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1.  Disruptive Innovations for Designing and Diffusing Evidence-based Interventions 
The American psychologist  2012;67(6):463-476.
The numbers of evidence-based interventions (EBIs) have been growing exponentially, both therapeutic and prevention programs. Yet, EBIs have not been broadly adopted in the United States. In order for our EBI science to significantly reduce disease burden, we need to critically re-examine our scientific conventions and norms. Innovation may be spurred by re-examining the biomedical model for validating EBIs and the compartmentalization of EBIs as disease-specific, institutionally-based, counseling programs. The model of Disruptive Innovations suggests that we re-engineer EBIs based on their most robust features in order to reach more people in less time and at lower cost. Four new research agendas will be required to support disruptive innovations in EBI science: synthesize common elements across EBIs; experiment with new delivery formats (e.g., consumer controlled, self-directed, brief, paraprofessional, coaching, and technology and media strategies); adopt market strategies to promote and diffuse EBI science, knowledge, and products; and adopt continuous quality improvement as a research paradigm for systematically improving EBIs, based on ongoing data and feedback. EBI science can have more impact if it can better leverage what we know from existing EBIs in order to inspire, engage, inform, and support families and children to adopt and sustain healthy daily routines and lifestyles.
doi:10.1037/a0028180
PMCID: PMC3951837  PMID: 22545596
Disruptive Innovations; evidence-based interventions; prevention science; mental health treatment
2.  Diabetes Buddies: Peer support through a mobile phone buddy system 
The Diabetes educator  2012;38(3):357-365.
Purpose
The purpose of this study is to test the feasibility and acceptability of a mobile phone-based peer support intervention among women in resource-poor settings to self-manage their diabetes. Secondary goals evaluated the intervention’s effectiveness to motivate diabetes-related health choices.
Methods
Women with diabetes (n=22) in Cape Town, South Africa participated in a 12-week program focused on providing and applying knowledge of health routines to manage diabetes. Women were linked with a buddy via a mobile phone for support and also questioned daily about a health behavior via text message. Women were assessed at recruitment, and then 3 and 6 months later by a trained interviewer using a mobile phone for data collection. The women were evaluated on technology uptake, reduction of BMI, blood glucose levels, and increases in positive coping and general health-seeking behaviors.
Results
Women exchanged 16739 text messages to buddies and received 3144 texts from the project. Women responded to 29% of texted questions (n=1321/14582). Women attended at least 9 of 12 possible intervention sessions; a third attended all 12 sessions (n = 8/22). Between baseline and three months, women increased their sleep and reported a higher level of positive action and social support coping, yet, blood glucose increased by 3.3 points. From 3 to 6 months, spiritual hope decreased and diastolic blood pressure increased. One year later, the 22 women continue to attend meetings.
Conclusion
Mobile phones are an easy and reliable way to provide peer support and disseminate health messages. Both positive and negative changes were observed in this pilot study.
doi:10.1177/0145721712444617
PMCID: PMC4059372  PMID: 22546740
3.  Outcomes of Home Visits for Pregnant Mothers and their Infants: a Cluster Randomised Controlled Trial 
AIDS (London, England)  2013;27(9):1461-1471.
Objective
To evaluate the effect of home visits by Community Health Workers (CHW) on maternal and infant well-being from pregnancy through the first six months of life for women living with HIV (WLH) and all neighbourhood mothers.
Design and Methods
In a cluster randomised controlled trial in Cape Town townships, neighbourhoods were randomised within matched pairs to either: 1) Standard Care, comprehensive healthcare at clinics (SC; n=12 neighbourhoods; n=169 WLH; n=594 total mothers), or 2) Philani Intervention Program, home visits by CHW in addition to SC (PIP; n=12 neighbourhoods; n=185 WLH; n=644 total mothers). Participants were assessed during pregnancy (2% refusal) and reassessed at one week (92%) and six months (88%) post-birth. We analysed PIP’s effect on 28 measures of maternal and infant well-being among WLH and among all mothers using random effects regression models. For each group, PIP’s overall effectiveness was evaluated using a binomial test for correlated outcomes.
Results
Significant overall benefits were found in PIP compared to SC among WLH and among all participants. Secondarily, compared to SC, PIP WLH were more likely to complete tasks to prevent vertical transmission, use one feeding method for 6 months, avoid birth-related medical complications, and have infants with healthy height-for-age measurements. Among all mothers, compared to SC, PIP mothers were more likely to use condoms consistently, breastfeed exclusively for 6 months, and have infants with healthy height-for-age measurements.
