Laura M. Bogart - US grants

Self-reported assessments of sexual behavior are commonly used to gauge levels of HIV risk in target populations and to determine the effects of prevention interventions on sexual risk behavior change. However the valid and reliable measurement of sexual behaviors via self-report has been hampered by methodological concerns related to individuals' inaccurate memory for previous sexual behaviors. Nevertheless, vitually no research has examined the cognitive mechanisms by which individuals recall sexual behaviors. Such information is crucial for pinpointing the types of biases that affect self-reports, which in turn could inform the design of more sexual behavior assessments. Support is requested for a methodological study that will use protocol analysis techniques to identify the cognitive strategies underlying individuals' responses to commonly- used measures of past sexual behaviors. One hundred men who have sex with men, 100 heterosexual men, and 100 heterosexual women who are at high risk for HIV will be recruited from urban settings. Participants will be asked to verbalize what they are thinking as they estimate frequencies of sexual behaviors, and numbers of partners for two different time periods (the past two weeks and the past three months). Participants' responses will be audio tapes, transcribed and analyzed with protocol analysis, which is a tool developed by cognitive psychologists to uncover the cognitive mechanisms used for recall and problem-solving. It is predicted that enumerations strategis, in which each separate occurrence of the event is recalled and then counted, will be used to recall low-frequency behaviors and behaviors in the past two weeks. In contrast it is predicted that estimation strategies, in which a rate of sexual behavior is recalled and then adjusted to estimate behavioral frequencies fort he time period assessed, will be used to recall high-frequency behaviors in the past three months. Further, it is expected that general impression strategies, in which a vague impression about the contents of memory is used to estimate frequencies, will be used to recall extremely high frequencies of sexual behavior. This research will identify the conditions under which different types of cognitive strategies and heuristics are used to recall sexual behaviors and sexual partners. Information about these cognitive strategies will ultimately be used to develop more reliable and valid assessments of sexual behavior that incorporate interviewers probes, cues, and contexts to aid recall.

DESCRIPTION (provided by applicant): As outlined in the goals of Healthy People 2010, eliminating racial/ethnic health disparities, especially with regard to HIV/AIDS, is a major priority in the U.S. Across all racial/ethnic groups and both genders, the highest rates of HIV and AIDS are among African American men, and the predominant mode of transmission among African American men is sex with men. African American men who have sex with men (MSM) are more than two times as likely to be infected with HIV than are MSM of other races/ethnicities. This application proposes a longitudinal study to investigate perceived stress and negative health care attitudes as possible barriers to antiretroviral treatment adherence among 200 HIV-infected African American MSM. Although effective HIV treatments are now available, patients must closely adhere for maximum reductions in HIV viral load and increased survival time. Some research indicates that African Americans are less likely to receive and adhere to antiretroviral medications than are Whites, and these differences in treatment patterns could contribute to observed lower survival times among African American, versus White, people with HIV/AIDS. Although discrimination is thought to contribute to racial/ethnic disparities in treatment behavior, research has not examined the manifold effects of discrimination on adherence among African American MSM, a subgroup at the nexus of the HIV/AIDS epidemic. In this application, discrimination is proposed to influence the health of African American MSM with HIV via multiple pathways, by increasing their chronic, environmental, general, and traumatic stress burden. These discrimination-related stressors are hypothesized to influence treatment behavior directly, via decreased ability to adhere to antiretroviral treatment regimens, as well as indirectly, through the formation of negative attitudes about the health care system (e.g., conspiracy beliefs about HIV). Findings will provide information concerning specific cultural barriers to quality health care among African American MSM with HIV and will be used to make policy recommendations for targeted culturally-relevant outreach measures that address identified barriers at multiple levels, including patients, communities, and health care organizations. In so doing, the conclusions of the proposed research will inform public policy regarding racial/ethnic disparities in health by suggesting factors that may place African American MSM at risk for treatment nonadherence and decreased survival.

