Programmes, resources, and needs of HIV-prevention nongovernmental organizations (NGOs) in Africa, Central/Eastern Europe and Central Asia, Latin America and the Caribbean.

This study assessed the programmes, resources, and needs of HIV-prevention nongovernmental organizations (NGOs) in 75 countries in Africa, Central/Eastern Europe and Central Asia, Latin America and the Caribbean. Multiple databases and expert recommendations were used to identify one major HIV-prevention NGO in the capital or a large city in each country, and in-depth interviews were conducted with each NGO Director. Most NGOs are carrying out their programmes with minimal funding and few regularly employed personnel. Most are highly dependent on international donors, but reliance on small grants with short funding periods limits programme development capacity. HIV-prevention activities varied by region, with African NGOs most likely to use peer education and community awareness events; Eastern European NGOs most likely to offer needle exchange; Latin American NGOs to have resource centres and offer risk reduction programmes; and Caribbean organizations to use mass education approaches. Across regions, NGOs most often targeted the general public and youth, although specialized at-risk groups were the additional focus of attention in some regions. Limited funding, governmental indifference or opposition, AIDS stigma, and social discomfort discussing sex were often cited as barriers to new HIV-prevention programmes. NGOs are critical service providers. However, their funding, programmes, and resource capacities must be strengthened if NGOs are to realize their full potential in HIV prevention.

Drug use and sexual risk behaviours among female Russian IDUs who exchange sex for money or drugs.

Countries of the former Soviet Union are experiencing the steepest increases in annual HIV incidence in the world. Over 80% of registered HIV cases in Russia have occurred among intravenous drug users (IDUs), but current conditions set the stage for a heterosexually-transmitted epidemic. IDUs who also trade sex for money or drugs may serve as a conduit, or 'bridge' group, through which HIV could make inroads into the general Russian population. The present study examined the prevalence of sex trading among female Russian IDUs, and further examined drug use, sexual behaviour, and perceived vulnerability in this group. Female IDUs (n=100) in St Petersburg, Russia participated; 37% reported a history of sex trading. This group reported a mean of 49.5 male sexual partners in the previous month and an average of 15.4 unprotected vaginal intercourse acts in the previous 30 days. A significant minority (44%) also reported sharing injection equipment with others. Mathematical models to calculate risk estimates for HIV seroconversion indicated that participants were at significant risk of contracting HIV and infecting sexual partners. Despite significant rates of risk behaviours, most participants perceived themselves to be at little risk of contracting HIV. Effective HIV prevention programmes targeted at this group are urgently needed and are likely to be a cost-effective step in curtailing the spread of HIV in the region.

HIV prevention nongovernmental organizations in Central and Eastern Europe: programs, resources and challenges.

HIV incidence is rising more rapidly in some areas of Central and Eastern Europe than anywhere else in the world. Carrying out effective HIV prevention programs requires the presence of "bridges" that can reach community populations most vulnerable to the disease. Nongovernmental organizations (NGOs) are in a natural role to conduct HIV prevention programs. The Directors of 29 HIV prevention NGOs representing almost all countries in Central and Eastern Europe participated in in-depth interviews by telephone. The broad topics of these interviews included descriptions of the three largest programs conducted by each NGO during the past six months, at-risk target populations served, major barriers faced, and funding sources that sponsored HIV prevention activities. NGO programs most often targeted injection drug users (IDUs); other stigmatized groups were less frequently served by NGOs in the sample. The most common types of prevention activities were needle exchange, HIV prevention peer education, and delivering AIDS presentations and distributing educational materials. Among the major barriers that hampered effective conduct of HIV prevention programs were a shortage of available financial resources, governmental indifference or opposition, and AIDS-related stigma. National governments rarely provided substantial funds for NGO programs, and most funding came from United Nations agencies or private foundations. The information sources reported to be most helpful in assisting NGOs in program development were sharing ideas with other NGOs, participating in conferences, and accessing information from the Internet. A number of programs reported by the NGO Directors were innovative, outstanding, and comprehensive. Five such exemplary programs are described in this article. HIV epidemics in the region are still potentially controllable. NGOs need immediate support so that they can carry out their community-based activities on a larger scale.