Conclusions
PIP is a model for countries facing significant reductions in HIV funding whose families face multiple health risks.
doi:10.1097/QAD.0b013e3283601b53
PMCID: PMC3904359  PMID: 23435303
HIV; maternal health; perinatal health
4.  Opportunities for HIV Combination Prevention to Reduce Racial and Ethnic Health Disparities 
The American psychologist  2013;68(4):237-246.
Despite advances in HIV prevention and care, African American and Latino Americans remain at much higher risk of acquiring HIV, are more likely to be unaware of their HIV-positive status, are less likely to be linked to and retained in care, or to have suppressed viral load than are Whites. The first National HIV/AIDS Strategy (NHAS) has reducing these disparities as one of its three goals by encouraging the implementation of combination high impact HIV intervention strategies. Federal agencies have expanded their collaborations in order to decrease HIV-related disparities by: better implementation of data-driven decision-making; integration and consolidation of the continuum of HIV care; and the reorganization of relationships among public health agencies, researchers, community-based organizations (CBO), and HIV advocates. Combination Prevention, the integration of evidence-based and impactful behavioral, biomedical, and structural intervention strategies to reduce HIV incidence, provides the tools to address the HIV epidemic. Unfortunately, health disparities exist at every step along the HIV testing-to-care continuum. This provides an opportunity and a challenge to everyone involved in HIV prevention and care to understand and address health disparities as integral to ending the HIV epidemic in the U.S. To further reduce health disparities, successful implementation of NHAS and combination prevention strategies will require multi-disciplinary teams, including psychologists with diverse cultural backgrounds and experiences, to successfully engage groups at highest risk for HIV and those already HIV-infected. In order to utilize the comprehensive care continuum, psychologists and behavioral scientists have a role to play in re-conceptualizing the continuum of care, conducting research to address health disparities, and creating community mobilization strategies.
doi:10.1037/a0032711
PMCID: PMC3947902  PMID: 23688091
5.  Adoption of Self-management Interventions for Prevention and Care 
Primary care  2012;39(4):649-660.
Seventy-five percent of spiraling healthcare costs can be attributed to chronic diseases, making prevention and management of chronic conditions one of our highest healthcare priorities, especially as we organize for patient-centered medical homes. Collaborative patient self-management in primary care has been repeatedly demonstrated to be efficacious in reducing both symptoms and increasing quality of life, yet there is no consensus on what, how, when, and by whom self-management programs are best implemented. In this article, we argue that self-management interventions effectively span the continuum of prevention and disease management. Self-management interventions rest on a foundation of five core actions: 1) activate motivation to change; 2) apply domain-specific information from education and self-monitoring; 3) develop skills; 4) acquire environmental resources; and 5) build social support. A range of delivery vehicles, including group interventions, primary care providers, and advanced wireless technology, are described and evaluated in terms of diffusion and cost-containment goals.
doi:10.1016/j.pop.2012.08.006
PMCID: PMC3990217  PMID: 23148958
self-management; self-regulation; chronic illness; chronic disease; interventions; prevention
6.  Vocational Training with HIV Prevention for Ugandan Youth 
AIDS and behavior  2012;16(5):1133-1137.
In a pilot study, young people in slums in Kampala, Uganda received an HIV prevention program (Street Smart) and were randomized to receive vocational training immediately (Immediate) or four months later (Delayed). Youth were monitored at recruitment, 4 months (85% retention), and 24 months (74% retention). Employment increased dramatically: Only 48% had ever been employed at recruitment, 86% were employed from months 21 to 24 post recruitment. Over two years, decreases were recorded in the number of sexual partners, mental health symptoms, delinquent acts, and drug use; condom use increased. Providing employment in low income countries, in conjunction with HIV prevention, may provide sustained support to young people to prevent HIV acquisition.
