mental health AIDS

Winter 2005 Newsletter / Volume 6, Issue 2

HIV Prevention News

About Women & Men

Harvey et al. (2004) continued the relationship focus by randomizing 146 young Hispanic couples – primarily of Mexican descent – to one of two intervention conditions: a three-session culture-specific, couple-based risk reduction intervention or a single session focusing on pregnancy and STD prevention. After 3 months, both groups reported reductions in unprotected vaginal intercourse and increased use of condoms and other contraceptive methods. "If further research confirms that simply bringing couples together for a single-session, culturally appropriate risk reduction intervention helps them adopt protective behaviors," reason the authors, then "more intensive (and costly) interventions may not be necessary" (p. 162).

Noar, Morokoff, and Harlow (2004) explored condom influence strategies (CISs) employed by an ethnically diverse convenience sample of 113 heterosexually active men and women at risk for HIV. They found that these individuals "use a variety of influence strategies (withholding sex, direct request, seduction, relationship conceptualizing, risk information, deception, and pregnancy prevention) when attempting to procure condom use with a sexual partner" (p. 1743) and that use of these strategies is associated with use of condoms. Notably, study participants at highest risk for contracting HIV were also less likely to use both CISs and condoms, while those endorsing CISs were also more likely to feel confident that they were capable of persuading their partners to utilize condoms. Two important implications for intervention emerge from these findings:

First, individuals may not benefit from skills-focused interventions if they are not convinced that they need to engage in the behavior (e.g., condom use) in the first place. ... As individuals' readiness to use condoms consistently increases, so does their motivation to use CISs with their sexual partners. Thus, interventions must first aid these individuals in an awareness of their risk before teaching them skills they may not use.

Second, interventions need to not only teach behavioral skills (e.g., condom influence and negotiation), but must also increase self-efficacy to carry out those skills. If individuals possess skills but have no confidence (self-efficacy) that they can successfully use those skills, then it is unlikely that they will put those skills to work ... . Further, as relapsing to unsafe sex is frequent in high HIV risk populations ..., even those who have begun to use condoms consistently may need continued support and intervention. (pp. 1746-1747)

Albarracín, Kumkale, and Johnson (2004) conducted a meta-analysis of 129 data sets to examine condom use behavior. Their analysis included both published and unpublished data sets available by June 2000 and descriptive of 30,270 participants. They found that members of groups lacking in social power (e.g., younger individuals, women, ethnic minority individuals, those with lower educational levels) had greater intentions toward use and were more inclined to use condoms when they believed that they could use them if they wanted to (i.e., they perceived that they had behavioral control over their use of condoms) in comparisons with people with greater social power. They also found that social norms (i.e., perceiving that one's social network supports condom use) affected condom use more strongly among younger persons, as well as those with greater access to advice from their social network on this topic (e.g., men, ethnic majority individuals, and those with higher educational levels) in comparisons with older persons and those with less access to such advice.

What do these findings suggest about prevention interventions?

The meta-analysis ... suggests that different preventive programmes may be necessary depending on whether the target recipients are older or younger, male or female, an ethnic majority or minority, educated or illiterate. Perceived behavioural control and norms influence actual condom use more when power and normative support are scarce than when they are plentiful. ... [Therefore], if interventions can only change the level of actual attitudes, norms or perceived behavioural control, then the intervention messages should target the factor that is most influential in a given population ... . Alternatively, interventions may attempt to influence the weight of attitudes, norms or perceived behavioural control, or even make structural changes to increase social resources or strengthen informational support for a given social group. (p. 717)

In other words, this review suggests that interventions designed to increase perceptions of personal control (e.g., behavioral skills interventions) as well as empowerment approaches "are likely to be more effective for younger, female, ethnic minority and less-educated recipients than for older, male, ethnic majority and more educated individuals, because control perceptions have stronger effects in the former groups" (p. 717). At the same time, interventions that are "designed to promote more positive subjective norms concerning condom use may be more effective for younger, male, more educated and ethnic majority individuals among whom norms are more influential than attitudes" (p. 717).

What prevention messages address the concerns of transgenders? To find out, Nemoto, Operario, Keatley, and Villegas (2004) conducted focus groups with 48 African-American, Latina, and Asian and Pacific Islander male-to-female (MTF) transgenders at risk for HIV who were living and/or working in San Francisco.

Participants were likely to report having unprotected sex with primary partners to signify love and emotional connection, as well as to receive gender validation from their partners. In contrast, viewing sex work with customers as a business encouraged intentions to use condoms. Safer sex intentions with customers were frequently undermined by urgent financial needs, which stemmed from transphobia, employment discrimination and costly procedures associated with gender transition. Participants reported using drugs as a way to cope with or escape life stresses associated with relationships, sex work, transphobia and financial hardship. (p. 724)

These findings suggest that interventions with MTF transgenders at risk for HIV

should address the social context of risk behaviours, particularly relationship and sex work issues related to gender validation, transphobia and drug use. ... [S]ervices should help MTF transgenders reevaluate norms for intimate relationships – for example, their motives for entering into relationships and how they express affection and set boundaries with primary partners without lowering their power for negotiation. ... Clearly, it is [also] important to educate both transgendered individuals and their partners about the prevalence of HIV in the transgender community, as well as the potential for HIV infection within the context of a primary relationship. (p. 734)

Finally, in a sample of 333 HIV-positive people engaged in medical care, Kozal et al. (2004) found that 23% had unprotected sex in the preceding 3-month period, representing 1,126 unprotected events with 191 different partners, 155 of whom were thought to be either HIV-negative or of unknown status. When risk behavior data were linked to data on HIV drug resistance, 24% of those engaging in unprotected sex did so while harboring drug-resistant strains of HIV. While these individuals represented about 5% of the entire study population, they "accounted for a large number of high-risk HIV transmission events with resistant virus, exposing a substantial number of partners" (p. 2185). "Of those variables that might differentiate antiretroviral-resistant patients engaging in risk behavior from resistant patients who are not, mental health functioning appears critical, and addressing mental health issues may be the key to reducing transmission risk behaviors" (pp. 2188-2189).

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