Susan S. Witte, Ph.D. - US grants

DESCRIPTION (provided by applicant): The proposed R03 (PA 99-113) is designed to examine parenting attitudes and behaviors among African American and Latino fathers attending methadone maintenance treatment programs (MMTPs), and to explore how parenting attitudes and behaviors are affected by a father's current and past experiences with drug use and intimate partner violence (IPV). Substance use and parenting literature indicate that drug use compromises positive fathering and can constitute barriers to healthy father-child relationships. In addition, studies on IPV have revealed a significant problem among men being treated for drug abuse, and an overlap of IPV and child abuse occurring in families. However, to date, surprisingly few efforts have been made to study the role of fathers in violent families and no studies have examined how fathering attitudes and behaviors are affected by IPV among drug-dependent men. Concurrently, there is substantial and growing evidence suggesting that fathers have positive influences on their children, and that fathering may have positive effects on the well being of men in general. In light of research indicating that positive father effects may be countered by IPV and child abuse, promoting positive father-child relationships among violent men is extremely complex. Building on findings generated from ongoing NIDA studies, and guided by social learning theory and an ecological framework, the study will collect contextual narratives on the experience of fatherhood among 72 African American and Latino men in a New York City-based MMTP through focus groups and in-depth interviews. Through a contextually rich, in-depth understanding of the complex dynamics of these relationships afforded through qualitative inquiry, we aim to further inform and enhance paternal support interventions and services to promote healthy father-child involvement. The findings will also inform an R01 application aimed at the development and efficacy testing (using quantitative methods) of a parenting support intervention provided in drug treatment settings for a random sample of drug-dependent fathers and their families. Dr. Susan Witte will conduct the study under the guidance of Dr. Nabila EI-Bassel of the Social Intervention Group (SIG) at the Columbia University School of Social Work, and in consultation with Drs. Suniya Luthar and Peter Steinglass.

[unreadable] DESCRIPTION (provided by applicant): Targeted, low cost, empirically-validated prevention interventions are needed to help prevent the proliferation of HIV/STIs among women in resource poor societies. Centrally located in Asia, Mongolia is bordered by Russia and China: two countries experiencing rapidly expanding HIV epidemics. Since 1990, Mongolia has endured devastating economic changes leading to over 36% of the population living in poverty, and driving a disproportionate number of women out of the labor force. Lack of employment has resulted in increases in internal and external migration among men in search of employment and a great increase in the number of women engaging in survival sex work along borders and trade routes. Such migration patterns have been linked with unprotected sex exchange transactions and transmission of HIV/STIs across geographic boundaries. Concurrent with increasing opportunities for risky heterosexual behaviors are rising rates of alcoholism and sexually transmitted infections (STIs). In the general adult population, 88% of men and 58% of women report alcohol use. Alcohol abuse among women is largely underreported due to cultural denial and stigma, but a pilot study among 48 women engaging in recent HIV/STI sexual risk behaviors found that 85% were engaged in harmful alcohol use. Up to 58% of women under the age of 25 have at least one diagnosed STI. Strong evidence that unprotected sexual contact in the presence of STIs enhances the probability of HIV transmission and that alcohol use is associated with increased sexual risk suggests that, without urgently needed interventions, Mongolia is poised to become a significant contributor to the regional Central Asian HIV epidemic. Innovative adaptation, introduction and testing of low cost, targeted, empirically validated prevention interventions may help prevent the rise of HIV in Mongolia. The proposed study is designed to achieve the following primary aims: 1) to adapt and combine a 4- session HIV sexual risk reduction intervention (HIV-SRR) and a 2-session motivational interviewing (Ml) intervention and tailor them to alcohol-abusing women who engage in high risk sexual behaviors in Mongolia; 2) to obtain preliminary estimates for the efficacy of the combined intervention (HIV-SRR+MI) on reduction in sexual risk behaviors by conducting a 3-arm randomized clinical trial (RCT) with 165 women, assigned to either a combination (HIV-SRR+MI) or single, time-matched (HIV-SRR) risk reduction intervention or a time-matched wellness promotion (WP-C) condition; and 3) to examine and enhance the feasibility of a future, larger-scale RCT testing the efficacy of the combination HIV-SRR+MI or single component HIV-SRR only interventions among the target population. Women clientele of the National AIDS Foundation (NAF) program in Ulaanbaatar, Mongolia will be recruited. Study assessments will be completed at baseline, immediately post-intervention, and 3 and 6 month follow-up. In partnership with the NAF, the Mongolian National Center for Communicable Diseases and the Center of Mental Health and Narcology, the study will be conducted by Drs. Susan Witte and Dr. Nabila EI-Bassel of the Social Intervention Group at the Columbia University School of Social Work. [unreadable] [unreadable] [unreadable]