doi:10.1007/s10461-011-0007-y
PMCID: PMC3947885  PMID: 21800180
vocational training; Ugandan youth; HIV/AIDS prevention
7.  Standardized Functions for Smartphone Applications: Examples from Maternal and Child Health 
Millennium Development Goals (MDGs) are unlikely to be met in most low- and middle-income countries (LMIC). Smartphones and smartphone proxy systems using simpler phones, equipped with the capabilities to identify location/time and link to the web, are increasingly available and likely to provide an excellent platform to support healthcare self-management, delivery, quality, and supervision. Smart phones allow information to be delivered by voice, texts, pictures, and videos as well as be triggered by location and date. Prompts and reminders, as well as real-time monitoring, can improve quality of health care. We propose a three-tier model for designing platforms for both professional and paraprofessional health providers and families: (1) foundational functions (informing, training, monitoring, shaping, supporting, and linking to care); (2) content-specific targets (e.g., for MDG; developmentally related tasks); (3) local cultural adaptations (e.g., language). We utilize the Maternal and Child Health (MCH) MDG in order to demonstrate how the existing literature can be organized and leveraged on open-source platforms and provide examples using our own experience in Africa over the last 8 years.
doi:10.1155/2012/973237
PMCID: PMC3530862  PMID: 23304136
8.  Attitudinal, Behavioral, and Biological Outcomes of a Community Popular Opinion Leader Intervention in China 
The effects of a community popular opinion leader (CPOL) intervention were examined among market vendors in a city on the eastern coast of China. Employees of 40 food markets were enrolled in a study that provided HIV-related education and tests, and treatment for sexually transmitted diseases (STDs). Twenty markets were randomly assigned to a CPOL intervention (N = 1695) and 20 markets to a control condition (N = 1616). Market employees in the intervention condition reported positive attitudes regarding STD/HIV prevention and more frequent discussions about safe sex than those in the control condition. Compared to baseline, the prevalence of unprotected sexual acts and new STDs were significantly lower within each study condition 24 months later. Although the CPOL intervention achieved its goal of shifting attitudes within food markets, the gains did not lead to the expected behavioral and biological outcomes.
doi:10.1521/aeap.2011.23.5.448
PMCID: PMC3917310  PMID: 22010808
9.  Reductions in sexually transmitted infections associated with popular opinion leaders in China in a randomised controlled trial 
Sexually Transmitted Infections  2011;87(4):337-343.
Objectives
A community level randomised controlled trial of a Community Popular Opinion Leader (C-POL) intervention to reduce bacterial and viral sexually transmitted infections (STIs) and unprotected extramarital sex was carried out over 2 years in five countries. The main study results did not find significant intervention effects. This paper presents a sub-analysis examining the differential intervention impacts among high-risk and low-risk participants in the China site.
Methods
From 2002 – 2006, 3912 migrant market vendors aged 18 and 49 years were recruited at an urban site in China. Markets were randomly assigned to the C-POL intervention (N=20 markets; n=1979) or standard-care control condition (N=20; n=1933). Both study condition venues received HIV/STI education, free condoms, STI testing and treatment, and training for pharmacists in antibiotic treatments. In intervention markets, C-POLs were identified and trained to diffuse messages regarding safer sex, STI treatment and partner discussions of sex. The primary biological outcome was incidence of new STIs (chlamydia, gonorrhoea, syphilis, trichomonas, herpes or HIV). The primary sexual behaviour risk outcome was any unprotected extramarital sex in the prior 3 months.
Results
In unadjusted analyses, women had significantly lower rates of STI infection at 24 months in the C-POL intervention (5.7%) compared to controls (8.3%; p=0.043). In mixed-effects regression models, intervention participants with STIs at previous assessments were about half as likely to have STIs at 24 months (OR 0.47, 95% CI 0.25 to 0.90) compared to controls.
Conclusions
The C-POL intervention lowers HIV risk among those at highest risk (ie, with a STI or engaging in high-risk sexual activities) rather than the general population.
doi:10.1136/sti.2010.046243
PMCID: PMC3098303  PMID: 21278400
10.  Intervening on Conflict, Parental Bonds, and Sexual Risk Acts among Adolescent Children of Mothers Living with HIV 
PLoS ONE  2014;9(7):e101874.
Objective
In 1993–1994, a psychosocial intervention conducted in New York City significantly improved outcomes for parents living with HIV and their adolescent children over six years. We examine if the intervention benefits are similar for adolescents of mothers living with HIV (MLH) in 2004–2005 in Los Angeles when MLH’s survival had increased substantially.
Methods
Adolescents of MLH in Los Angeles (N = 256) aged 12–20 years old were randomized with their MLH to either: 1) a standard care condition (n = 120 adolescent-MLH dyads); or 2) an intervention condition consisting of small group activities to build coping skills (n = 136 adolescent-MLH dyads, 78% attended the intervention). At 18 months, 94.7% of adolescents were reassessed. Longitudinal structural equation modeling examined if intervention participation impacted adolescents’ relationships with parents and their sexual risk behaviors.
