Sex and Female Empowerment (SAFE): Learning from health care providers, men and women to design a sexual health intervention for women with substance use disorders.

BACKGROUND: Substance Use Disorder (SUD) treatment is a promising setting to provide sexual health education to women. This study examined barriers and possible solutions to effectively providing sexual health education and services during SUD treatment. METHODS: To obtain a full picture of the barriers and solutions, 29 cisgender women and 17 cisgender men in treatment for a SUD and four health care providers in North Carolina were interviewed regarding the domains of pregnancy-planning, barriers to reproductive health services and contraception, selecting a method of contraception and desired aspects and elements of a sexual health intervention. RESULTS: Eight themes and 12 sub-themes emerged that included how addiction impacts pregnancy planning and pregnancy motivations, the stigma and fear regarding accessing health services, the lack of accurate knowledge of the human reproductive cycle and contraceptive methods and worries about contraception side-effects. Recommendations for interventions to reduce unintended pregnancy in this treatment population included the need for simple and focused information given by trusted communicators in a short time frame in accessible locations, and offering incentives for participation such as food and transportation. CONCLUSION: As SUD treatment providers and programs look to improve access to sexual health and contraceptive options for women with SUD, these eight themes provide helpful guidance in crafting future interventions.

Sex and female empowerment (SAFE): A randomized trial comparing sexual health interventions for women in treatment for opioid use disorder.

BACKGROUND: Unintended pregnancies are prevalent among women with opioid use disorder (OUD). The Sex and Female Empowerment (SAFE) project developed a social-cognitive, theory-driven intervention to increase acceptance of and adherence to contraceptive practices among women receiving medication for OUD (MOUD). This study evaluated the feasibility and acceptability of two SAFE interventions (Face-to-face and Computer-adapted) compared to usual care as well as their efficacy to improve contraception utilization. METHODS: This pilot randomized trial enrolled 90 heterosexual, non-pregnant, reproductive-age women receiving MOUD. Participants were randomized into either a: SAFE Face-to-face intervention, SAFE Computer-adapted intervention, or usual care (UC) condition (n = 30 each) and followed for 6 months. Outcome measures included intervention completion, intervention satisfaction, attendance at a contraception consultation appointment, and long-acting reversible contraceptive (LARC) method receipt. A generalized linear model was used for inferential testing and to estimate least squares means (predicted probabilities for binary outcomes) and their standard errors. RESULTS: Compared to the UC condition, both the SAFE Face-to-face and the SAFE Computer-adapted intervention had higher intervention completion [Means (Standard Errors) = 0.97 (.03) and 0.97 (.03), respectively, vs. 0.53 (.09); ps<.001], higher intervention satisfaction [Ms (SEs) = 3.7 (.11) and 3.8 (.11), respectively, vs. 3.1 (.11); ps<0.001), higher contraception consultation visit attendance [Ms(SEs) = 0.80 (.07) and 0.73 (.08) vs. 0.33 (.09); p < .001], and greater LARC receipt [Ms(SEs) = 0.77 (.08) and 0.73 (.08) vs. 0.23 (.08); p < .001). CONCLUSIONS: SAFE appears feasible and efficacious for supporting women in contraception decision-making. Integrating SAFE into women's comprehensive OUD treatment services holds promise to increase contraceptive decision-making and initiation of a chosen method.

The influence of social determinants on sexual risk among out-of-school African American female adolescents.

