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1.  Disparities in access to HIV prevention among men of Mexican descent living in the Midwestern United States 
Men of Mexican descent (MMD) in the U.S. are disproportionately affected by HIV. Understanding MMD’s access to HIV prevention is necessary to reduce their transmission rates. We explored disparities in access to HIV prevention among MMD of different assimilation status, healthcare access, and sexual risk behavior.
322 Midwestern MMD completed a survey assessing their access to passive interventions (e.g., lectures), interactive interventions (e.g., counseling), HIV testing, media information, and information from the Internet.
64% MMD had received passive interventions, 36% interactive interventions, 42% HIV testing, 41% information from media, and 12% from the Internet. MMD who were less assimilated to the U.S., had lower healthcare access, and were at risk for HIV, were less likely to have accessed prevention interventions but more likely to have received media information.
Access to HIV prevention among Midwestern MMD is tied to their assimilation and healthcare access. Findings have implications for developing strategies of intervention delivery.
PMCID: PMC4078897  PMID: 20686851
2.  Perceived Need for a Parental Decision Aid for the HPV Vaccine: Content and Format Preferences 
Health promotion practice  2011;13(2):214-221.
The human papillomavirus (HPV) is a precursor of cervical cancer. In 2006, the Federal Drug Administration licensed a vaccine to protect against four types of HPV. Three years postlicensure of the vaccine, HPV vaccination is still fraught with controversy. To date, research suggests that contrary to popular notions, parents are less concerned with controversies on moral issues and more with uncertainty regarding because long-term safety of a drug is resolved after licensure. This study was designed to understand whether mothers from diverse ethnicities perceive a need for a decision support tool. Results suggest that the design of a culturally tailored decision support tool may help guide parents through the decision-making process.
PMCID: PMC4073688  PMID: 21444922
HPV vaccine; decision aid preferences; ethnicity
3.  Methods and protocol of a mixed method quasi-experiment to evaluate the effects of a structural economic and food security intervention on HIV vulnerability in rural Malawi: The SAGE4Health Study 
SpringerPlus  2014;3:296.
Poverty and lack of a predictable, stable source of food are two fundamental determinants of ill health, including HIV/AIDS. Conversely, episodes of poor health and death from HIV can disrupt the ability to maintain economic stability in affected households, especially those that rely on subsistence farming. However, little empirical research has examined if, and how, improvements in people’s economic status and food security translate into changes in HIV vulnerability.
In this paper, we describe in detail the methods and protocol of an academic-NGO collaboration on a quasi-experimental, longitudinal study of the mechanisms and magnitude of the impact of a multilevel economic and food security program (Support to Able-Bodied Vulnerable Groups to Achieve Food Security; SAFE), as implemented by CARE. Primary outcomes include HIV vulnerability (i.e., HIV risk behaviors, HIV infection), economic status (i.e., income, household assets) and food security (including anthropometric measures). We recruited participants from two types of areas of rural central Malawi: traditional authorities (TA) selected by CARE to receive the SAFE program (intervention group) and TAs receiving other unrelated CARE programming (controls). In the intervention TAs, we recruited 598 program participants (398 women, 200 men) and interviewed them at baseline and 18- and 36-month follow-ups; we interviewed 301 control households. In addition, we conducted random surveys (n = 1002) in the intervention and control areas with a 36-month assessment interval, prior to and after implementation of SAFE. Thus, we are examining intervention outcomes both in direct SAFE program participants and their larger communities. We are using multilevel modeling to examine mediators and moderators of the effects of SAFE on HIV outcomes at the individual and community levels and determine the ways in which changes in HIV outcomes feed back into economic outcomes and food security at later interviews. Finally, we are conducting a qualitative end-of-program evaluation consisting of in-depth interviews with 90 SAFE participants.
In addition to examining pathways linking structural factors to HIV vulnerability, this research will yield important information for understanding the impact of a multilevel environmental/structural intervention on HIV, with the potential for other sustainable long-term public health benefits.
PMCID: PMC4082534  PMID: 25019044
Food security; Microfinance; Village savings and loans; HIV; Quasi-experimental design; Malawi
4.  Psychiatric Risk Factors for HIV Disease Progression: The Role of Inconsistent Patterns of Anti-Retroviral Therapy Utilization 
In the era of anti-retroviral therapy (ART), depression and substance use predict hastened HIV disease progression but the underlying biological or behavioral mechanisms that explain these effects are not fully understood.