HIV risk behaviour among men who have sex with men in public sex environments: an ecological evaluation.

Men who have sex with men (MSM) in public sex environments (PSE) may be at high risk for HIV/AIDS. The majority of research on HIV risk behaviour among MSM has been conducted in open access venues more likely to be linked to networks that openly endorse preventive messages and safer sex norms. This study investigated risk practices among MSM in a PSE in order to develop effective prevention intervention strategies. Three outreach workers with previous MSM prevention experience trained in ethnographic and fieldwork observation techniques provided direct observation data. Seventy-seven observations, each lasting a minimum of two hours, were conducted over a five-month period at three city public parks. Of 614 men observed, over 250 exhibited activities and behaviours related to, or potentially related, to HIV-risk relevant sexual behaviour. Direct sexual contact between two or more men was observed 19 times, while men entering or leaving a sex area of the park was observed 66 times. Outreach workers were able to interact directly with 72 MSM, primarily discussing safer sex strategies. Sexual encounters occurred in more open areas of the PSE with partners migrating to secluded areas for intense and sexual interactions. Future prevention interventions will need to be tailored, and targeted, to specific sexual exchange access points in PSE.

Bridging the gap between the science and service of HIV prevention: transferring effective research-based HIV prevention interventions to community AIDS service providers.

OBJECTIVES: AIDS service organizations (ASOs) rarely have access to the information needed to implement research-based HIV prevention interventions for their clients. We compared the effectiveness of 3 dissemination strategies for transferring HIV prevention models from the research arena to community providers of HIV prevention services. METHODS: Interviews were conducted with the directors of 74 ASOs to assess current HIV prevention services. ASOs were randomized to programs that provided (1) technical assistance manuals describing how to implement research-based HIV prevention interventions, (2) manuals plus a staff training workshop on how to conduct the implementation, or (3) manuals, the training workshop, and follow-up telephone consultation calls. Follow-up interviews determined whether the intervention model had been adopted. RESULTS: The dissemination package that provided ASOs with implementation manuals, staff training workshops, and follow-up consultation resulted in more frequent adoption and use of the research-based HIV prevention intervention for gay men, women, and other client populations. CONCLUSIONS: Strategies are needed to quickly transfer research-based HIV prevention methods to community providers of HIV prevention services. Active collaboration between researchers and service agencies results in more successful program adoption than distribution of implementation packages alone.

Dilemmas in conducting qualitative sex research in applied field settings.

Although resources are available to inform researchers of the many technical skills necessary to conduct qualitative research, individuals working in applied field settings often encounter ethical, moral, and sociopolitical dilemmas that cannot be resolved through the application of technical skills. The purpose of this article is to present examples of dilemmas faced by qualitative research methodologists studying sexual behavior in applied field settings. Possible solutions to these dilemmas are discussed within a theoretical and conceptual framework. The examples and discussion are organized around four broad topic areas: informed consent, privacy, confidentiality, and personal relationships.

Life optimism, substance use, and AIDS-specific attitudes associated with HIV risk behavior among disadvantaged innercity women.

The development of more effective human immunodeficiency virus (HIV) prevention programs for disadvantaged women requires identification of factors associated with risk. In the present study, 158 women - all of whom met criteria indicative of HIV risk - were recruited in innercity primary healthcare clinics and administered measurements that assessed variables in three domains believed pertinent to HIV sexual risk behavior: (1) substance use in the past 3 months, (2) acquired immunodeficiency syndrome (AIDS)-specific cognitive and attitudinal factors, including AIDS risk knowledge, condom attitudes, perceived risk for AIDS, behavior change intentions, and perceived self-efficacy, and (3) life context variables, including self-esteem, fatalism, personal optimism toward the future, and current life satisfaction. When women were categorized into highest and lower groups based on their recent risk behavior, AIDS-specific cognitive and attitudinal factors, as expected, differentiated the groups. However, women at highest risk for HIV also most often used a variety of substances and scored lower in self-esteem, held views more characterized by personal fatalism and low optimism concerning the future, and had greater life dissatisfaction than women at lower risk. HIV prevention programs for disadvantaged women require attention not only to AIDS-specific knowledge, attitudes, and skills development but also to broader issues of life context that, if unaddressed, may limit women's ability and motivation to reduce risk for HIV/AIDS.

