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1.  Sexual Identity, Identity Disclosure, and Health Care Experiences: Is There Evidence for Differential Homophobia in Primary Care Practice? 
Background
Given extant health disparities among women who belong to the sexual minority, we must understand the ways in which access to and satisfaction with health care contribute to such disparities. The purpose of this study was to explore how sexual minority women’s (SMW) health care experiences compared with those of their heterosexually identified counterparts. We also sought to investigate whether there were differences within SMW in this regard. Finally, we explored whether participant satisfaction and comfort with health care providers (HCPs) differed depending upon HCP knowledge of participants’ sexual orientation.
Methods
We administered surveys to 420 women including lesbian, gay, bisexual, or other “queer” identified women (n = 354) and heterosexually identified women (n = 66).
Findings
Contrary to our expectations, we found that SMW were as likely to have had a recent health care appointment, to have been recommended and to have received similar diagnostic and preventive care, and to feel comfortable discussing their sexual health with their HCPs. They were, however, less likely to report being satisfied with their HCPs. We found no differences between lesbian SMW and non-lesbian SMW with respect to these indicators. We found important differences with respect to sexual orientation disclosure and health care satisfaction, however. Those participants whose HCPs purportedly knew of their minority sexual orientation reported greater satisfaction with their HCPs and greater comfort discussing their sexual health than those whose providers were presumably unaware.
Conclusion
We discuss important clinical and research implications of these findings.
doi:10.1016/j.whi.2013.07.004
PMCID: PMC4141482  PMID: 24183408
2.  Health Care Provider Perspectives on Informal Supporters’ Involvement in HIV Care 
Qualitative health research  2011;21(11):1554-1566.
Positive social support has been associated with medication adherence and slowed disease progression among people living with HIV. The nature of support within the medical context itself has not been adequately investigated, however. The purpose of our study was to describe HIV health care providers’ perspectives on informal supporter-oriented health care and whether and how the involvement of patients’ adult informal supporters in health care and health care decision making is helpful or beneficial. We conducted in-depth qualitative interviews with 11 HIV specialists between March and September, 2005. Using directed qualitative content analysis, we first describe the frequency and course of others’ involvement and the type of support provided. We then situate these findings within the context of role theory and consider the meaning they have in terms of the negotiated relationships among and between patients, providers, and informal supporters. Finally, we provide research and clinical recommendations based on these findings that are designed to improve patient care.
doi:10.1177/1049732311413783
PMCID: PMC4141479  PMID: 21709129
caregivers / caregiving; families; caregiving; health care; health care professionals; HIV/AIDS; social support
3.  High-Risk Women's Willingness to Try a Simulated Vaginal Microbicide: Results from a Pilot Study 
Women & health  2005;42(2):71-88.
Vaginal microbicides could provide an important option for women in the prevention of HIV and other STIs. Researchers have examined women's preferences for specific product characteristics; however, much remains to be learned about women's willingness to use them with a variety of partners. This study examined high-risk women's experiences using simulated microbicides during a two-week trial. Ninety-six women completed the trial by using the product and reporting their experiences with different partner types. Analyses were conducted to examine differences between women who always used the product and those who used it less than all the time and whether risk and relationship attitudes were associated with simulated microbicide use during participants' most recent sexual encounters. All participants used the product and on an average of 79-94% of sexual encounters. The majority of the participants reported liking the simulated product. Women indicated that they would want to use microbicides in order to feel in control of their health, to avoid having to ask their partner, and because microbicides would be easier to use than condoms. Women who used the product 100% of the time had less relationship power; however, greater sexual assertiveness for STI prevention predicted simulated microbicide use during the most recent sexual encounter, and interventions may need to focus on promoting sexual assertiveness for disease prevention.
PMCID: PMC2919063  PMID: 16537301
microbicides; HIV prevention; sexual assertiveness; acceptability
4.  Physician Awareness of Sexual Orientation and Preventive Health Recommendations to Men Who Have Sex With Men 
Sexually transmitted diseases  2011;38(1):63-67.