Results
Compared to the standard care, adolescents in the intervention condition reported significantly more positive family bonds 18 months later. Greater participation by MLH predicted fewer family conflicts, and was indirectly associated with less adolescent sexual risk behavior at the 18 month follow-up assessment. Anticipated developmental patterns were observed - sexual risk acts increased with age. Reports were also consistent with anticipated gender roles; girls reported better bonds with their mothers at 18 months, compared to boys.
Conclusions
Adolescents of MLH have better bonds with their mothers as a function of participating in a coping skills intervention and reduced sexual risk-taking as a function of MLH intervention involvement.
doi:10.1371/journal.pone.0101874
PMCID: PMC4092062  PMID: 25010119
11.  Reducing Risky Sexual Behavior and Substance Use Among Currently and Formerly Homeless Adults Living With HIV 
American journal of public health  2008;99(6):1100-1107.
Objectives
We examined the efficacy of the Healthy Living Program in reducing risky sexual behavior and substance use among adults with HIV infection who were marginally housed (i.e., homeless at some point over a 37-month period).
Methods
We had previously conducted a randomized controlled trial with 936 adults living with HIV infection. In that study, 3 intervention modules of 5 sessions each addressed different goals: reducing risky sexual acts and drug use, improving the quality of life, and adhering to healthful behaviors. Participants were interviewed at baseline and at 5, 10, 15, 20, and 25 months; 746 completed 4 or more assessments. In this study, we analyzed sexual behavior and drug use outcomes for the 35% (n=270 of 767) of participants who were considered marginally housed.
Results
Among the marginally housed participants, there were significantly greater reductions in unprotected risky sexual acts, the number of sexual partners of HIV negative or unknown serostatus, alcohol or marijuana use, and hard drug use among the intervention group than among the control group.
Conclusions
Intensive, skill-focused intervention programs may improve the lives of marginally housed adults living with HIV infection.
doi:10.2105/AJPH.2007.121186
PMCID: PMC2679793  PMID: 18799777
12.  Comparisons of HIV-Affected and Non-HIV-Affected Families Over Time 
This study compares HIV-affected families and their non-HIV-affected neighbors’ behavioral health outcomes and family conflict. To compare two groups from the same neighborhoods at four points over 18 months, mothers with HIV (MLH) (N=167) and their school-age children (age 6 to 20) were recruited from clinical care settings in Los Angeles, CA and neighborhood control mothers (NCM) without HIV (N=204) were recruited from modal neighborhoods. In addition, children living at home who were 12 years and older were recruited. We assessed parenting behaviors, family conflict, mental health, sexual behavior, substance use, and HIV-related health behaviors over time. MLH perceived greater economic insecurity at baseline, less employment, and involvement in romantic relationships. MLH reported more emotional distress and substance use than NCM. MLH, however, reported lowered HIV transmission risk. The random regressions indicated that MLH exhibited higher levels and became significantly less depressed and less anxious over time than their non-HIV-affected neighbors. MLH also reported less initial family violence and conflict reasoning than NCM; violence decreased and conflict increased over time for MLH relative to NCM. Children of MLH decreased their marijuana use but hard drug users of MLH increased their risk, over time, compared to children of NCM. Moreover, children of MLH reported more internalizing behaviors than children of NCM. Even when compared to other families living in the same economically disadvantaged communities, MLH and their children continue to face challenges surrounding family conflict, and key behavioral health outcomes, especially with respect to substance use and mental health outcomes. These families, however, show much resilience and MLH report lowered levels of HIV transmission risk, their children report no greater levels of HIV transmission risk and levels of family violence were lower than reported by families in the same neighborhoods.
doi:10.1080/17450128.2012.713532
PMCID: PMC3650635  PMID: 23671458
HIV+ Mothers; Family interventions; Parenting behaviors; Sexual behavior; substance abuse
13.  Intervention Outcomes among HIV-affected Families Over 18 Months 
AIDS and Behavior  2012;16(5):1265-1275.