[unreadable] DESCRIPTION (provided by applicant): Although HIV clinical management has improved dramatically since the advent of highly active antiretroviral therapy (HAART), engaging individuals into HIV care at every stage of illness poses significant challenges. Treatment advocacy (TA) programs have been implemented by AIDS service organizations (ASOs) in part as a response to these challenges. TA aims to empower patients through client-centered counseling regarding HIV and antiretroviral therapy (ART), advocating on behalf of the patient with providers and the health care system, and making referrals to health care and clinical trials. Although TA programs have been in existence for most of the HIV epidemic and represent a potentially brief and cost-effective intervention that can be effectively implemented across ASOs in the U.S., we are not aware of any systematic, rigorous evaluations of its effects on engagement in care, initiation of ART, and ART adherence. No research has yet determined which elements of TA programs are important for successful HIV care management. We propose to conduct an exploratory investigation of the TA program at AIDS Project Los Angeles (APLA), the largest ASO in Los Angeles. We will combine a process evaluation of the influence of TA on key HIV care management decisions with longitudinal quantitative assessments administered to TA and non-TA clients. The process evaluation will consist of qualitative interviews with 42 clients, treatment advocates, and medical providers. In addition, a diverse sample of 90 clients, 45 who receive TA services from APLA, and a socio- demographically comparable group of 45 clients of a different ASO that does not offer TA services, will be tracked over 6 months. We will monitor initial engagement in HIV care among 30 clients with no HIV primary care provider; initiation of ART among 30 clients with CD4<350; and adherence to medications among 30 clients on ART. We will conduct a preliminary assessment of the effects of TA services on key decisions and outcomes related to HIV care, and explore factors and specific components of the TA program that facilitate or impede TA's effects. In addition to evaluating overall effects, we will explore correlates of successful outcomes among African American and Latino clients in particular. This study has high potential to influence the public health, as its findings may guide the development of interventions to enhance TA services in ASOs across the U.S., as well as policy efforts ultimately aimed at improving the health of people with HIV. [unreadable] [unreadable] [unreadable]

DESCRIPTION (provided by the applicant): African Americans with HIV fare worse than their White counterparts, with large racial/ethnic disparities at all points along the HIV care continuum. Compared to Whites with HIV, African Americans with HIV have lower levels of engagement and retention in care, and are less likely to be on state-of-the art antiretroviral treatment (ART);those on ART are less likely to be adherent at high enough levels for the treatment to be effective. The proposed 5-year project focuses on HIV-related medical mistrust (e.g., misconceptions, conspiracies such as that HIV is a form of genocide) as a barrier to HIV care and treatment behaviors. Specifically, the project will examine how social contexts, specifically, social networks (i.e., the constellation of social relationships surrounding an individual), may influence the spread of HIV-related medical mistrust, and in turn, affect treatment behaviors among African Americans with HIV. A total of 240 African Americans with HIV (120 not engaged in care, 120 on ART) will be followed over 12-months;data will be collected on the flow of HIV-related mistrust beliefs across social networks, as well as HIV care outcomes over time (engagement in care, adherence to ART). The research will conclude with active intervention conceptualization in partnership with community stakeholders in order to identify innovative social network-based solutions for improving treatment behaviors and ultimately, reducing disparities. The specific aims are: (1) To identify social network sources of HIV-related information (i.e., mistrust, misconceptions, conspiracies, and accurate information) among African Americans with HIV;(2) To examine the ways in which social network characteristics related to HIV mistrust are associated with HIV treatment behaviors across the HIV care continuum (engagement in care, antiretroviral treatment use, antiretroviral treatment adherence);and (3) Together with community stakeholders, to use study findings to identify novel intervention solutions to address mistrust and improve HIV treatment behaviors for African Americans with HIV. HIV-related mistrust is hypothesized to be spread through social networks and associated with specific network characteristics;individuals with high HIV-related mistrust are hypothesized to be less likely to be engaged in care and to be adherent to ART;and social network composition (e.g., level of mistrust in network) and structure (e.g., closeness of network members) are predicted to be related to HIV treatment behaviors (e.g., the relationship between mistrust and adherence will be greater for individuals in networks with high levels of mistrust). No research to date has used a social network approach to understanding the flow of HIV-related information and misconceptions among people with HIV.