Background
Men who have sex with men (MSM) have unique health risks and needs. Providers who assume patients to be heterosexual may be providing suboptimal care. This study sought (1) to describe primary care provider (PCP) knowledge of patients' sexual orientation and the demographic and provider-related factors associated with such knowledge; and, (2) to assess whether PCP knowledge of sexual orientation was associated with appropriate recommendations for preventive and diagnostic health care services.
Methods
A total of 271 MSM completed a cross-sectional survey. We measured MSMs' disclosure of their sexual orientation and demographic information, and PCP recommendations for preventive health services.
Results
Most participants' PCPs (72%) knew the participants' sexual orientation. Participants with female, gay, and/or younger PCPs were more likely to have disclosed their sexual orientation. Black men, men from rural areas, and men with incomes under $15,000 per year were less likely to have disclosed their sexual orientation. PCP knowledge of sexual orientation was associated with a higher likelihood that PCPs recommended disease screening and preventive health measures: 59% versus 13% for human immunodeficiency virus testing, 32% versus 16% for hepatitis A or B vaccination. Inconsistencies were found between participants' self-reported risk behaviors and PCP recommendations.
Conclusions
Disclosure of sexual orientation is associated with several patient-related and provider-related characteristics. Lack of disclosure to providers significantly decreased the likelihood that appropriate health services were recommended to participants. Efforts to promote discussion of sexual orientation within the primary health care setting should be directed toward both PCPs and MSM.
doi:10.1097/OLQ.0b013e3181ebd50f
PMCID: PMC4141481  PMID: 20706178
5.  Patients' Perspectives on Informal Caregiver Involvement in HIV Health Care Appointments 
AIDS Patient Care and STDs  2009;23(12):1043-1051.
Abstract
HIV treatment advances have had a major impact on disease-related morbidity and mortality. However, not all HIV-positive persons are experiencing improved health outcomes. In the United States in particular, patient nonadherence and prescription bias may explain some health disparities. To address these factors, researchers and practitioners may benefit from enlisting support from an underutilized resource: patients' families and significant or supportive others. Little is known about informal caregiver involvement in treatment planning or how such involvement might affect health care delivery and receipt. The purpose of this study was to investigate patient perspectives on informal caregiver involvement in treatment planning, including the perceived consequences of others' involvement. Forty-two predominantly African American HIV-positive adults who were partnered at the time of diagnosis were recruited in 2005 from infectious disease clinics in Milwaukee, Wisconsin. Participants took part in individual semistructured interviews. They were asked questions pertaining to their diagnosis, treatment planning, and informal caregiver involvement at medical appointments. Data were recorded, transcribed, and coded for themes using NVivo 7 qualitative software. A minority of those interviewed were accompanied to medical appointments. Still, participants overwhelmingly identified more potential benefits than disadvantages to others' involvement. Benefits categories include improved information communication, the development of stronger relationships, improved family health, and successful treatment outcomes. Disadvantages of involvement included negative emotional and behavioral consequences for the patient and disrupted patient–provider communication. Recommendations for health care providers are discussed.
doi:10.1089/apc.2009.0020
PMCID: PMC2832646  PMID: 19929228
6.  If I Didn't Have HIV I'd Be Dead Now: Illness Narratives of Drug Users Living with HIV/AIDS 
Qualitative health research  2005;15(5):586-605.
The purpose of this study was to illuminate the experiences of poor, urban HIV-positive drug users. Sixty participants were asked about HIV risk behaviors, the impact of HIV on their lives, religious beliefs, life plans, relationships, and work-related issues both prior to and since diagnosis. A theoretical framework was developed using Frank's (1995; 1998) Illness Narratives and Boss and Couden's (2002) Ambiguous Loss theories. Themes pertaining to both physical and emotional or spiritual dimensions were located within Benefit, Loss, or Status Quo orientations. The findings contribute to researchers' understanding of the HIV/AIDS illness experiences among the very marginalized and they have important implications for physical and mental health care professionals working with HIV-positive drug users.
doi:10.1177/1049732304271749
PMCID: PMC2910614  PMID: 15802537
7.  Evaluation of a peer-led hypertension intervention for veterans: impact on peer leaders 
Health Education Research  2013;28(3):426-436.