DESCRIPTION (provided by applicant): Despite two decades of research demonstrating the efficacy of science-based interventions to reduce risk behaviors, the science of HIV prevention dissemination is still in its early stages. HIV infections continue to rise worldwide, and heterosexual contact remains the primary and escalating route of transmission. There is a critical need for increased capacity, scale and speed for HIV prevention intervention dissemination approaches, such as those increasingly implemented in educational and medical arenas, which use multimedia and internet-based approaches. This revised application proposes a technology transfer study that will advance the science of HIV prevention dissemination research by testing whether employing multimedia and internet-based technology for implementation of an evidence-based, couple-level HIV prevention intervention improves adoption outcomes beyond existing dissemination strategies. Proposed is a randomized clinical trial to compare the effectiveness of disseminating a traditional, manualized package of Project Connect (Traditional), a 6-session, relationship-based HIV/STI prevention intervention for heterosexual couples at high risk for HIV/STI transmission, versus a multimedia, internet-based version of Project Connect (Multimedia) to clients at community-based organizations (CBOs) across New York State. Eighty participating CBOs providing HIV prevention services will be randomized to receive either the Traditional or Multimedia intervention and training packages. All agencies will receive two days of on-site training and two planned technical assistance conference calls by study investigative staff in the first two months following training. Telephone assessments completed by up to 6 staff at each agency (total of 480 participants) will measure primary outcomes, mediating, moderating and process measure variables at baseline, 6-, 12- and 18-months post-technology transfer. The primary outcome of the study is adoptions of the Connect intervention. The unit of analysis is the CBO. The proposed study will be conducted by Dr. Susan Witte, Dr. Nabila EI-Bassel, and the investigative team at the Social Intervention Group at the Columbia University School of Social Work, in collaboration with Dr. Robert Remien, of the HIV Center for Behavioral Research and Dr. Frank Moretti, Executive Director of the Columbia Center for New Media Teaching and Learning (CCNMTL).

DESCRIPTION (provided by applicant): The proposed study represents the first test of a savings-led microfinance intervention combined with HIV prevention on reductions of sexual risk behaviors among female sex workers (FSWs). The study may advance the gender-specific prevention repertoire for women who are at risk for HIV and STIs globally. More specifically, the US/Mongolian collaborative research team will: (1) integrate social cognitive and asset theories in the development and implementation of a microfinance intervention that will promote women's HIV risk reduction and economic self-sufficiency; (2) test a combination of multiple evidence-based microfinance components (financial literacy, business development training/mentorship, and matched savings), which are derived from asset theory, to promote HIV risk reduction and economic self sufficiency; (3) test a microfinance model that is sensitive to the unique needs of FSWs by (a) providing substantial training for personal financial literacy and business management [which most microfinance institutions do not provide]; (b) teaching women about the risks of credit before referring to loan programs; and (c) providing matched savings to build assets towards business development; and (4) test for the first time whether microfinance with a matched savings component can impact reductions in sexual risk among sex workers in a low income country. We will randomly assign 134 FSWs meeting eligibility criteria and completing a baseline assessment to either an evidence-based HIV sexual risk reduction intervention (HIVSRR) plus microfinance (HIVSRR+MF) or to the HIVSRR alone as a control condition, conducting follow-up assessments at immediate post test, 3 and 6 months post intervention. Evidence suggests that such combination of microfinance and HIV prevention may have a greater potential for risk reduction among women who-- because of their reliance on sexual behavior as a means of economic support-- have a compromised ability to be concerned with longer term health consequences such as HIV or sexually transmitted infections (STIs). This study responds to the identified need in the literature for rigorous testing of combination microfinance and HIV prevention in support of sexual risk reduction among women where individually based interventions are too limited, and gender, economic and migration issues restrict the impact of existing prevention intervention strategies. PUBLIC HEALTH RELEVANCE: The proposed study represents the first test of a savings-led microfinance intervention combined with HIV prevention on reductions of sexual risk behaviors among female sex workers (FSWs). We will randomly assign 134 FSWs meeting eligibility criteria and completing a baseline assessment to either an evidence-based HIV sexual risk reduction intervention (HIVSRR) plus microfinance (HIVSRR+MF) or to the HIVSRR alone as a control condition, conducting follow up assessment at immediate post test, 3 and 6 months post intervention.