Current HIV prevention activities for women and gay men among 77 ASOs.

Community-based AIDS service organizations (ASOs) are important providers of HIV prevention services in cities throughout the United States. This study examined the types of HIV prevention programs that are being undertaken by ASOs and assessed the kinds of new programs that ASOs feel are needed as the HIV epidemic continues to evolve. Factors that will need attention as new HIV prevention programs are developed by ASOs include high turnover of personnel in the organizations, capacity building that will be needed for ASOs to offer more intensive or specialized programs, and strategies to provide technical assistance as ASOs develop new types of programs.

"Lifepoint": a case study in using social science community identification data to guide the implementation of a needle exchange program.

The public health benefits of needle exchange programs (NEPs) are well known. NEPs lower risk factors for HIV transmission by providing injection drug users (IDUs) with clean syringes and needles; harm reduction materials; and referrals to drug, sexually transmitted disease, mental health, and medical treatment facilities. While exchange programs continue to be implemented, there have been few reports illustrating how social science and community assessment research can be used to guide the development of NEPs. Using the Lifepoint needle exchange program in Milwaukee as a case study, this paper shows how social science methods can be used to understand IDU culture through the community identification process, link qualitative and observational findings to program decision making, and guide the implementation and operation of a needle exchange. The community identification process showed that there were different IDU subcultures in the city indicating that the NEP would need to be tailored to meet the distinctive needs of multiple drug use networks. Ethnographic field observations and key informant and systems representative interviews resulted in a two-stage NEP planning process that included a community task force on IDUs and of the development of methods to operationalize community assessment findings into the operating plan of the NEP. This process illustrates the importance of integrating a systematic community analysis in the planning of a NEP.

Factors influencing attitudes within AIDS service organizations toward the use of research-based HIV prevention interventions.

Although the efficacy of small-group, risk reduction interventions based on cognitive behavioral principles has been widely documented in HIV behavioral research literature, little is known about how AIDS service organizations (ASOs) view these research-based models. From a nationwide sample of 77 ASOs, this study assessed factors influencing attitudes of prevention program directors and frontline staff toward research-based interventions. Characteristics of individual respondents as well as organizational characteristics of the ASO itself were used to predict perceived benefits of adopting this type of intervention, perceived efficacy (confidence) in the ASO's ability to implement it, and perceived barriers to adoption. Findings revealed uniformly positive perceptions of benefits among respondents from ASOs of different sizes and organizational experiences, although directors held more favorable evaluations than frontline staff. Respondents from ASOs that were larger, had previously delivered group or workshop interventions, or had received outside technical assistance in the past expressed more confidence in the ability of their ASO to implement the intervention. On the other hand, older and more highly education individuals had less confidence in their organization's ability to implement the model. Resource constraints (money, staff, and time) were the most common barriers cited by the respondents. Overall, higher organizational role and longer tenure at an ASO were associated with the perception of more barriers to adopting science-based interventions. Respondents from ASOs with a history of receiving technical assistance reported fewer perceived barriers. The successful dissemination of HIV prevention models from the research arena to the service arena will require mechanisms to provide appropriate funding and technical assistance, particularly to smaller organizations. Mindful of the resource constraints faced by ASOs, researchers can facilitate this process by attempting to develop interventions that are less resource- and time-consuming than current models.

Barriers to care among persons living with HIV/AIDS in urban and rural areas.