Volunteer peer leaders (PLs) benefit from their involvement in health interventions but we know little about how they compare with other non-PL volunteers or with the intervention recipients themselves. We randomized 58 veterans’ service organizations’ posts (e.g. VFW) to peer- versus professionally led self-management support interventions. Our primary research questions were whether hypertensive PLs changed over the course of the project, whether they changed more than hypertensive volunteers who were not randomized to such a role [i.e. post representatives (PRs)] and whether they changed more than the intervention recipients with respect to health knowledge, health beliefs and health outcomes from baseline to 12 months. After the intervention, PLs provided open-ended feedback and participated in focus groups designed to explore intervention impact. Hypertensive PLs improved their systolic blood pressure and hypertension knowledge and increased their fruit/vegetable intake and pedometer use. We found no differences between PLs and PRs. PLs improved knowledge and increased fruit/vegetable intake more than intervention recipients did; they provided specific examples of personal health behavior change and knowledge acquisition. Individuals who volunteer to be peer health leaders are likely to receive important benefits even if they do not actually take on such a role.
doi:10.1093/her/cyt004
PMCID: PMC3716214  PMID: 23406721
8.  Influence of Coping, Social Support, and Depression on Subjective Health Status Among HIV-Positive Adults With Different Sexual Identities 
The authors examined associations between psychosocial variables (coping self-efficacy, social support, and cognitive depression) and subjective health status among a large national sample (N = 3,670) of human immunodeficiency virus (HIV)-positive persons with different sexual identities. After controlling for ethnicity, heterosexual men reported fewer symptoms than did either bisexual or gay men and heterosexual women reported fewer symptoms than did bisexual women. Heterosexual and bisexual women reported greater symptom intrusiveness than did heterosexual or gay men. Coping self-efficacy and cognitive depression independently explained symptom reports and symptom intrusiveness for heterosexual, gay, and bisexual men. Coping self-efficacy and cognitive depression explained symptom intrusiveness among heterosexual women. Cognitive depression significantly contributed to the number of symptom reports for heterosexual and bisexual women and to symptom intrusiveness for lesbian and bisexual women. Individuals likely experience HIV differently on the basis of sociocultural realities associated with sexual identity. Further, symptom intrusiveness may be a more sensitive measure of subjective health status for these groups.
doi:10.3200/BMED.34.4.133-144
PMCID: PMC2653049  PMID: 19064372
coping; depression; HIV; sexual identity; symptoms; social support
9.  REASONS FOR HIV DISCLOSURE OR NONDISCLOSURE TO CASUAL SEXUAL PARTNERS 
The purpose of this study was to investigate reasons HIV-positive gay men give for disclosing or not disclosing their serostatus to their casual sexual partners. Participants were 78 HIV-positive gay men who were part of a larger HIV and disclosure project. A clear factor structure for disclosure emerged which suggests that issues of responsibility dominated men's decisions to disclose. No clear factor structure for nondisclosure emerged. Reasons for disclosure or nondisclosure to casual sexual partners were varied and this data could provide new insights for secondary prevention efforts. More research needs to be conducted to better understand salient issues in considering whether to disclose.
PMCID: PMC1325221  PMID: 12627744
10.  Sexual Risk-Taking among High-Risk Urban Women with and without Histories of Childhood Sexual Abuse: Mediating Effects of Contextual Factors 
Journal of child sexual abuse  2010;19(1):43-61.
This study investigated the mechanisms of risk for urban women at high risk for HIV with and without childhood sexual abuse (CSA) histories. CSA survivors reported more unprotected intercourse and sexually transmitted infections (STIs). The association of STI locus of control with frequency of unprotected sex was fully mediated by being intoxicated during sex and engaging in sex work, whereas the association between relational control and unprotected sex was not mediated by contextual factors for the CSA group. The mechanisms of risk are different for those with divergent CSA histories and thus interventions should be developed to educate women with a history of CSA about ways to avoid revictimization, particularly within a context of poverty, prostitution, and drug use.
doi:10.1080/10538710903485591
PMCID: PMC2905625  PMID: 20390778
Childhood Sexual Abuse; Drug Use; Sexual Risk; HIV Risk; STI Risk
11.  Acceptability of Hypothetical Microbicides among Women in Sex Establishments in Rural Areas in Southern China 
Sexually transmitted diseases  2008;35(1):102-110.
