention implications are discussed such as developing and adapting culturally appropriate HIV prevention interventions for Hispanics that address gender roles and partner communication

Initial Feasibility of a Woman-Focused Intervention for Pregnant African-American Women

African-American women who use crack are vulnerable to HIV because of the complex social circumstances in which they live. Drug-abuse treatment for these women during pregnancy may provide time for changing risk behaviors. This paper examines the initial 6-month feasibility of a women-focused HIV intervention, the Women's CoOp, adapted for pregnant women, relative to treatment-as-usual among 59 pregnant African-American women enrolled in drug-abuse treatment. At treatment entry, the women were largely homeless, unemployed, practicing unsafe sex, and involved in violence. Results indicated marked reductions in homelessness, use of cocaine and illegal drugs, involvement in physical violence, and an increase in knowledge of HIV from baseline to 6-month followup for both conditions. Findings suggest that the Women's CoOp intervention could be successfully adapted to treat this hard-to-reach population. Future studies should examine the efficacy of the pregnancy-adapted Women's CoOp for women not enrolled in drug-abuse treatment

Correlates of Male Condom Use Skills among High-Risk Women in South Africa

This exploratory study examines the performance of 295 South African women—who recently traded sex for goods or had unprotected sex—on a male condom use mastery index. Bivariate and multivariate logistic regression analyses were conducted to determine whether age, marital status, highest education obtained, male condom use at first penetrative sex, receiving prior demonstration of male condom use, recent sexually transmitted infection (STI) symptoms, and recently trading sex were significantly associated with index scores. Adjusted odds ratios indicated that age and STI symptoms were negatively associated with condom skills; women who were older and had a higher number of recent STI symptoms were more likely to have lower scores. Furthermore, participants executed, on average, approximately one-third of condom use steps correctly. These findings suggest a need for increased behavioral skills training for women engaging in sexual risk behaviors because many lack the skills required to use a male condom properly

Experiences of Violence and Association with Decreased Drug Abstinence Among Women in Cape Town, South Africa

Drug abuse is a contributing factor in women’s HIV risk in low-income communities in Cape Town, South Africa. This study assessed whether experiencing violence is associated with reduced drug abstinence among adult women (n = 603) participating in a randomized field trial for an HIV prevention study in Cape Town. In relation to drug abstinence at 12-month follow-up, multivariable regression models were used to assess (1) baseline partner and non-partner victimization, and (2) victimization at 12-month follow-up among participants reporting baseline victimization. Baseline partner (AOR = 0.6; 95 % CI 0.4–0.9) and non-partner victimization (AOR = 0.6; 95 % CI 0.4–0.9) were associated with a reduced likelihood of drug abstinence at follow-up. Among participants who reported victimization at baseline, those no longer reporting victimization at follow-up did not differ significantly in drug abstinence compared with those who reported victimization at follow-up. The study findings highlight the lasting impact of victimization on women’s drug use outcomes, persisting regardless of whether violence was no longer reported at follow-up. Overall, the findings support the need for the primary prevention of violence to address the cycle of violence, drug use, and HIV among women in this setting

Pregnant and Nonpregnant Women in Cape Town, South Africa: Drug Use, Sexual Behavior, and the Need for Comprehensive Services

The multiple risks associated with methamphetamine use are of serious concern for women. These risks and consequences are magnified during pregnancy. This secondary analysis of a parent study compared 26 pregnant to 356 nonpregnant women in Cape Town, South Africa, on selected demographic, psychosocial, and HIV-risk domains to identify their treatment service needs. Proportionally, more pregnant than nonpregnant women are using methamphetamine, P = .01, although a very high rate of women used methamphetamine. Women reported similar monthly rates of sexual intercourse, but pregnant women were significantly less likely to report condom use, P < .0001, maintaining their risky behavior. Both groups reported elevated Center for Epidemiological Studies Depression Scale CES-D means, suggesting a need for depression treatment. Results demonstrate a pervasive need for women's comprehensive treatment, regardless of pregnancy status. Moreover, findings support the urgent need for women-focused and pregnancy-specific treatment services for methamphetamine use. Finally, a job-skills training/employment component focus is suggested