DESCRIPTION (provided by applicant): The proposed study will examine the efficacy of a combined HIV and microfinance intervention to reduce biologically confirmed sexually transmitted infections (STIs), and new incidence of HIV and HCV, as well as reported sexual and drug risk behaviors among 520 women who have injected drugs in the past year and who engage in sex trading in Temirtau and Pavlodar, Kazakhstan. Kazakhstan is one of nine countries worldwide that has experienced a continuing rise in HIV infections (>25%) over the past decade. The epidemic is exacerbated by structural forces such as poverty and a lack of employment options for people who use drugs, especially women, which makes transactional sex a survival strategy. Recent calls for action by HIV prevention scientists have emphasized the need for innovative structural interventions for women engaged in sex work who are also drug-involved. The proposed study builds on findings from an R34 by the investigative team testing a combination HIV prevention and microfinance intervention. Building on successful protocols and significant results, we will randomly assign 520 women who inject drugs and engage in sex trading from Temirtau and Pavlodar, Kazakhstan to either (1) a 4 session HIV prevention intervention combined with a 6 session financial literacy intervention, enrollment in an existing vocational training program and receipt of matched savings (HIVRR+MF); or to the 4 session HIV prevention intervention alone. The HIVRR intervention is guided by social cognitive theory. The HIVRR+MF intervention integrates asset theory with social cognitive theory. The MF includes: 1) financial literacy; 2) vocational training; and 3) micro-savings to support transitionto a more permanent employment status. We hypothesize that increasing financial literacy, enhancing vocational skills required to fill marketable positions in the local economy, and beginning a personal savings program, combined with HIV risk reduction, will lead to significant reductions in study outcomes compared to an HIVRR intervention without a microfinance intervention. A qualitative component to examine factors that facilitate or impede women's ability to participate in and benefit from a microfinance intervention, and a cost and cost effectiveness analysis will provide additional data to inform a disseminable program if findings are significant. The findings from this study will be important not only for Central Asia, but may also have vital public health implications in the U.S. and other countries where HIV/STIs and HCV remain high and employment rates remain low among drug- involved women engaged in sex trading.

