Retaining hard-to-reach women in HIV prevention and vaccine trials: Project ACHIEVE.

Project ACHIEVE, which conducts HIV prevention research studies, maintains a women's site in the South Bronx in NewYork City. Owing to a focused retention effort at the South Bronx site, high retention rates were achieved in a vaccine preparedness study for women at high risk of HIV infection. Comparable retention rates have been achieved in HIV vaccine trials with similar cohorts of women at this site. These results suggest that concerns about retaining hard-to-reach populations should not cause these populations to be excluded from HIV vaccine and prevention trials.

Involving women in HIV vaccine efficacy trials: lessons learned from a vaccine preparedness study in New York City.

This paper identifies the recruitment strategies and human immunodeficiency virus (HIV) risk behaviors of at-risk women in an HIV vaccine preparedness study in New York City, assesses how these behaviors changed over time, and draws implications for women's involvement in HIV vaccine efficacy trials. Noninjecting HIV-1 negative women (N = 89) were recruited into an HIV vaccine preparedness study. An observational cohort study design was used. Women were recruited from clinics and community-based organizations (40%), through other study participants (24%), through newspaper advertisements (20%), and through street outreach (16%). Most women who refused (72%) also came from clinics and agencies. Retention after 12 months was 67%; after 18 months, it was 62%. The proportion of women reporting unprotected vaginal sex in the previous 3 months was 85% at baseline and declined to 70% after 12 months (P < .05). There have been no seroconversions detected. Recruitment efforts to include at-risk women in HIV vaccine efficacy trials must be diverse and actively involve community agencies. Successfully retaining these cohorts over time and detecting a high enough HIV seroincidence rate present ongoing challenges that will need to be addressed to ensure women's involvement in future trials in the US.

Acceptability of a stage-matched expert system intervention to increase condom use among women at high risk of HIV infection in New York City.

There is an urgent need to develop and implement effective methods for sexual behavior change to curb the spread of HIV. Condoms remain one of the most effective strategies for achieving this, yet consistent condom use is generally low, especially among those at highest risk. This article describes the acceptability of an interactive computer-based expert system designed to increase condom use in women at high risk of HIV infection. The expert system is based on the transtheoretical stages of change model. Using a computer, participants respond to questions about their attitudes and behavior toward using condoms and receive immediate feedback which is matched to their readiness to use condoms. The women were found to be at all stages of change for condom use, although a large proportion of the women (42%) were at early stages of behavior change because they were considering but not using condoms every time during sex with men. The expert system was found to be acceptable to this high-risk group of women. They almost unanimously agreed that they found the feedback useful, would return to use the system again, and would recommend it to a friend. These findings indicate that traditional intervention strategies which assume individuals are ready to use condoms consistently would be appropriate for only about one third of these women, underscoring the importance and potential utility of stage-matched interventions.

PIP: Condoms remain one of the most effective strategies for achieving sexual behavior change to curb the spread of HIV; yet consistent condom use is generally low, especially among those at highest risk. This article describes the acceptability of an interactive computer-based expert system designed to increase condom use in women at high risk of HIV infection in New York City. The expert system is based on the transtheoretical stages of change model. Using a computer, participants respond to questions about their attitudes and behavior concerning using condoms and receive immediate feedback, which is matched to their readiness to use condoms. The women were found to be at all stages of change for condom use, although a large proportion of the women (42%) were at early stages of behavior change because they were considering but not using condoms every time they have sex with men. The expert system was found to be acceptable to this high-risk group of women. They almost unanimously agreed that they found the feedback useful, would return to use the system again, and would recommend it to a friend. The findings indicate that traditional intervention strategies, which assume individuals are ready to use condoms consistently, would be appropriate for only about one-third of these women, underscoring the importance and potential utility of stage-matched interventions.

Predictors of reported condom use in central Harlem youth as conceptualized by the health belief model.

PURPOSE: To examine the relationship of reported condom use to specific sociodemographics, psychosocial variables, and perceptions of and motivations for condom use as conceptualized by the Health Belief Model. METHODS: This study performed a cross-sectional survey of 557 adolescents enrolled in a hospital-based pregnancy prevention program in an urban community hospital (Harlem Hospital). Multiple logistic regression analysis examined the combined relationship of the significant psychosocial variables to consistent condom use. RESULTS: Males were less likely than females to report teen-parent conflict and depression and more likely to report support for birth control, participation in community activities, and favorable attitudes toward delaying parenthood. Consistent with the Health Belief Model adjusting for age, the strongest predictors of consistent condom use were partner preference for condoms, perceived benefit of avoidance of pregnancy, male gender, and support for birth control (usually by a parent). CONCLUSIONS: The data on this urban, predominantly African-American sample of adolescents suggest the importance of the influences on specific motivations to use protection--that is, the wish to avoid pregnancy, human immunodeficiency virus/acquired immunodeficiency syndrome, and sexually transmitted diseases, although the mechanisms are still unclear. In addition, gender and the modifying effects of parental and partner support of the use of protection strongly influence the reported use of condoms by adolescents. These factors (in addition to psychosocial factors such as depression) may be important in planning interventions to increase condom use by sexually active teens.

PIP: The relationship of condom use to the sociodemographic, psychosocial, and cognitive factors included in the Health Belief Model was investigated in a cross-sectional study of 557 primarily low-income, African-American youth 12-19 years of age (mean age, 15.9 years) enrolled in a pregnancy prevention program at Harlem Hospital, New York City, during 1991-93. 74% reported ever having sex, 51% in the preceding 3 months. At last intercourse, 47% used no protection, 43% reported condom use, and 10% used another method. Males were more than 4 times as likely to report condom use than females. Males had more assets, more positive attitudes toward delaying parenthood, less teen-parent conflict, less depression, and more social support for birth control than females. Consistent with the Health Belief Model, the strongest predictors of consistent condom use (after adjustment for age) were partner preference for condoms, perceived benefit of avoidance of pregnancy, male gender, and social (mostly parental) support for birth control. These factors should be considered in the planning of interventions to increase condom use among sexually active teenagers.

AIDS: knowledge, skills and attitudes among vocational trainees and their trainers.

In order to assess the adequacy of learning about the human immunodeficiency virus (HIV) and the acquired immune deficiency syndrome (AIDS) in vocational training for general practice, a postal questionnaire survey was carried out among trainers and their trainees in seven health regions of England and Scotland. A total of 616 trainers (62%) and 538 trainees (58%) responded to the questionnaire asking about their knowledge, skills and attitudes regarding HIV and AIDS. Trainees' principal difficulties with HIV and AIDS resembled those of general practitioners currently in practice. More than 60% of trainees lacked knowledge about HIV and AIDS in babies, 50% would not accept intravenous drug misusers onto their list, only 12% found it easy to discuss sex with homosexual male patients, and only 37% felt able to offer counselling about HIV and AIDS. Trainees who had had a tutorial on HIV and AIDS as part of vocational training were significantly more knowledgeable than the remainder (P less than 0.01). In addition, trainees who found workshops on HIV and AIDS useful were more willing than others to take on drug misusers (P less than 0.05) and more confident in their ability to counsel patients with HIV infection (P less than 0.01). No significant associations were found between the trainers' own knowledge, attitudes and skills regarding HIV and AIDS and those of their trainees. It is concluded that there is a need to improve teaching about HIV and AIDS in vocational training for general practice. All general practitioner trainees should receive a tutorial to update their knowledge about HIV and AIDS, and attend a suitable workshop to challenge unfavourable attitudes and improve confidence in counselling.