Efficacy of the Young Women's CoOp: An HIV Risk-Reduction Intervention for Substance-Using African-American Female Adolescents in the South

HIV/sexually transmitted infection (STI) risk-reduction interventions are needed to address the complex risk behaviors among African-American female adolescents in disadvantaged communities in North Carolina. In a two-group randomized trial, we reached 237 sexually active, substance-using African-American female adolescents, to test a risk-reduction intervention, the Young Women’s CoOp (YWC), relative to a nutrition control. In efficacy analyses adjusting for baseline condom use, at three-month follow-up participants in the YWC were significantly less likely to report sex without a condom at last sex relative to control. There were mixed findings for within-group differences over follow-up, underscoring the challenges for intervening with substance-using female youths

Pregnant and Nonpregnant Women in Cape Town, South Africa: Drug Use, Sexual Behavior, and the Need for Comprehensive Services

The multiple risks associated with methamphetamine use are of serious concern for women. These risks and consequences are magnified during pregnancy. This secondary analysis of a parent study compared 26 pregnant to 356 nonpregnant women in Cape Town, South Africa, on selected demographic, psychosocial, and HIV-risk domains to identify their treatment service needs. Proportionally, more pregnant than nonpregnant women are using methamphetamine, P = .01, although a very high rate of women used methamphetamine. Women reported similar monthly rates of sexual intercourse, but pregnant women were significantly less likely to report condom use, P < .0001, maintaining their risky behavior. Both groups reported elevated Center for Epidemiological Studies Depression Scale CES-D means, suggesting a need for depression treatment. Results demonstrate a pervasive need for women's comprehensive treatment, regardless of pregnancy status. Moreover, findings support the urgent need for women-focused and pregnancy-specific treatment services for methamphetamine use. Finally, a job-skills training/employment component focus is suggested

An implementation science protocol of the Women’s Health CoOp in healthcare settings in Cape Town, South Africa: A stepped-wedge design

Abstract Background HIV persists as a public health emergency in South Africa, especially among women of childbearing age. In response to the HIV epidemic, the Joint United Nations Programme on HIV/AIDS has put forth the 90–90-90 global goals to achieve an AIDS-free generation by 2020. This goal aspires to have 90% of people living with HIV diagnosed; 90% of those who test positive on sustained antiretroviral therapy (ART); and 90% of those on ART be virally suppressed. Ensuring access to ART is an important first step in reducing HIV incidence, especially among vulnerable populations such as women who use substances and bear the burden of HIV in South Africa. Additionally, alcohol and other drug (AOD) use and exposure to gender-based violence are associated with increased risk of HIV infection and reduced adherence to ART. However, no research has estimated ART adherence rates for women who use substances in South Africa since the government approved the provision of ART to all people living with HIV. Methods The Women’s Health CoOp (WHC) is an evidence-based, woman-focused, behavioral intervention that addresses the intersecting risks of AODs, sex behaviors, and violence and victimization, with the primary goal of increasing skills and knowledge to reduce substance abuse and HIV risks and to improve ART adherence. The WHC has been packaged for further dissemination. This article describes the study protocol used to assess the feasibility and acceptability of implementing the WHC intervention into standard of care in Cape Town health clinics and substance abuse rehabilitation centers to reduce HIV risk behavior and increase ART adherence among women who use substances and are living with HIV. Discussion Because few of the interventions that demonstrate efficacy for HIV prevention and ART adherence in randomized trials are sustainable, studies to adapt and test intervention variations are needed to determine the best strategies for implementing them in real-world, high-risk settings. However, implementation in real-world settings presents challenges. Consequently, intervention developers should consider the strengths and limitations of their anticipated implementation setting by engaging with key stakeholders before, during, and after the adaptation and implementation process when developing and attempting to scale-up interventions. Trial registration NCT 02733003 and date approved 1/21/2016