Formative research was conducted to understand the social determinants of HIV risk among African American female adolescents as part of a systematic adaptation of an evidence-based behavioral HIV prevention intervention, the Women's CoOp. Semi-structured in-depth interviews were conducted between November 2008 and April 2009 with 20 African American female adolescents aged 16-18 who reported engaging in sex, using alcohol or other drugs, and dropping out of school. All interviews were audio recorded, transcribed, and coded for key themes and emergent content patterns. The findings indicate that while female adolescents are knowledgeable about HIV and other sexually transmitted infections (STIs), myriad social factors relate to their level of risk. Interpersonal relationships, primarily with older boyfriends and friends, played a pivotal role in their decision-making regarding sex risk behavior, substance use, and educational attainment. A lack of viable employment opportunities, exacerbated by the lack of a high school education, resulted in some young women trading sex to make money. In addition, violence, victimization, and gang involvement are pervasive in their communities. Out-of-school African American female adolescents face a plethora of issues that are directly and indirectly related to their sex risk behaviors and consequently their HIV/STI risk. To reach a vulnerable population disproportionately affected by HIV and other STIs, these factors must be addressed in prevention interventions, when feasible. The findings were incorporated into the intervention adaptation that is currently being tested in a randomized controlled trial.

Double jeopardy--drug and sex risks among Russian women who inject drugs: initial feasibility and efficacy results of a small randomized controlled trial.

BACKGROUND: With HIV prevalence estimated at 20% among female injecting drug users (IDUs) in St. Petersburg, Russia, there is a critical need to address the HIV risks of this at-risk population. This study characterized HIV risks associated with injecting drug use and sex behaviors and assessed the initial feasibility and efficacy of an adapted Woman-Focused intervention, the Women's CoOp, relative to a Nutrition control to reduce HIV risk behaviors among female IDUs in an inpatient detoxification drug treatment setting. METHOD: Women (N = 100) were randomized into one of two one-hour long intervention conditions--the Woman-Focused intervention (n = 51) or a time and attention-matched Nutrition control condition (n = 49). RESULTS: The results showed that 57% of the participants had been told that they were HIV-positive. At 3-month follow-up, both groups showed reduced levels of injecting frequency. However, participants in the Woman-Focused intervention reported, on average, a lower frequency of partner impairment at last sex act and a lower average number of unprotected vaginal sex acts with their main sex partner than the Nutrition condition. CONCLUSION: The findings suggest that improvements in sexual risk reduction are possible for these at-risk women and that more comprehensive treatment is needed to address HIV and drug risks in this vulnerable population.

Pregnant and nonpregnant women in cape town, South Africa: drug use, sexual behavior, and the need for comprehensive services.

The multiple risks associated with methamphetamine use are of serious concern for women. These risks and consequences are magnified during pregnancy. This secondary analysis of a parent study compared 26 pregnant to 356 nonpregnant women in Cape Town, South Africa, on selected demographic, psychosocial, and HIV-risk domains to identify their treatment service needs. Proportionally, more pregnant than nonpregnant women are using methamphetamine, P = .01, although a very high rate of women used methamphetamine. Women reported similar monthly rates of sexual intercourse, but pregnant women were significantly less likely to report condom use, P < .0001, maintaining their risky behavior. Both groups reported elevated Center for Epidemiological Studies Depression Scale CES-D means, suggesting a need for depression treatment. Results demonstrate a pervasive need for women's comprehensive treatment, regardless of pregnancy status. Moreover, findings support the urgent need for women-focused and pregnancy-specific treatment services for methamphetamine use. Finally, a job-skills training/employment component focus is suggested.

Initial feasibility of a woman-focused intervention for pregnant african-american women.

African-American women who use crack are vulnerable to HIV because of the complex social circumstances in which they live. Drug-abuse treatment for these women during pregnancy may provide time for changing risk behaviors. This paper examines the initial 6-month feasibility of a women-focused HIV intervention, the Women's CoOp, adapted for pregnant women, relative to treatment-as-usual among 59 pregnant African-American women enrolled in drug-abuse treatment. At treatment entry, the women were largely homeless, unemployed, practicing unsafe sex, and involved in violence. Results indicated marked reductions in homelessness, use of cocaine and illegal drugs, involvement in physical violence, and an increase in knowledge of HIV from baseline to 6-month followup for both conditions. Findings suggest that the Women's CoOp intervention could be successfully adapted to treat this hard-to-reach population. Future studies should examine the efficacy of the pregnancy-adapted Women's CoOp for women not enrolled in drug-abuse treatment.