Objectives and Goal
The objectives of this study were to measure the potential acceptability of a hypothetical microbicide among women in sex establishments in rural areas of Southern China, and demographic, behavioral and social context factors likely to affect microbicide acceptability.
Study Design
This was a cross-sectional survey, using a quota sampling, among 300 women from sex establishments in three rural towns. An interviewer-administered standardized questionnaire was used to measure the acceptability score of hypothetical microbicides’ characteristics, as well as sexual relationships and behaviors, and other contextual factors.
Results
Findings showed a generally positive response to microbicides, indicated by an acceptability index score of 2.89 (SD, 0.56, scale of 1–4) in the overall sample. Multivariate analysis shows the acceptability score varied significantly by study sites, type of sex-work establishments, marital status, sex partner type, vaginal product experience, locus of control by partners and locus of control by chance.
Conclusions
Microbicides may be acceptable among sex workers in rural settings in China; however, contextual factors should be carefully considered in education and promotion of microbicides in the future.
doi:10.1097/OLQ.0b013e31814b8546
PMCID: PMC2892031  PMID: 17767093
HIV/AIDS; microbicide; acceptability; sex worker; China
12.  The Risk Avoidance Partnership: Training Active Drug Users as Peer Health Advocates 
Journal of drug issues  2006;36(3):541-570.
Efforts have expanded to create AIDS prevention programs for drug users that consider the social context and interpersonal relationships within which risky practices take place. The Risk Avoidance Partnership (RAP) project is designed to train active drug users as “Peer/Public Health Advocates” (PHAs) to bring a structured, peer-led intervention into the sites where they and their drug-using social networks use illicit drugs. The RAP Peer Health Advocacy training curriculum and peer-led intervention promote harm reduction among drug users and support drug-user organization to reduce infectious disease and other harm in the context of injection drug use, crack cocaine use, and sexual activity. Initial findings suggest that RAP PHAs perceive a significant positive role change in themselves while conducting health advocacy work, and willingly and successfully carry the peer-led intervention into locations of high-risk drug activity to deliver it to their peers even in the absence of project staff support.
PMCID: PMC2662598  PMID: 19337568
HIV/AIDS prevention; drug abusers; peer intervention; health advocacy; social network intervention
13.  Microbicide Acceptability Among High-Risk Urban U.S. Women: Experiences and Perceptions of Sexually Transmitted HIV Prevention 
Sexually transmitted diseases  2004;31(11):682-690.
SUMMARY
A study of microbicide acceptability among high-risk African American, Puerto Rican, non-Hispanic White, and other women in Hartford, Connecticut indicated limited experience with vaginal contraceptives but significant interest in and willingness to adopt vaginal microbicides for HIV/STI prevention.
Objectives
To measure microbicide acceptability among high-risk women in Hartford, Connecticut and contextual factors likely to affect acceptability and use.
Goal
To assess usefulness of microbicides for HIV/STI prevention for high-risk women.
Study Design
Ethnographic interviews (n=75) and a survey (n=471) explored women’s perspectives on HIV/STI prevention, vaginal contraceptives similar to microbicides, and microbicide acceptability. Participants (n=94) in a two-week behavioral trial used an over-the-counter vaginal moisturizer to simulate microbicide use during sex with primary, casual, and/or paying partners.
Results
Findings showed limited experience with vaginal contraceptives, but high interest in microbicides as an alternative to condoms, indicated by an acceptability index score of 2.73 (SD .49, scale 1–4) in the overall sample. General microbicide acceptability varied by ethnicity, prior contraceptive and violence/abuse experiences, relationship power, and other attitudinal factors. The simulation trial indicated significant willingness to use the product in various locations and with all types of partners.
Conclusions
Vaginal microbicides may improve prevention outcomes for high-risk inner-city women.
PMCID: PMC1567977  PMID: 15502677
microbicides; HIV; STI; women’s health; drug users; sex workers

Results 1-13 (13)