We evaluate the efficacy of a family-based intervention over time among HIV-affected families. Mothers Living with HIV (MLH; n=339) in Los Angeles and their school-aged children were randomized to either an intervention or control condition and followed for 18 months. MLH and their children in the intervention received 16 cognitive-behavioral, small-group sessions designed to help them maintain physical and mental health, parent while ill, address HIV-related stressors, and reduce HIV-transmission behaviors. At recruitment, MLH reported few problem behaviors related to physical health, mental health, or sexual or drug transmission acts. Compared to MLH in the control condition, intervention MLH were significantly more likely to monitor their own CD4 cell counts and their children were more likely to decrease alcohol and drug use. Most MLH and their children had relatively healthy family relationships. Family-based HIV interventions should be limited to MLH who are experiencing substantial problems.
doi:10.1007/s10461-011-0075-z
PMCID: PMC3338883  PMID: 22020758
HIV+ Mothers; Family interventions; Parenting behaviors; Sexual behavior; substance abuse
14.  Reducing STD/HIV stigmatizing attitudes through community popular opinion leaders in Chinese markets 
Human communication research  2012;38(4):379-405.
Reducing STDs and HIV/AIDS incidence requires campaigns designed to change knowledge, attitudes and practices of risky sexual behavior and its consequences. In China, a significant obstacle to such changes is the stigma associated with these diseases. Thus one campaign intervention strategy is to train credible community popular opinion leaders to discuss these issues in everyday social venues. This study tested the effectiveness of such an approach on reducing HIV/AIDS stigma, across two years, from a sample of over 4500 market vendors, in three conditions. Results showed an increasing growth in market communication about intervention messages, and concomitant declines in stigmatizing attitudes, across time, with the greatest changes in community popular opinion leaders, significant changes in intervention non-opinion leaders, and little change in the control markets.
doi:10.1111/j.1468-2958.2012.01436.x
PMCID: PMC4059367  PMID: 24944433
STD; HIV; communication campaign; public opinion leader; stigma; China; repeated measures
15.  Collecting Maternal Health Information From HIV-Positive Pregnant Women Using Mobile Phone-Assisted Face-to-Face Interviews in Southern Africa 
Background
Most of the world’s women living with human immunodeficiency virus (HIV) reside in sub-Saharan Africa. Although efforts to reduce mother-to-child transmission are underway, obtaining complete and accurate data from rural clinical sites to track progress presents a major challenge.
Objective
To describe the acceptability and feasibility of mobile phones as a tool for clinic-based face-to-face data collection with pregnant women living with HIV in South Africa.
Methods
As part of a larger clinic-based trial, 16 interviewers were trained to conduct mobile phone–assisted personal interviews (MPAPI). These interviewers (participant group 1) completed the same short questionnaire based on items from the Technology Acceptance Model at 3 different time points. Questions were asked before training, after training, and 3 months after deployment to clinic facilities. In addition, before the start of the primary intervention trial in which this substudy was undertaken, 12 mothers living with HIV (MLH) took part in a focus group discussion exploring the acceptability of MPAPI (participant group 2). Finally, a sample of MLH (n=512) enrolled in the primary trial were asked to assess their experience of being interviewed by MPAPI (participant group 3).
Results
Acceptability of the method was found to be high among the 16 interviewers in group 1. Perceived usefulness was reported to be slightly higher than perceived ease of use across the 3 time points. After 3 months of field use, interviewer perceptions of both perceived ease of use and perceived usefulness were found to be higher than before training. The feasibility of conducting MPAPI interviews in this setting was found to be high. Network coverage was available in all clinics and hardware, software, cost, and secure transmission to the data center presented no significant challenges over the 21-month period. For the 12 MHL participants in group 2, anxiety about the multimedia capabilities of the phone was evident. Their concern centered on the possibility that their privacy may be invaded by interviewers using the mobile phone camera to photograph them. For participants in group 3, having the interviewer sit beside vs across from the interviewee during the MPAPI interview was received positively by 94.7% of MHL. Privacy (6.3%) and confidentiality (5.3%) concerns were low for group 3 MHL.
Conclusions
Mobile phones were found both to be acceptable and feasible in the collection of maternal and child health data from women living with HIV in South Africa.
Trial Registration
Clinicaltrials.gov NCT00972699; http://clinicaltrials.gov/ct2/show/NCT00972699 (Archived by WebCite at http://clinicaltrials.gov/ct2/show/NCT00972699)
doi:10.2196/jmir.2207
PMCID: PMC3713928  PMID: 23748182
mobile phones; human immunodeficiency virus; mobile health
16.  Common Processes in Evidence-Based Adolescent HIV Prevention Programs 
AIDS and behavior  2008;12(3):374-383.