DESCRIPTION (provided by applicant): In South Africa, >5 million people, including many adolescents, are living with HIV. Prevalence is increasing throughout South Africa, most precipitously in the Western Cape, the site of our proposed study. However, efforts to reduce HIV among South African youth through national campaigns, mass media, and schools have had limited success. South African youth prevention programs have generally not involved parents, though parents have the potential to prevent adolescent sexual risk through communication, supervision, and involvement. We propose to pilot test a multisession worksite-based program to help parents learn how to take an active role in rearing sexually healthy youth. We will culturally adapt our NIH-funded, US worksite-based parenting program, Talking Parents, Healthy Teens, for use in South Africa. This program had substantial effects on improving parent-adolescent communication about sex that have persisted to the 9- month follow-up survey; strikingly, some effects became stronger in between the immediate and the 3- and 9- month follow-ups. Such communication has the potential to mediate longer-term sexual behavior outcomes. The worksite setting is convenient for parents and sustainable for South African employers. Although our program's main goal will be to reach adolescents through parents, we expect that it will also influence parents' HIV-related attitudes and behaviors. South African adults tend to be reluctant to attend HIV prevention programs due to stigma, but a program focused on adolescents may attract parents, promoting the health of both generations. Our specific aims are to: (1) Adapt a US-developed worksite-based program for parents of adolescents to the South African context; (2) Examine whether a worksite-based program for parents of adolescents in South Africa improves the parent-child relationship, including general parent-child communication and communication about sexual health and HIV risk-reduction, as perceived by parents and adolescents; (3) Explore program effects on parents' HIV testing and sexual behaviors; and (4) Explore program effects on theoretically important psychosocial mediators of behavior change (e.g., greater self- efficacy for refusing sex and using condoms, and more perceived disadvantages of unprotected sex). The proposed research is a unique opportunity to adapt and pilot test an innovative HIV prevention intervention that promotes the health of families in a culturally acceptable and sustainable setting. PUBLIC HEALTH RELEVANCE: In South Africa (SA), adolescent HIV prevalence is high. Current SA youth HIV prevention efforts have had limited success. We propose to adapt and pilot test a multisession worksite-based program to help SA parents promote healthy adolescent sexual development. The program will be based on our successful NIH- funded US worksite program, which had substantial effects on parent-child communication about sex.