Adapting an evidence-based HIV prevention intervention for pregnant African-American women in substance abuse treatment.

An adaptation of an evidence-based, woman-focused intervention designed to reduce HIV risk behaviors was conducted for pregnant, African-American women in substance abuse treatment in North Carolina. The intervention adaptation process included focus groups, expert panels, and the filming of women who spoke about their experiences with pregnancy, drug use, sex risk behaviors, HIV testing and treatment, need for substance abuse treatment, violence, and victimization. The assessment instrument was adapted for pregnant women and the intervention was organized into a 4-session PowerPoint presentation, with an additional session if a woman tested positive for HIV. All sessions and assessment instrument were installed on laptop computers for portability in treatment programs. We pilot tested our adaptation with 59 pregnant African-American women who had used an illicit drug within the past year and were enrolled in substance abuse treatment. At baseline, 41% were currently homeless, 76% were unemployed, 90% had not planned their current pregnancy, and approximately 70% reported drug use since finding out about the pregnancy. This sample of participants rated the intervention sessions and were highly satisfied with their experience, resulting in a mean satisfaction score of 6.5 out of 7. Pregnant African-American women who use drugs need substance abuse treatment that they do not currently access. Woman-focused HIV interventions help to address intersecting risk behaviors and need for treatment prevalent among this vulnerable group.

Health services utilization among South African women living with HIV and reporting sexual and substance-use risk behaviors.

HIV health services are critical in sub-Saharan African where the burden of the HIV pandemic is devastating. Existing studies suggest that HIV-infected individuals from marginalized populations who know their status do not seek health services because they are unaware of available treatment and care options, may not understand how to access services, or have poor access to and utilization of health care services. This study examined factors associated with health service utilization in a sample of poor, underserved recently diagnosed HIV-positive South African women with sexual and substance use risk behaviors. The data were collected between June 2004 and May 2008. Primary outcomes included consultation with a medical professional and utilization of any health services since learning of HIV status at 3- and 6-month follow-up assessments. The study findings suggest that denial of HIV status may be a barrier to care, leading study participants to avoid utilizing health services specific to their disease and to prefer more general medical care services. In multivariate analyses, prior use of health services, financially supporting others, and sex trading were strongly associated with health service use at follow-up assessments. The study findings suggest a reduced likelihood of health services utilization among participants who met DSM-IV criteria for drug abuse as well as participants with greater numbers of poor physical health symptoms. As an important preliminary step in examining the issue of health services utilization in sub-Saharan Africa, the findings suggest an urgent need to promote HIV prevention and early testing, to strengthen long-term HIV care services, and to increase access to services.

Sustainability of intervention effects of an evidence-based HIV prevention intervention for African American women who smoke crack cocaine.

BACKGROUND: HIV prevention intervention efficacy is often assessed in the short term. Thus, we conducted a long-term (mean 4.4 years) follow-up of a woman-focused HIV intervention for African American crack smokers, for which we had previously observed beneficial short-term gains. METHODS: 455 out-of-treatment African American women in central North Carolina participated in a randomized field experiment and were followed up to determine sustainability of intervention effects across three conditions: the woman-focused intervention, a modified NIDA intervention, and a delayed-treatment control condition. We compared these groups in terms of HIV risk behavior at short-term follow-up (STFU; 3-6 months) and long-term follow-up (LTFU; average 4 years). RESULTS: The analyses revealed two distinct groups at STFU: women who either eliminated or greatly reduced their risk behaviors (low-risk class) and women who retained high levels of risk across multiple risk domains (high-risk class). At STFU, women in the woman-focused intervention were more likely to be in the low HIV risk group than the women in control conditions, but this effect was not statistically significant at LTFU. However, low-risk participants at STFU were less likely to be retained at LTFU, and this retention rate was lowest among women in the woman-focused intervention. CONCLUSIONS: Short-term intervention effects were not observed over 4 years later, possibly due to differential retention across conditions. The retention of the highest risk women presents an opportunity to extend intervention effects through booster sessions for these women.