Dissemination of evidence-based HIV prevention programs for adolescents will be increased if community interventionists are able to distinguish core, essential program elements from optional, discretionary ones. We selected five successful adolescent HIV prevention programs, used a qualitative coding method to identify common processes described in the procedural manuals, and then compared the programs. Nineteen common processes were categorized as structural features, group management strategies, competence building, and addressing developmental challenges of adolescence. All programs shared the same structural features (goal-setting and session agendas), used an active engagement style of group management, and built cognitive competence. Programs varied in attention to developmental challenges, emphasis on behavioral and emotional competence, and group management methods. This qualitative analysis demonstrated that successful HIV programs contain processes not articulated in their developers’ theoretical models. By moving from the concrete specifics of branded interventions to identification of core, common processes, we are consistent with the progress of “common factors” research in psychotherapy.
doi:10.1007/s10461-008-9369-1
PMCID: PMC4028968  PMID: 18330687
Evidence-based adolescent HIV prevention interventions; Common processes; Core elements; HIV; Structural and procedural practices; Qualitative analysis
17.  Comparisons of Prevention Programs for Homeless Youth 
There are six HIV prevention programs for homeless youth whose efficacy has been or is currently being evaluated: STRIVE, the Community Reinforcement Approach, Strengths-Based Case Management, Ecologically-Based Family Therapy, Street Smart, and AESOP (street outreach access to resources). Programs vary in their underlying framework and theoretical models for understanding homelessness. All programs presume that the youths’ families lack the ability to support their adolescent child. Some programs deemphasize family involvement while others focus on rebuilding connections among family members. The programs either normalize current family conflicts or, alternatively, provide education about the importance of parental monitoring. All programs aim to reduce HIV-related sexual and drug use acts. A coping skills approach is common across programs: Problem-solving skills are specifically addressed in four of the six programs; alternatively, parents in other programs are encouraged to contingently reward their children. Each program also engineers ongoing social support for the families and the youth, either by providing access to needed resources or by substituting a new, supportive relationship for the existing family caretaker. All of the interventions provide access to health and mental health services as basic program resources. A comparison of HIV prevention programs for homeless youth identifies the robust components of each and suggests which programs providers may choose to replicate.
doi:10.1007/s11121-008-0119-4
PMCID: PMC4028969  PMID: 19067164
HIV prevention programs; Homeless youth; Comparison; Components
18.  Alcohol consumption among HIV-positive pregnant women in KwaZulu-Natal, South Africa: prevalence and correlates 
Drug and alcohol dependence  2011;120(1-3):113-118.
Background
HIV-positive pregnant women who drink put their children at risk of both HIV and fetal alcohol spectrum disorders. The province of KwaZulu-Natal (KZN) has the highest prevalence of HIV in South Africa, but has not before been considered an area of high alcohol consumption among women. This paper analyzes a large sample of HIV+ pregnant women in KZN to examine alcohol consumption in that population.
Methods
Data came from assessments of women enrolled in Prevention of Mother-To-Child Transmission programs at 8 clinics in KZN. Descriptive statistics and logistic regressions were used to examine the prevalence and correlates of alcohol consumption and binge drinking.
Results
Of 1201 women assessed, 18% reported drinking during pregnancy, and 67% of drinkers usually binged when drinking (had 3+ drinks in one sitting). Over one-third of drinkers binged twice a month or more. Women living in urban and peri-urban locations were more likely to drink, as were those with indicators of higher economic status and greater social engagement. Married women were less likely to drink, while women who had poorer mental health, used tobacco, or had a greater history of sexual risk-taking were more likely to drink.
Conclusion
Health care workers in KZN should be aware that pregnant women who drink are likely to do so at a level that is dangerous for their babies. Some factors associated with drinking indicate social/environmental influences that need to be counteracted by greater dissemination of information about the dangers of drinking, and greater support for abstinence or moderation.
doi:10.1016/j.drugalcdep.2011.07.004
PMCID: PMC3223298  PMID: 21820252
Alcohol; HIV; pregnancy; South Africa
19.  Predicting depression in mothers with and without HIV: The role of social support and family dynamics 
AIDS and behavior  2012;16(8):2198-2208.