People living with HIV disease, particularly those in small towns and rural areas, face many barriers that prevent them from receiving important life-care services. We developed the Barriers to Care Scale (BACS) to delineate the problem severity of factors that impede care and service provision among a sample of 226 men and women living with HIV disease in a single midwestern state. Both urban and rural respondents indicated that major barriers to life-care services included the lack of knowledge about HIV among citizens in the community, insufficient personal financial resources, the lack of employment opportunities for people living with HIV, and the lack of supportive and understanding work environments. Rural persons living with HIV disease, compared to their urban counterparts, assigned significantly higher problem severity ratings to the following barriers: the need to travel long distances to medical facilities and personnel; a shortage of adequately trained medical and mental health professionals; a lack of personal or public transportation; and community residents' stigma toward people living with HIV. The large number of barriers to care identified in the present study indicates that innovative programmes designed to remove these barriers and improve the life quality of rural persons living with HIV are urgently needed.

Psychosocial differences between urban and rural people living with HIV/AIDS.

During the past decade, many investigations have examined the life circumstances of people living with HIV disease. Most of these studies, however, have focused on HIV-infected people in large metropolitan areas. This study compares the psychosocial profiles of rural and urban people living with HIV disease. Anonymous, self-administered surveys were completed by 276 people with HIV/AIDS in a Midwestern state. The assessment instrument measured respondents' quality of life, perceptions of loneliness, social support, experiences with AIDS-related discrimination, access to services, and illness-related coping strategies. Compared with their urban counterparts, rural people with HIV reported a significantly lower satisfaction with life, lower perceptions of social support from family members and friends, reduced access to medical and mental health care, elevated levels of loneliness, more community stigma, heightened personal fear that their HIV serostatus would be learned by others, and more maladaptive coping strategies. Programs that are designed to improve the life circumstances of people with HIV disease in rural areas--particularly those that facilitate access to adequate health care, increase perceptions of social support, and improve illness-related coping--are urgently needed.

Differences between completers and early dropouts from 2 HIV intervention trials: a health belief approach to understanding prevention program attrition.

OBJECTIVES: The purpose of this study was to identify factors predicting program attrition among participants in human immunodeficiency virus (HIV) risk reduction trials. METHODS: Participants were gay/bisexual men and severely mentally ill adults recruited to take part in HIV risk reduction small-group interventions. Program completers were compared with participants who were assessed at baseline but then failed to attend any sessions. The health belief model provided a framework for selection of possible predictors of program attrition. RESULTS: Younger age was associated with early dropout in both samples. Other predictors among gay/bisexual men included involvement in an exclusive sexual relationship, minority ethnicity, injection drug use, and higher perceived severity of AIDS. Severely mentally ill dropouts were less knowledgeable about safer sex methods and more likely to hold positive outcome expectancies for condom use. CONCLUSIONS: Evaluation of intervention effectiveness among vulnerable population segments is threatened if there is selective attrition. Better methods are needed to attract and maintain participation in HIV prevention programs. Alternatively, wider application of "intention to treat" analysis of intervention outcomes is recommended to minimize selection bias due to program dropout.

Patterns, predictors, and situational contexts of HIV risk behaviors among homeless men and women.

The study discussed in this article investigated psychosocial, relationship, and situational factors associated with HIV risk in a sample of 152 inner-city homeless men and women. Although men at risk of AIDS often had multiple sexual partners, women reported fewer different partners but more frequent unprotected intercourse with them. Different factors were associated with HIV risk level among men and women. In men, high-risk patterns were associated with negative attitudes toward condom use, low levels of intentions to use condoms, high perceived risk of AIDS, and low perceived self-efficacy for avoiding risk. Women at high risk of HIV infection had greater life dissatisfaction; were less optimistic and held more fatalistic views about the future; held more negative condom attitudes; perceived themselves to be at risk; and frequently used alcohol, marijuana, and crack cocaine. HIV prevention efforts tailored to the different risk circumstances of men and women are urgently needed in social services programs for homeless people.

Developmental stages and spiritual coping responses among economically impoverished women living with HIV disease.