DESCRIPTION (provided by applicant): Compared to other races/ethnicities, African Americans with HIV have lower levels of engagement in care, are less likely to be on antiretroviral treatment (ART), and are more likely to delay care and ART initiation; those on ART are less likely to be adherent at high enough levels for the treatment to be effective. We propose to test an innovative, culturally relevant treatment advocacy (TA) intervention for African Americans with HIV that targets social and cultural issues contributing to poor HIV treatment behaviors. TA, which has been sustained in many community organizations throughout the HIV epidemic, has never been systematically evaluated. TA facilitates patient navigation through the medical system and provides tailored HIV treatment education and client-centered counseling to improve adherence and engagement in care. TA targets social and contextual issues in healthcare and patients' lives by advocating to providers to improve patient-provider relationships, recommending changes in treatment and/or providers (if needed), and referring patients to mental health and social services. TA is particularly appropriate for African Americans with HIV, who may be mistrustful of providers: it can be conducted outside of the medical system in a safe, neutral community setting by individuals not associated with patients' healthcare. We developed a culturally relevant TA program that additionally discusses factors such as racism that undermine healthcare in Black communities, by acknowledging and directly addressing patients' medical mistrust and stigma as coping strategies that arise in response to oppression. The specific aims are to (1) conduct a randomized controlled trial to examine the effects of a culturally relevant TA program on adherence among African Americans with HIV; (2) identify culturally relevant mediators that explain the effects of treatment advocacy on antiretroviral treatment adherence among African Americans with HIV (e.g., improved behavioral adherence skills, coping with stress/discrimination, mental health, and patient satisfaction; lower levels of HIV misconceptions, internalized HIV stigma/homophobia, medical mistrust, and substance use); and (3) explore culturally relevant moderators of the effects of treatment advocacy on antiretroviral treatment adherence among African Americans with HIV (e.g., discrimination, incarceration, poverty, social support, spirituality, trauma). A sample of 200 African Americans with HIV will be randomly assigned to a TA intervention or wait-list control group. Participants will complete surveys at screening, and at 3- and 6-months post-baseline, to assess pre-, intra-, and post- intervention effects on adherence. PUBLIC HEALTH RELEVANCE: African Americans with HIV have lower levels of engagement in care and treatment adherence than do Whites with HIV, and the predictors of these behaviors differ by race/ethnicity; however, few culturally relevant interventions have been tested. We propose to conduct a randomized controlled trial (RCT) of an innovative, culturally relevant treatment advocacy (TA) intervention for African Americans with HIV that targets cultural and social issues contributing to health disparities. TA, which has been sustained in communities throughout the HIV epidemic but never been rigorously tested, facilitates medical system navigation and adherence through client-centered counseling and education; advocacy to providers; and referrals for social services.

DESCRIPTION (provided by applicant): Black men who have sex with men (MSM) bear the greatest burden of HIV across all races/ethnicities and risk groups, accounting for ~40% of diagnoses among MSM of all races/ethnicities, and one-third among all men. Compared to other races/ethnicities, Blacks living with HIV are less likely to be diagnosed, to be engaged in care, and to receive and adhere to antiretroviral treatment (ART). Black MSM in particular show very low ART adherence. In this 3-year intervention development study, we propose to develop and pilot test a culturally relevant intervention to reduce medical mistrust and address discrimination among Black MSM living with HIV. Our work with Black MSM suggests that culturally relevant factors such as perceived discrimination and HIV- related medical mistrust (e.g., HIV conspiracy beliefs, like HIV is a manmade virus) contribute to disparities in HIV treatment behaviors, in some cases even more than factors known to be highly influential like depression and substance use. Black MSM living with HIV are at the nexus of 3 stigmatized social categories (HIV-serostatus, race, sexual orientation) from which they face discrimination, which in turn can lead to disparities by increasing detrimental stress responses related to poor self-control (maladaptive coping, poor health behaviors). Discrimination also fosters mistrust of public health entities, and suspicion of medical treatments. However, no interventions have been developed to overcome these culturally relevant barriers. In the proposed innovative community-based participatory research project, we will partner with a Black-MSM- serving AIDS service organization (ASO) with high success in engaging Black MSM in research. In Phase 1, we will conduct qualitative interviews with 30 Black MSM and 20 social service and mental health providers, and engage stakeholders in a community advisory process to obtain input on sustainable intervention components that can improve the effectiveness of service delivery. In Phase 2, we will conduct a process evaluation of one pilot intervention group of 10 participants, delivered via a community HIV support group. In Phase 3, we will conduct a small randomized pilot trial with 3 intervention groups and 3 control groups (10 participants each). The specific aims are to: 1. Conduct qualitative semi-structured interviews with Black MSM, and engage AIDS service organization (ASO) staff and mental health counselors, in order to develop intervention modules that address mistrust and discrimination among Black MSM. 2. Examine whether the pilot intervention can reduce mistrust and improve coping responses to discrimination among Black MSM. 3. Explore pilot intervention effects on mental health, antiretroviral treatment adherence, and engagement in care among Black MSM. Our goal is for the proposed culturally relevant intervention to be exportable to interventions already developed for improving adherence and engagement in care among people living with HIV. If shown to be effective in future R01-funded research, our intervention will be flexible for use in community settings, such as in existing HIV support groups already being sustained throughout the US.