Using outcome data from 603 participants enrolled in a randomized controlled trial of a behavioral intervention, binary logistic and linear regression were employed to examine whether inconsistent patterns of ART utilization partially mediated the effects of depression and substance use on higher HIV viral load over a 25-month follow-up.
Elevated affective symptoms of depression independently predicted ART discontinuation (Adjusted OR [AOR] = 1.39, 95% CI = 1.08 – 1.78), and use of stimulants at least weekly independently predicted intermittent ART utilization (AOR = 2.62, 95% CI = 1.45 – 4.73). After controlling for the average self-reported percentage of ART doses taken and baseline T-helper (CD4+) count, elevated depressive symptoms predicted a 50% higher mean viral load, and weekly stimulant use predicted a 137% higher mean viral load. These effects became non-significant after accounting for inconsistent patterns of ART utilization, providing evidence of partial mediation.
Inconsistent patterns of ART utilization may partially explain the effects of depression and stimulant use on hastened HIV disease progression.
PMCID: PMC3494991  PMID: 21116186
Access; Adherence; Antiretroviral; Cocaine; Depression; Disease Progression; Highly Active; HIV/AIDS; HIV Viral Load; Methamphetamine; Substance Use; Utilization
5.  The Cross-Cultural Variation of Predictors of Human Papillomavirus Vaccination Intentions 
Journal of Women's Health  2011;20(2):225-230.
The influence of health beliefs on human papillomavirus (HPV) vaccine acceptability have been extensively documented in past research. However, studies documenting the generalizability of prior findings to culturally diverse participants are lacking. The importance of generalizability studies is underscored by the immense disparities in cervical cancer rates across ethnicities. Moreover, theory in cultural psychology suggests that beliefs derived from personal expectations may not be the strongest predictors of intentions in individuals socialized in collectivist cultures. The purpose of this research was to investigate the strongest predictors of mothers' intentions to vaccinate their daughters across three cultural groups: Hispanic, non-Hispanic white, and African American.
One hundred fifty mothers were recruited from Public Health Department clinics in Milwaukee, Wisconsin. Mothers were asked to answer measures that assessed personal and normative predictors of intentions.
Results indicated that predictors of vaccination intentions varied cross-culturally. Specifically, culture moderated the influence of norms on intentions.
Interventions designed for Hispanics may be more effective if norms, rather than attitudes, are targeted.
PMCID: PMC3064873  PMID: 21314448
6.  HIV misconceptions associated with condom use among black South Africans: an exploratory study 
In South Africa, approximately 20% of 15–49-year-olds are infected with HIV. Among black South Africans, high levels of HIV/AIDS misconceptions (e.g. HIV is manufactured by whites to reduce the black African population; AIDS is caused by supernatural forces or witchcraft) may be barriers to HIV prevention. We conducted a cross-sectional study of 150 young, black adults (aged 18–26; 56% males) visiting a public clinic for sexually transmitted infections, to investigate whether HIV/AIDS misconceptions were related to low condom use in main partner relationships. We assessed agreement with HIV/AIDS misconceptions relating to the supernatural (e.g. witchcraft as a cause of HIV) and to genocide (e.g. the withholding of a cure). In multivariate models, agreement that ‘Witchcraft plays a role in HIV transmission’ was significantly related to less positive attitudes about condoms, less belief in condom effectiveness for HIV prevention, and lower intentions to use condoms among men. The belief that ‘Vitamins and fresh fruits and vegetables can cure AIDS’ was associated with lower intentions among men to use condoms. Women who endorsed the belief linking HIV to witchcraft had a higher likelihood of unprotected sex with a main partner, whereas women who endorsed the belief that a cure for AIDS was being withheld had a lower likelihood of having had unprotected sex. Knowledge about distinct types of HIV/AIDS misconceptions and their correlates can help in the design of culturally appropriate HIV-prevention messages that address such beliefs.