Many women with HIV are primary caregivers for their children. Social factors, including family dynamics, play a major role in women’s depression. We hypothesized an impact of HIV seropositivity on greater depression mediated through poorer family functioning and social support. Participants include 332 Mothers Living with HIV (MLH) and 200 Neighborhood Control Mothers (NCM) recruited in Los Angeles County. The NCM were matched by neighborhood. All had children ages 6 through 20. Analyses using structural equation modeling (SEM) indicated HIV seropositivity was positively correlated with depression and negatively correlated with positive social support and effective family functioning. In a predictive path model, the relationship between having HIV and depressed mood was mediated by social support and family functioning. Findings offer explanation for increased depression resulting from HIV and social and family dynamics, and suggest innovative interventions to abate psychosocial health problems and lower risk for depression among women with HIV.
doi:10.1007/s10461-012-0149-6
PMCID: PMC3990227  PMID: 22311149
Depression; family dynamics; social support; HIV+ mothers
20.  Identifying preferences for mobile health applications for self-monitoring and self-management: Focus group findings from HIV-positive persons and young mothers 
Objective
Self-management of risk behaviors is a cornerstone of future population health interventions. Using mobile phones for routine self-monitoring and feedback is a cost-efficient strategy for self-management and ecological momentary interventions (EMI). However, mobile health applications need to be designed to be highly attractive and acceptable to a broad range of user groups. To inform the design of an adaptable mobile health application we aimed to identify the dimensions and range of user preferences for application features by different user groups.
Methods
Five focus group interviews were conducted: two (n = 9; n = 20) with people living with HIV (PLH) and three with young mothers (n = 6; n = 8; n = 10). Thematic analyses were conducted on the focus group sessions’ notes and transcripts.
Results
Both groups considered customization of reminders and prompts as necessary, and goal setting, motivational messaging, problem solving, and feedback as attractive. For PLH, automated and location-based reminders for medication adherence and sharing data with healthcare providers were both acceptable and attractive features. Privacy protection and invasiveness were the primary concerns, particularly around location tracking, illegal drug use, and sexual partner information. Concerns were ameliorated by use scenario or purpose, monetary incentives, and password protection. Privacy was not a major concern to mothers who considered passwords burdensome. Mothers’ preferences focused on customization that supports mood, exercise and eating patterns, and especially using the mobile phone camera to photograph food to increase self-accountability.
Conclusions
Individualization emerged as the key feature and design principle to reduce user burden and increase attractiveness and acceptability. Mobile phone EMI uniquely enables individualization, context-aware and real-time feedback, and tailored intervention delivery.
doi:10.1016/j.ijmedinf.2012.05.009
PMCID: PMC3473096  PMID: 22704234
Ecological momentary intervention; Mobile health; Behavioral self-monitoring; Self-management; HIV; Young mothers
21.  Improving Health and Mental Health for People Living with HIV/AIDS: 12-month Assessment of a Behavioral Intervention in Thailand 
American journal of public health  2010;100(12):2418-2425.
Objectives
. People living with HIV (PLH) in Thailand face multiple stressors. We examined findings from a randomized controlled intervention trial designed to improve the quality of life of PLH in Thailand.
Methods
. A total of 507 PLH were recruited from four district hospitals in northern and northeastern Thailand and were randomized to an intervention group (n = 260) or a standard care group (n = 247). Computer-assisted personal interviews were administered at baseline, 6, and 12 months.
Results
At baseline, the characteristics of PLH in the intervention and the standard care condition were comparable. The mixed effects models used to assess the effect of the intervention revealed that PLH in the intervention condition reported significant improvement in their general health (β = 2.51, P = .001) and mental health (β = 1.57, P = .02) over 12 months, compared to those in the standard care condition.
Conclusions
We demonstrated successful efficacy of an intervention designed to improve the quality of life of PLH in Thailand. Interventions must be performed in a systematic, collaborative manner to ensure their cultural relevance, sustainability, and overall success.
doi:10.2105/AJPH.2009.185462
PMCID: PMC2978166  PMID: 20966372
22.  Philani Plus (+): A Mentor Mother Community Health Worker Home Visiting Program to Improve Maternal and Infants’ Outcomes 
Pregnant mothers in South African townships face multiple health risks for themselves and their babies. Existing clinic-based services face barriers to access, utilization, and human resource capacities. Home visiting by community health workers (CHW) can mitigate such barriers. The Philani Plus (+) Intervention Program builds upon the original Philani CHW home-visiting intervention program for maternal and child nutrition by integrating content and activities to address HIV, alcohol, and mental health. Pregnant Mothers at Risk (MAR) for HIV, alcohol, and/or nutrition problems in 24 neighborhoods in townships in Cape Town, South Africa (n=1,239) were randomly assigned by neighborhood to an intervention (Philani Plus (+), N=12 neighborhoods; n=645 MAR) or a standard-care control condition of neighborhood clinic-based services (N=12 neighborhoods; n=594 MAR). Positive peer deviant “Mentor Mother” CHWs are recruited from the township neighborhoods and trained to deliver four antenatal and four postnatal home visits that address HIV, alcohol, nutrition, depression, health care regimens for the family, caretaking and bonding, and securing government-provided child grants. The MAR and their babies are being monitored during pregnancy, 1 week post-birth, and 6 and 18 months later. Among the 1,239 MAR recruited: 26% were HIV-positive; 27% used alcohol during pregnancy; 17% previously had low-birthweight babies; 23% had at least one chronic condition (10% hypertension, 5% asthma, 2% diabetes); 93% had recent sexual partners with 10% known to be HIV+; and 17% had clinically significant prenatal depression and 42% had borderline depression. This paper presents the intervention protocol and baseline sample characteristics for the “Philani Plus (+)” CHW home-visiting intervention trial.