DESCRIPTION (provided by applicant): In Uganda, HIV prevalence is estimated to be over 7% among those aged 15-49 and is rising. Yet, only 21% of Ugandans are aware of their HIV-serostatus. Community HIV testing has increased in Uganda and sub- Saharan Africa recently, and holds promise in efficiently reaching individuals from high-risk rural and migrant communities that are not touched by healthcare-based testing. In Uganda, most community testing is delivered in temporary, mobile venues, and can reach large numbers of people (up to 1,900 per day). Nevertheless, community testing presents considerable challenges for timely linkage to care after diagnosis. In rural settings, people who test positive may be referred to clinics many kilometers away; unpaved roads combined with lack of adequate transportation may deter care- seeking. Referral to care is especially difficult for high-risk migrant populations such as people in trading/market communities (who frequently move to different markets across the region), or fisherfolk (who spend most of the time fishing away from home, and who have multiple landing sites at different lakeshore locations). We propose to systematically explore barriers to and facilitators of linkage to care using iterative mixed (qualitative and quantitative methods, to ultimately develop novel solutions that are feasible for scale-up in diverse community testing venues. The specific aims are: (1) to use qualitative methods to understand the organizational protocol for, barriers to, and facilitators of linkage to care, and potential noel solutions, in three different types of community HIV testing settings (rural villages, trading communities, fishing communities); and (2) to examine quantitatively the barriers to and facilitators of linkage to care among people newly diagnosed with HIV at different community HIV testing settings. In Phase 1, we will conduct 10 qualitative interviews with key stakeholders in community-based organizations that conduct community testing, and observe three diverse testing scenarios in high-risk communities (trading communities, fishing communities, rural villages) to understand the current protocol for testing and referrals to care. We will also conduc qualitative interviews with 30 individuals who receive a positive test result to explore potential barriers to and facilitators of linkage to care. In Phase 2, we will quantitatively and longitudinaly examine barriers to and facilitators of linkage to care, as well as time to receipt of care, among sample of 240 individuals who test positive for HIV (80 per testing site type). In Phase 3, using an iterative process, we will conduct additional qualitative interviews with 5 key stakeholders (from Phase 1) and 18 HIV-positive testing clients (from Phase 2), in order to elicit feedback about the meaning of the Phase 1 and Phase 2 results, and input on innovative solutions for linkage to care following receipt of a positive test result in community HIV testing.

PROJECT SUMMARY In Botswana, the setting of the proposed study, nearly one in five adults are living with HIV. Men in Botswana over age 40, the focus on the present research, show relatively high levels of HIV prevalence and risk behavior, and low levels of HIV testing. Moreover, higher income is associated with increased risk of being HIV-positive in sub-Saharan Africa (SSA). The proposed research will use mixed methods to develop an intervention that de- stigmatizes and encourages HIV testing among men of middle-to-higher socio- economic status (SES) in Gaborone, Botswana. We will focus on increasing HIV testing among men of higher SES. Fear of being stigmatized among financially secure men in employment in Botswana may contribute to low HIV testing uptake. The Specific Aims are: Aim 1: To initially conduct formative qualitative work to explore the role of stigma on low HIV testing uptake among 20 men via face to face interviews, and then to obtain feedback about potential interventions using asynchronous online focus group discussion among 40 men all with relatively high socio-economic status (SES) in Botswana. Aim 2: To develop and conduct a small pilot test of a local, culturally appropriate HIV testing strategy targeting 100 men in the higher-SES in Botswana. Hypothesis: At least 60% of men will access the new HIV testing strategy, equivalent to a ~20% point increase above testing strategies not tailored to men. Aim 3: To build capacity for HIV stigma and related behavioral research by conducting focused workshops in Botswana. To reach the remaining 10-10-10, it is essential to develop differentiated, tailored approaches for risk groups, such as men of relatively higher SES, that are untouched by existing prevention and testing frameworks in countries of high HIV prevalence.!