This subproject is one of many research subprojects utilizing theresources provided by a Center grant funded by NIH/NCRR. The subproject andinvestigator (PI) may have received primary funding from another NIH source,and thus could be represented in other CRISP entries. The institution listed isfor the Center, which is not necessarily the institution for the investigator.
Specific Aims and Results1.0 Validate and culturally adapt the 'Risk Reduction Counseling-Puerto Rico' (RReduC-PR), a newly developed HIV and sexually transmitted infection (STI) risk reduction intervention based on the RESPECT-2, a pre and post counseling developed by the Centers for Disease Control (CDC) which incorporates the rapid HIV test as part of its model.2.0 Administer the intervention in women from 3 different cohorts: (street sex workers and/or crack users (CBO); women referred with a sexually transmitted infection (STI-C); and women who attend a family planning clinic (FPC)) (30 women per group, N=90).3.0 Characterize the three groups as to: sociodemographic, economic, general health, and lifestyles, sexual practices, history of childhood abuse, depression symptoms, domestic violence, and health believes. 4.0 Determine HIV, Gonorrhea, and Chlamydia incidences and prevalence in the three cohorts.SignificanceThis study uses the rapid HIV test; which is a new technology. Interventions that incorporate this tool into their current practices are essential. Along with this type of testing a pre and post counseling is provided at the same session. Existing interventions provide the framework and experience for the application to specific minority populations; however, culturally adapting instruments is essential to ensure effectiveness. Many behavioral interventions or counseling to reduce HIV risk have proven to be effective in diverse populations. The RESPECT-2 intervention, developed by the CDC for English speaking populations, was translated into Spanish and culturally adapted to the Puerto Rican population. The RESPECT-2 uses the rapid HIV test to reduce the time and number of visits.Oftentimes original instruments or interventions are discarded after cultural adaptation and result in an entirely new intervention, derived from the past adaptation experiences. Studies employing only a translated intervention, which is not culturally adapted, will not reflect the true realities of the targeted minority populations. Results: The study originally intended to translate and culturally adapt the RESPECT-2, an HIV counseling intervention from the Center of Disease Control (CDC). The translation of the intervention module was conducted in the first phase. The validation process initiated with the pilot intervention which consisted of focus groups with women from three diverse risk behavior groups: street sex workers/crack users, STI clinics, and family planning clinics in Puerto Rico. Data form the first phase indicated that participants found the translated RESPECT-2 insensitive regarding sexual topics. Most considered the intervention repetitive, disorganized, and disrespectful. Participants thought that the time allocated to sensible topics was limiting. Several terms were confusing, ambiguous, and unclear. These factors negatively influenced the empathy between the counselor and the participant. These responses and reactions were attributed to cultural differences. Consequently, a new version of the intervention module was developed, 'The Risk Reduction Counseling-Puerto Rico' (RReduC-PR). This new counseling, takes into consideration the language, sensibility, education level, and lifestyles of the three study groups. A new rapid HIV counseling intervention was developed from this preliminary work. The process continued with the recruitment of 60 participants from each site on the first year and 90 participants for 2 additional years, leading to a total of 270 participants.In view of the first phase preliminary findings, some modifications were made to the second phase of this study. These changes intended to improve the accuracy of the data obtained, retention rates, and reliability of the results. These amendments were submitted and approved by the University of Puerto Rico, Medical Science Campus IRB. These changes included: an increase in sample, increase in the time range of the participant follow up (from 12 months to 18 months), and the inclusion of two additional contact visits. A satisfaction questionnaire was also included. This provides the participants a confidential space to express their feedback toward the intervention and procedures. The time interval was modified so there will be a visit follow up one year after the initial visit and six months after that visit. This decision was based on a previous study conducted at the Maternal Infant Studies Center (2005) which suggested the need for a longer study period to monitor STI risk reduction behaviors. This study observed a decrease between the risk behaviors in the first twelve months and a reappearance of these behaviors when monitored on the 18th month. Further emphasis was placed on retention techniques since this second phase involves a longer time range for the follow up visits (from one year to eighteen months). With proper consent, participants are photographed at the clinic, and 2 study identification cards are developed. One is provided to them and the second is kept at the clinic for identification purposes. This strategy has been proven effective in improving the retention of the CBO participants by providing the outreachers reminders of the participants which they are looked for in the community for their follow up visits. Another