DESCRIPTION (provided by applicant): The proposed study will examine the efficacy of a combined HIV and microfinance intervention to reduce biologically confirmed sexually transmitted infections (STIs), and new incidence of HIV and HCV, as well as reported sexual and drug risk behaviors among 520 women who have injected drugs in the past year and who engage in sex trading in Temirtau and Pavlodar, Kazakhstan. Kazakhstan is one of nine countries worldwide that has experienced a continuing rise in HIV infections (>25%) over the past decade. The epidemic is exacerbated by structural forces such as poverty and a lack of employment options for people who use drugs, especially women, which makes transactional sex a survival strategy. Recent calls for action by HIV prevention scientists have emphasized the need for innovative structural interventions for women engaged in sex work who are also drug-involved. The proposed study builds on findings from an R34 by the investigative team testing a combination HIV prevention and microfinance intervention. Building on successful protocols and significant results, we will randomly assign 520 women who inject drugs and engage in sex trading from Temirtau and Pavlodar, Kazakhstan to either (1) a 4 session HIV prevention intervention combined with a 6 session financial literacy intervention, enrollment in an existing vocational training program and receipt of matched savings (HIVRR+MF); or to the 4 session HIV prevention intervention alone. The HIVRR intervention is guided by social cognitive theory. The HIVRR+MF intervention integrates asset theory with social cognitive theory. The MF includes: 1) financial literacy; 2) vocational training; and 3) micro-savings to support transitionto a more permanent employment status. We hypothesize that increasing financial literacy, enhancing vocational skills required to fill marketable positions in the local economy, and beginning a personal savings program, combined with HIV risk reduction, will lead to significant reductions in study outcomes compared to an HIVRR intervention without a microfinance intervention. A qualitative component to examine factors that facilitate or impede women's ability to participate in and benefit from a microfinance intervention, and a cost and cost effectiveness analysis will provide additional data to inform a disseminable program if findings are significant. The findings from this study will be important not only for Central Asia, but may also have vital public health implications in the U.S. and other countries where HIV/STIs and HCV remain high and employment rates remain low among drug- involved women engaged in sex trading.

Female Sex Workers (FSWs) in sub-Saharan Africa (SSA) have been identified as a high-risk group for the spread of HIV/AIDS, with those in poor areas and ?HIV hotspots? being especially vulnerable. Research has shown that the primary reason poor women engage in commercial sex work is financial instability. Given these challenges, poor women require support over and above HIV prevention education. We propose to test the impact of adding economic empowerment (EE) components to traditional HIV risk reduction (HIVRR) to reduce new incidence of sexually transmitted infections (STIs) and of HIV among FSWs in Rakai and Masaka districts in Uganda. Guided by social-cognitive and asset theories, the study provides an avenue for FSWs to explore alternative means of safe and sustainable income to replace sex work. The study is informed by a previously tested microfinance (MF) intervention for FSWs in Mongolia, a pilot study conducted with FSWs in Masaka and Rakai, surveillance studies by RHSP, and EE interventions among AIDS-affected families in Uganda. Using a cluster-design we will randomly assign 990 FSWs from 33 matched town centers to one of three study arms (11 town centers in each condition): (1) A control arm comprising of treatment as usual (TAU) for FSWs in the study area bolstered with 4 evidence-based sessions of HIVRR provided by local providers (n=330); or (2) A treatment arm including TAU, 4 sessions of HIVRR, combined with receipt of a matched savings account (HIVRR+S) to be used on short- and/or long-term consumption and skills development as per participants? own discretion (n=330); or (3) A treatment arm including TAU, 4 sessions of HIVRR, combined with a matched savings account to be used on short-term and/or long term consumption and skills development as per a participant?s own discretion plus 6 sessions of financial literacy and 8 mentoring sessions for supportive transition to alternative income options (HIVRR+S+FLM) (n=330). This RCT study?s aims are to: Aim1: Examine the impact of a financial savings-led MF intervention using HIVRR+S and HIVRR+S+FLM on HIV biological and behavioral outcomes in FSWs (Primary outcomes: women?s cumulative incidence of biologically- confirmed STIs and reported number and proportion of unprotected sexual acts with regular and paying partners; Secondary outcomes: women?s rate of new HIV cases, proportion of monthly income from sex and non- sex work, reported number and proportion on preventive behaviors, and for HIV+ women only, viral load as a marker of ART adherence). Aim 2: Examine intervention mediation and effect modification to assess whether primary outcomes are mediated/moderated by participant characteristics; whether key theory-driven variables and Behavioral Economics measures mediate/moderate intervention outcomes. Aim 3: Qualitatively and quantitatively examine implementation in each study condition; and Aim 4: Assess the cost and cost-effectiveness of the HIVRR+S and HIVRR+S+FLM intervention compared with traditional HIVRR in terms of cumulative number of STI and HIV cases averted over the 24-month period.