PMCID: PMC3144581  PMID: 21804784
health beliefs; HIV/AIDS knowledge; sexual behaviour; social psychology
7.  Relationships over Time between Mental Health Symptoms and Transmission Risk Among Persons Living with HIV 
Relationships between mental health symptoms (anxiety and depression) or a positive state of mind and behavior associated with HIV transmission (substance use and risky sexual behavior) were explored in a longitudinal study on persons living with HIV (PLH; n = 936) who were participants in a transmission-prevention trial. Bivariate longitudinal regressions were used to estimate the correlations between mental health symptoms and HIV-related transmission acts for three time frames: at the baseline interview; over 25 months; and from assessment to assessment. At baseline, mental health symptoms were associated with transmission acts. Elevated levels of mental health symptoms at baseline were associated with decreasing alcohol or marijuana use over 25 months. Over 25 months, an increasingly positive state of mind was associated with decreasing alcohol or marijuana use; an increasingly positive state of mind in the immediate condition and increasing depressive symptoms in the lagged condition were related to increasing risky sexual behavior. Our findings suggest that mental health symptoms precede a decrease in substance use and challenge self-medication theories. Changes in mental health symptoms and sexual behavior occur more in tandem.
PMCID: PMC2845324  PMID: 20307117
HIV; Mental Health; Depression; Anxiety; Substance Abuse; Sexual behavior
8.  Disparities in Reported Reasons for Not Initiating or Stopping Antiretroviral Treatment Among a Diverse Sample of Persons Living with HIV 
Disparities in the use of antiretroviral therapy (ART) for HIV disease have been documented across race, gender, and substance use groups.
The current analysis compares self-reported reasons for never taking or stopping ART among a diverse sample of men and women living with HIV.
Cross-sectional interview.
HIV + (N = 3,818) adults, 968 of whom reported discontinuing or never using ART.
Computerized self-administered and interviewer-administered self-reported demographic and treatment variables, including gender, race, ethnicity, CD4 count, detectable viral load, and reported reasons for not taking antiretroviral therapy.
Despite equivalent use of ART in the current sample, African-American respondents were 1.7 times more likely to report wanting to hide their HIV status and 1.7 times more likely to report a change in doctors/clinics as reasons for stopping ART (p = .049, and p = .042) and had odds 4.5 times those of non-African Americans of reporting waiting for viral marker counts to worsen (p = < .0001). There was a lower tendency (OR = 0.4) for women to endorse concerns of keeping their HIV status hidden as a reason for stopping ART compared to men (p = .003). Although those with an IDU history were less likely to be on ART, no differences in reasons for stopping or never initiating ART were found between those with and without an IDU history.
A desire to conceal HIV status as well as a change in doctors/clinics as reasons for discontinuing ART were considerably more common among African Americans, suggesting that perceived HIV/AIDS stigma is an obstacle to maintenance of treatment. Findings also indicate differences in reasons for stopping ART by gender and a perceived desire to wait for counts to worsen as a reason for not taking ART by African Americans, regardless of detectable viral load, CD4 count, age, education, employment, sexual orientation, and site.
PMCID: PMC2628985  PMID: 19015925
HIV/AIDS; treatment disparities; gender; race; ethnicity; substance use
9.  Effects of behavioral intervention on substance use among people living with HIV: the Healthy Living Project randomized controlled study 
Addiction (Abingdon, England)  2008;103(7):1206-1214.
Reductions in substance use were examined in response to an intensive intervention with people living with human immunodeficiency virus (HIV) (PLH).
Design, setting and participants
A randomized controlled trial was conducted with 936 PLH who had recently engaged in unprotected sexual risk acts recruited from four US cities: Milwaukee, San Francisco, New York and Los Angeles. Substance use was assessed as the number of days of use of 19 substances recently (over the last 90 days), evaluated at 5-month intervals over 25 months.
A 15-session case management intervention was delivered to PLH in the intervention condition; the control condition received usual care.
An intention-to-treat analysis was conducted examining reductions on multiple indices of recent substance use calculated as the number of days of use.
Reductions in recent substance use were significantly greater for intervention PLH compared to control PLH: alcohol and/or marijuana use, any substance use, hard drug use and a weighted index adjusting for seriousness of the drug. While the intervention-related reductions in substance use were larger among women than men, men also reduced their use. Compared to controls, gay and heterosexual men in the intervention reduced significantly their use of alcohol and marijuana, any substance, stimulants and the drug severity-weighted frequency of use index. Gay men also reduced their hard drug use significantly in the intervention compared to the control condition.
A case management intervention model, delivered individually, is likely to result in significant and sustained reductions in substance use among PLH.
PMCID: PMC2665995  PMID: 18494840
HIV; intervention studies; randomized controlled trial; substance abuse; unprotected sex
10.  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.
