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Researchers adapt HIV prevention program from MSM to African American cohort
Study finds high victimization, poverty in cohort
One of the challenges facing HIV/AIDS clinics attempting to implement prevention programs for African Americans is that there are few evidence-based programs directed toward this population available and approved by the Centers for Disease Control and Prevention (CDC) of Atlanta, GA.
Investigators continue to work to fill in this gap by adapting and designing interventions that relate culturally to African American men and women.
One program that was originally designed for prevention among gay men and women involves having community peers provide HIV prevention information in standardized educational sessions. Investigators have adapted it to be used among African Americans who are HIV positive.
"We took this intervention for white men who have sex with men (MSM) and changed it to work in our community," says Nancy Glick, MD, an attending physician in infectious diseases at Mount Sinai Hospital Medical Center in Chicago, IL.
"The CDC has been looking for new interventions, and they have been somewhat more proactive in doing that," Glick says. "Since we're funded through HRSA, hopefully this intervention will be disseminated."
The result of the research work is the Treatment Advocacy Program, which involves having peers in the community meet individually with HIV-positive people, says Sheela Raja, PhD, a clinical psychologist with the Mount Sinai Hospital Medical Center.
Researchers invited experts and community leaders to assist them with adapting the prevention material, and they incorporated their suggestions into the intervention materials, Raja notes.
The intervention follows the IMB perspective, providing clients with information, followed by motivational interviewing, and behavioral change. After each module, the peer educators and participants completed a Behavioral Goals Worksheet.1
Preliminary data are revealing. Participants earned on average less than $10,000 per year and 60 percent had less than a high school degree.
Also, investigators found that the African American HIV-infected population had multiple stressors, including depression, domestic violence, and other types of victimization, Raja says.
"We administered a depression scale and 60 percent of our HIV population screened positive for depression, compared with the national co-morbidity study which indicates that 16 percent of the American population has depression," Raja says.
"We asked whether in their lifetimes they'd ever been a victim of assault or battery or ever had unwanted intercourse, and it is amazing the rates of victimization," she adds. "About half of the patients in our study had been a victim of something -- with men it was street violence; with women it was sexual assault."
When these issues were discovered, the participants were referred to appropriate services, and investigators trained the peer educators on how to deal with these problems when they arose, Raja notes.
"We have learned that you can never underestimate in an urban population all of the other issues that people might be facing, and it's really true that sometimes HIV is last on people's lists, which may include violence, stigma, and poverty," she says.
The study is ongoing, but so far the adaptation work and use of the program has shown that it will be a continuing challenge for HIV providers to combat myths about the epidemic within the African American community, Raja says.
"Using the community feedback led to interesting changes to the intervention," Raja says. "For example, we decided to increase the information we had about HIV risks, and we decided to include information about myths of HIV in our population."
One of the myths noted was that anal sex for women was a safer form of sex than vaginal sex, Raja says.
"We thought, 'Oh my goodness!'" Raja says.
Another myth discovered was equally striking: "Some peers reported that among African American women there is a myth out there that basically a man who has been incarcerated is a fabulous catch because he's been on the inside and is clean and is working out," Raja says. "They think the men can't have sex while they're in prison."
In some cases, focus group participants suggested specific wording for the intervention, Raja recalls.
"This was true especially for describing different types of sex," Raja says. "They said we should also include [the slang] in case people weren't aware of the technical terms."
Focus groups and other input also suggested that women were unaware of the female condom and how it might help reduce their HIV risk, Raja notes.
So as part of the intervention, women are shown the condom and educated about its use.
Peer educators piloted the intervention and suggested minor changes, as well, she says.
"So it was a pretty involved process, which we started in 2003, in actually tailoring the intervention and then rolling it out," Raja says. "We've collected outcomes data and have a couple more months to go on the project, but it has been promising."
The original intervention on which this adapted version is based demonstrated decreasing risk behaviors, she adds.
"What's nice about this intervention is that it uses peers, people from the community, and we're finding that people really respond well to it," Glick says. "People in the community are opening up in a way that they haven't previously, and that is a strong kind of intervention."
The intervention provides eight sessions with a focus on medication adherence, sexual safety, HIV education and communication, drug and alcohol use, and mood management.1
Another change investigators made to the intervention was to rewrite the mood management materials, Raja says.
"The mood management materials were very cognitive-based," Raja says. "So if you're in a negative situation, you can think about it positively."
The focus group said that they couldn't tell people how to think, she recalls.
"They said, "You'll get a negative reaction if you frame it like that,'" she says. "So they wanted us to give people a different way to cope, making it more behavioral than cognitive."
The result was the development of specific behavioral skills to help participants improve communication and manage negative moods, Raja says.