doi:10.1007/s11121-011-0238-1
PMCID: PMC3907085  PMID: 21850488
HIV; Maternal & child health; Alcohol; Nutrition; Home visiting; South Africa; Community health workers (CHW); Paraprofessionals
23.  A US Policy Perspective on Oral Preexposure Prophylaxis for HIV 
American journal of public health  2011;101(6):982-985.
Orally administered pre-exposure prophylaxis is an innovative and controversial HIV prevention strategy involving the regular use of antiretroviral medications by uninfected individuals.
Antiretroviral medications protect against potential HIV infection by reducing susceptibility to the virus.
Recent clinical trial results indicate that preexposure prophylaxis can be safe and efficacious for men who have sexual intercourse with men, yet there remain policy considerations surrounding costs, opportunity costs, and ethical issues that must be addressed before broad implementation in the United States. Resources for HIV prevention are limited, thus cost-effectiveness analyses of PrEP implementation in non-experimental situations are needed to allocate prevention funding most productively. Findings from the randomized clinical trials that PrEP is efficacious should mark the beginning of the policy discussion, not its end.
doi:10.2105/AJPH.2010.300066
PMCID: PMC3093264  PMID: 21493945
24.  A Cluster Randomized Controlled Trial Evaluating the Efficacy of Peer Mentors to Support South African Women Living with HIV and Their Infants 
PLoS ONE  2014;9(1):e84867.
Objective
We evaluate the effect of clinic-based support by HIV-positive Peer Mentors, in addition to standard clinic care, on maternal and infant well-being among Women Living with HIV (WLH) from pregnancy through the infant's first year of life.
Methods
In a cluster randomized controlled trial in KwaZulu-Natal, South Africa, eight clinics were randomized for pregnant WLH to receive either: a Standard Care condition (SC; 4 clinics; n = 656 WLH); or an Enhanced Intervention (EI; 4 clinics; n = 544 WLH). WLH in the EI were invited to attend four antenatal and four postnatal meetings led by HIV-positive Peer Mentors, in addition to SC. WLH were recruited during pregnancy, and at least two post-birth assessment interviews were completed by 57% of WLH at 1.5, 6 or 12 months. EI's effect was ascertained on 19 measures of maternal and infant well-being using random effects regressions to control for clinic clustering. A binomial test for correlated outcomes evaluated EI's overall efficacy.
Findings
WLH attended an average of 4.1 sessions (SD = 2.0); 13% did not attend any sessions. Significant overall benefits were found in EI compared to SC using the binomial test. Secondarily, over time, WLH in the EI reported significantly fewer depressive symptoms and fewer underweight infants than WLH in the SC condition. EI WLH were significantly more likely to use one feeding method for six months and exclusively breastfeed their infants for at least 6 months.
Conclusions
WLH benefit by support from HIV-positive Peer Mentors, even though EI participation was partial, with incomplete follow-up rates from 6–12 months.
Trial Registration
ClinicalTrials.gov NCT00972699
doi:10.1371/journal.pone.0084867
PMCID: PMC3898948  PMID: 24465444
25.  Spontaneous remission of sexually transmitted diseases must be considered in randomised controlled trials 
doi:10.1136/sextrans-2011-050009
PMCID: PMC3252597  PMID: 21459899
Sexually transmitted diseases; spontaneous remission; randomised controlled trials; HIV women; Africa; antenatal HIV; behavioural science; HIV; China; public health; social science; psychology; epidemiology; mathematical model; law ethics; notification; chlamydia; sexual health; behavioural interventions

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