PMCID: PMC2653049  PMID: 19064372
coping; depression; HIV; sexual identity; symptoms; social support
11.  Predictors of Attrition among High Risk HIV-Infected Participants Enrolled in a Multi-Site Prevention Trial 
AIDS and behavior  2008;12(6):974-977.
Recruiting and retaining high-risk individuals is critical for HIV prevention trials.
The current analyses addressed predictors of trial dropout among high-risk HIV-infected men and women.
Trial dropouts (n=74) were more likely to be younger, depressed, and not taking antiretroviral therapy than those who continued (n=815). No other background, substance use, or transmission risk differences were found, suggesting no dropout bias on key risk outcomes.
Efforts are warranted for early detection and treatment of depression and for improving retention of younger participants.
PMCID: PMC2574761  PMID: 18202908
Clinical Trials; Prevention; Retention; Depression
12.  HIV Risk Reduction for the Seriously Mentally Ill: Pilot Investigation and Call for Research 
Research indicates that people with serious mental illnesses (SMI; e.g., schizophrenia, schizoaffective disorder, bipolar disorder) are at enhanced risk for infection with the human immunodeficiency virus (HIV). To decrease this risk, we piloted a six-session HIV-risk reduction intervention for two single-gender groups (9 women, 8 men; M age = 39.8 years) of SMI outpatients. The intervention and assessment were based on the Information-Motivation-Behavioral Skills model of HIV-preventive behavior (Fisher & Fisher, 1992) and employed activities designed specifically for people with a SMI. Data were collected at pre-and post-intervention, and at a one-month follow-up. Results indicated that this brief intervention resulted in enhanced HIV-related knowledge, and trends toward enhanced skill at condom use negotiation and condom use self-efficacy. Overall, a modest decrease in risk behavior among participants was observed. Thus, this pilot investigation revealed that HIV-related risk of the SMI can be reduced through traditional behavioral skills and education methods. Future research employing control groups, more intensive interventions, and baseline screening for high risk is encouraged.
PMCID: PMC2561916  PMID: 9194005
13.  Understanding HIV-Related Risk Among Persons with a Severe and Persistent Mental Illness: Insights from Qualitative Inquiry 
We conducted focus groups with 36 men and women who were receiving treatment for a severe and persistent mental illness (SPMI) to learn more about the social context of their intimate relationships and the psychological antecedents of their sexual decision-making. Qualitative analysis of focus group transcripts indicated that (a) sexual activity tended to be unplanned and occurred in social networks where HIV risk may be elevated, (b) HIV-related knowledge was superficial and insufficient to guide safer sexual behavior, (c) participants’ HIV risk perception was often based upon factors unrelated to their sexual behaviors, and (d) communication skills for HIV risk reduction were poor. We discuss how qualitative methods yielded insights not readily available through quantitative approaches, and offer recommendations for HIV risk assessment and prevention among persons with a SPMI.
PMCID: PMC2547347  PMID: 10221553
HIV; severe and persistent mental illness (SPMI); focus groups
14.  Reliability and Validity of Self-Report Measures of HIV-Related Sexual Behavior 
Archives of sexual behavior  1998;27(2):155-180.
The trustworthiness of self-reported sexual behavior data has been questioned since Kinsey’s pioneering surveys of sexuality in the United States (Kinsey et al. 1948, 1953). In the era of HIV and AIDS, researchers and practitioners have employed a diversity of assessment techniques but they have not escaped the fundamental problem of measurement error. In this article, we review the empirical literature produced since Catania et al.’s (1990) review regarding reliability and validity of self-administered and automated questionnaires, face-to-face interviews, telephone interviews, and self-monitoring approaches. We also provide specific recommendations for improving sexual behavior assessment. It is imperative that standardized self-report instruments be developed and used for sexual risk-behavior assessment.
PMCID: PMC2452986  PMID: 9562899
sexual behavior; HIV-risk behavior; self-report assessment; reliability; validity
15.  Reliability of the Timeline Followback Sexual Behavior Interview 
The reliability of self-reported sexual behavior is a question of utmost importance to HIV-prevention research. The Timeline Followback (TLFB) interview, which was developed to assess alcohol consumption on the event level, incorporates recall-enhancing techniques that result in reliable information. In this study, the TLFB interview was adapted to assess HIV-related sexual behaviors and their antecedents, and its reliability was assessed. The interview was administered to 110 participants (46% women, M age = 19.7; range = 18 – 41), and 58 participants who reported sexual behavior during the previous three months returned one week later for a second interview. Test-retest intraclass correlations (□) from the TLFB protocol showed that all sexual behaviors were reported reliably (□ range = .86 to .97, median = .96). Bootstrapping, a non-parametric statistical technique, was used for significance testing in the reliability analyses. Reliability was equivalent across each of the three months assessed with the TLFB, and was equivalent to conventional assessment methods (i.e., single-item questions). These findings show that the TLFB sexual behavior interview provides reliable reports of sexual behavior over 3 months and yields event-level data that are extremely valuable for sexual behavior and HIV-prevention research.