retention technique was the establisher of contact visits. They were added so that there would be less time between visits and participants would maintain contact and interest in the study. In each of these visits, participants benefit form hygiene materials, condoms, lubricants, and snacks. By attending, participants also acquire a better knowledge of their health status, and receive immediate referrals if needed. As of April 30, 2007, a total of 116 participants have been recruited. Of these, 55 where from the family planning clinic, 31 from the STI clinic, and 60 from the CBO. More than half of the participants from the first phase have finished with all of their follow up visits (62%). Data shows a decrease in their risk behaviors and an increase in their knowledge of HIV/STI. These participants refer high satisfaction rates with the intervention and with the rapid HIV test. Retention rates in the first phase have been high between the CBO participants (94%) and among the family planning clinic (90%). Lower rates have been observed between the STI clinic participants (75%). The loss of these participants can be related to reactive GC/CT test results, living far from the metropolitan area, and living in a rehabilitation home. Based on these previous experiences, several retention strategies have been implemented. Among these, the replacement of participants in case of: missing the first follow up visit, HIV reactive, incarceration, or death. Participants who live in rehabilitation homes or too far from the metropolitan area (study site) are excluded form the sample. Letters reminding appointments are also sent to the participant's home by person, mail, or email. After implementation of these strategies current retention rates for phase II are 100% in all three sites. According to the Satisfaction Questionnaire, participants indicate comprehension of the intervention and feeling comfortable with the interview. Most of the participants indicate relief by knowing their HIV test results in 20 minutes. They also report that the interview is non offensive and organized. All of the participants indicated that they would highly recommend this intervention to a friend. Preliminary ResultsDemographic data indicates that the highest age range was found in the CBO. Most of the participants from the FPC and the CBO were single. The majority of the participants from the STI clinic were in a consensual relationship. Most of the women from the FPC completed undergraduate studies (71%) while most of the participants from the STI clinic (24%), and the CBO (47%) have not completed high school. The majority of the FPC participants reported having a monthly income of $1,200 or more (43%) while the STI-C (24%) and CBO (94%) participants reported a monthly income of less than $300. The highest depression indexes on the CES-D depression scale were obtained in the CBO participants and the lowest index was reported in the FPC. Most of the participants from the FPC reported currently being employed, while the STI-C, and CBO reported being unemployed. Most of the participants from the CBO (77%) reported exchanging sex for money/food/drugs. They also reported the highest number of sexual partners. Most of the FPC participants reported being in monogamous relationships (95%). Most of the new GC/CT diagnoses reveled in the study tests were found in the STI clinic (1 Gonorrhea ; 5 Chlamydia). The only site with HIV reactive results is the CBO (6 cases). At their first visit, most of the participants indicate that they do not use condoms or use them inconsistently. Some street sex workers who had 20 partners per day mentioned that they found it too difficult to find that amount of condoms daily. Most FPC participants concerns about safe sex practices are related to pregnancies, not STIs. Most of them reported using the birth control pill instead of condoms, since they were in a monogamous relationship. Most of the STI-C participants who did not practice safe sex, indicated not using condoms because they were in a stable relationship or because their partner would consider the use of condoms a sign of mistrust or infidelity.Perceptions about barrier methods varied by site. The most positive perceptions were from the STI-C and CBO participants. They trusted the barrier methods and used it whenever available. Most of the FPC participants had negative attitudes toward the use of condoms. Many indicated that it caused them discomfort, allergic reactions, or frequent breakage.Preliminary data reveals a decrease in risk behaviors between the pre and post visit. All of the participants from the FPC and STI-C and most of the participants from the CBO (85%) indicate that they have followed their risk reduction plan. Condom use has increased in all the three sites. Most of the participants especially in the FPC, have grown awareness about the importance of knowing their sexual partners' status and are now asking them to get tested for HIV. A decrease in sharing needles has been observed among intravenous drug users. An increase has also been observed in monogamous relationships and less impulsive sexual practices. In the one year follow up visit, participants reported focusing more on the hygiene of their sexual toys. Six percent of the participants indicated in the first visit being with a partner who they suspect may have an STI. In the last visit, all of these participants reported no longer having these practices. Forty four percent (4/9) of the participants who indicated in the first visit exchanging sex for money or drugs, reported no longer having these practices.
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