Substance abuse, treatment needs and access among female sex workers and non-sex workers recruited in Pretoria, South Africa

Abstract Background This study examined cross-sectional data collected from substance-using female sex workers (FSW) and non-sex workers (non-SW) in Pretoria, South Africa, who entered a randomized controlled trial. Methods Women who reported alcohol use and recently engaging in sex work or unprotected sex were recruited for a randomized study. The study sample (N = 506) comprised 335 FSW and 171 female non-SW from Pretoria and surrounding areas. Self-reported data about alcohol and other drug use as well as treatment needs and access were collected from participants before they entered a brief intervention. Results As compared with female non-SW, FSW were found to have a greater likelihood of having a past year diagnosis of alcohol or other drug abuse or dependence, having a family member with a history of alcohol or other drug abuse, having been physically abused, having used alcohol before age 18, and having a history of marijuana use. In addition, the FSW were more likely to perceive that they had alcohol or other drug problems, and that they had a need for treatment and a desire to go for treatment. Less than 20% of participants in either group had any awareness of alcohol and drug treatment programs, with only 3% of the FSW and 2% of the non-SW reporting that they tried but were unable to enter treatment in the past year. Conclusion FSW need and want substance abuse treatment services but they often have difficulty accessing services. The study findings suggest that barriers within the South African treatment system need to be addressed to facilitate access for substance-using FSW. Ongoing research is needed to inform policy change that fosters widespread educational efforts and sustainable, accessible, woman-sensitive services to ultimately break the cycle for current and future generations of at-risk South African women

Seek, test, treat: substance-using women in the HIV treatment cascade in South Africa

Abstract Background Women in South Africa who use alcohol and other drugs face multiple barriers to HIV care. These barriers make it difficult for women to progress through each step in the HIV treatment cascade from diagnosis to treatment initiation and adherence. This paper examines correlates of HIV status, newly diagnosed HIV status, and use of antiretroviral therapy (ART). Methods Outreach workers recruited sexually active Black African women who used substances in Pretoria as part of a U.S. National Institutes of Health-funded geographically clustered randomized trial examining the effect of an intervention to reduce alcohol and drug use as well as sexual risk behaviors. To address the question of interest in the current investigation, cross-sectional baseline data were used. At study enrollment, all participants (N = 641) completed an interview, and underwent rapid HIV testing and biological drug screening. Those who tested positive for HIV and were eligible for ART were asked about their barriers to initiating or adhering to ART. Bivariate and multivariable logistic regression analyses were conducted to determine correlates of HIV status, newly diagnosed HIV, and ART use. Results At enrollment, 55% of participants tested positive for HIV, and 36% of these women were newly diagnosed. In multivariable analyses of the entire sample, women who had completed 10th grade were less likely to be living with HIV (OR 0.69; CI 0.48, 0.99) and those from the inner city were more likely to be living with HIV (OR 1.83; CI 1.26, 2.67). Among HIV-positive participants, women were less likely to be newly diagnosed if they had ever been in substance abuse treatment (OR 0.15; CI 0.03, 0.69) or used a condom at last sex (OR 0.58; CI 0.34, 0.98) and more likely to be newly diagnosed if they were physically assaulted in the past year (OR 1.97; CI 1.01, 3.84). Among women eligible for ART, fewer were likely to be on treatment (by self-report) if they had a positive urine test for opiates or cocaine (OR 0.27; CI 0.09, 0.80). Conclusions These results, although cross-sectional, provide some guidance for provincial authorities to address barriers to HIV care for sexually active, substance-using vulnerable women in Pretoria. Targeting the inner city with prevention campaigns, expanding and improving substance abuse treatment programs, linking clients with simultaneous HIV testing and treatment, and targeting women who have experienced sexual assault and violence may help the government achieve the UNAIDS 90-90-90 treatment target. Clinical Trials.gov NCT01497405 registered on December 1, 2011