PMCID: PMC2435070  PMID: 9755348
16.  Behavioral Risk for HIV Infection Among Adults with a Severe and Persistent Mental Illness: Patterns and Psychological Antecedents 
Community mental health journal  1997;33(2):133-142.
Behaviors associated with transmission of the human immunodeficiency virus (HIV) were measured in a sample of 60 adults with a severe and persistent mental illness (SPMI). Results revealed that 68% had sex in the last year; 13% of men and 30% of women reported two or more male partners, and 24% of men also reported two or more female partners. Condom use was inconsistent. Sex partners were often met in a psychiatric clinic or bar, and a substantial number were injection drug users or known to be non-monogamous. Overall, 48% of men and 37% of women reported at least one risk factor. Hypothesized psychological antecedents of HIV-related risk behavior were also measured, including knowledge, motivation for risk reduction, and self-efficacy regarding risk-reduction. Many participants were misinformed regarding HIV transmission and risk reduction. Motivational indices indicated that attitudes toward condoms were slightly positive, and that social norms were generally supportive of condom use. However, participants tended to rate themselves at only slight risk for infection, undermining their motivation for condom use. Participants indicated only modest levels of self-efficacy in situations requiring sexual assertiveness. These findings, coupled with the elevated seroprevalence of HIV among persons having a SPMI, point to the need for risk assessment and counseling by mental health care providers.
PMCID: PMC2430059  PMID: 9145255
17.  Does Alcohol Lead to Sexual Risk Behavior? Findings from Event-Level Research 
Annual review of sex research  2000;11:125-157.
The belief that alcohol use leads to sexual risk behavior is nearly ubiquitous. To determine if this belief is warranted, we identify theory and research regarding the alcohol, risky-sex link. We focus our review on studies that use the event-level methodology because this approach provides a particularly sensitive but stringent test of the alcohol, risky-sex connection. Overall, the data from available event-level studies indicate that people who use condoms when they are sober also tend to use them when drinking; people who fail to use condoms when drinking probably also fail to use them when sober. We recognize several empirical exceptions to this rule and provide suggestions for future research.
PMCID: PMC2426779  PMID: 11351830
18.  The Relation of Alcohol Use to HIV-Risk Sexual Behavior Among Adults with a Severe and Persistent Mental Illness 
The authors examined the relationship between alcohol use and HIV-risk sexual behavior and tested whether alcohol use immediately prior to sex is related to decreased condom use. The participants were 159 adults living with a severe and persistent mental illness. Each participated in a structured interview to assess all sexual and drug-use behavior over a 3-month period. Analysis of 3,026 sexual behaviors reported by 123 sexually active participants indicated that at the global level participants who drank more heavily were more likely to have engaged in sexual risk behavior. At the event level, however, alcohol use was not related to condom use during vaginal or anal intercourse; that is, participants who used condoms when sober tended to use them to the same extent when drinking.
PMCID: PMC2424204  PMID: 11302280
19.  Psychological Distress, Substance Use, and Adjustment among Parents Living with HIV 
Background: Being a parent, especially a custodial parent, living with HIV was anticipated to increase psychological distress and challenges to self-care.
Methods: Mental health symptoms, substance use, and health care utilization were assessed among 3,818 HIV-infected adults, including custodial parents, noncustodial parents, and nonparents, in four AIDS epicenters.
Results: Custodial parents demonstrated significantly poorer medication adherence and attendance at medical appointments, but were similar to nonparents and noncustodial parents in mental health symptoms and treatment utilization for mental health and substance use problems. Noncustodial parents demonstrated the highest levels of recent substance use and substance abuse treatment. Many of the apparent psychosocial disadvantages exhibited by parents were moderated by other markers of risk, such as African-American ethnicity, lack of current employment income, and injection drug use.
Conclusions: Interventions specific to the psychosocial stressors facing families living with HIV are needed.
PMCID: PMC1395483  PMID: 16148246

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