Identifies environmental markers, situational appraisals, perceived ability to mediate situations and outcomes, primary coping strategies, and purposes served by religion and spirituality in 10 HIV-positive women recruited from a regional health care clinic. Findings indicated that the women experienced a disintegration of family during their early developmental years, yielding feelings of hopelessness and isolation; that their sexual development was marked by rape and incest, and their early adulthood was characterized by failed relationships, pregnancies, drugs, and alcohol. Reports that the women's religious influences were predominantly maternal and provided a model for intercessory prayer. Notes that prior to their diagnosis of HIV, participants described their coping as escapist, while after diagnosis they believed there was a divine intercession renewing their spiritual growth and connectedness with others. Reports that the women's personal spirituality was greatly influenced by prayer, television ministries, and reading the Bible. Suggests the interventions that actively recruit women into social support services, health care systems, and faith congregations are needed and that television ministries may serve as access points for connecting women with necessary services.

Reduction in risk behavior among adults with severe mental illness who learned to advocate for HIV prevention.

OBJECTIVES: The study evaluated the relative impact of HIV risk reduction interventions for adults with severe mental illness living in the inner city. METHODS: A total of 104 chronically mentally ill men and women were interviewed to determine sexual risk behavior over the past month and to assess HIV risk-related psychological characteristics, including their knowledge about risk behavior, their belief in their ability to change their behavior, their perceptions of peer and social norms about safer sex, their expectancies about the outcomes of these changes, and their perceived barriers to condom use. Participants were then randomly assigned to one of three conditions: a single AIDS education session, a seven-session cognitive-behavioral HIV risk reduction group intervention, or a seven-session group intervention that combined the cognitive-behavioral intervention with training to act as a risk reduction advocate to friends (advocacy training). Individuals were reinterviewed three months after completion of the intervention. RESULTS: Although all participants exhibited change at follow-up in some risk-related psychological characteristics and sexual risk behaviors, participants who received the cognitive-behavioral intervention that included the advocacy training reported greater reductions in rates of unprotected sex and had fewer sexual partners at follow-up. CONCLUSIONS: HIV prevention interventions that teach risk reduction skills and then encourage participants to advocate behavior change to others appear to strengthen participants' capacity to change their behavior to reduce HIV risk, even those from a disenfranchised group such as severely mentally ill adults.

Psychosocial predictors of life satisfaction among persons living with HIV infection and AIDS.

As AIDS becomes a more chronic but manageable illness, understanding quality of life issues among persons living with this disease has become an important goal of health care researchers. However, most quality of life investigations of persons living with HIV disease have relied heavily on clinical samples (e.g., hospitalized patients, psychiatric outpatients). The present study sought to identify psychosocial predictors of general life satisfaction in a community sample of 275 persons living with HIV/AIDS in a large midwestern state. Principal components and multiple regression analyses revealed that improved physical/functional well-being, increased social support, more frequent use of active coping strategies, and fewer incidents of AIDS-related discrimination and stigma predicted higher levels of general life satisfaction (R2 = 39). Intervention strategies likely to produce higher levels of life satisfaction among persons living with HIV disease are discussed.

Women living with HIV/AIDS: the dual challenge of being a patient and caregiver.

More than 60,000 women in the United States have been diagnosed with AIDS, and millions of women worldwide are infected with HIV. Most of these women will die at an early age, leaving their children motherless. During their HIV illness, women confront the challenge of being both patient and family caregiver. Little research has explored this dual challenge. The authors conducted semistructured one-hour interviews with HIV-positive women that focused on the impact of the HIV diagnosis on the women's lives. Significant factors emerging from the interviews included the impact of stigma associated with HIV/AIDS, disbelief of the diagnosis, the lack of a guardian for their children, the paucity of women's support groups, and barriers associated with seeking services. All women exhibited evidence of clinical depression. A model for multidisciplinary intervention is proposed that focuses on women's needs within their family systems.

The response of religious congregations to the spiritual needs of people living with HIV/AIDS.

Investigates the perceptions and responses of members of five diverse religious congregations to the spiritual needs of people living with AIDS, the impact of AIDS on membership participation, and the beliefs held by different congregations regarding AIDS. Evaluates and compares the AIDS-related perceptions of 204 participants in five congregations (Buddhists, Catholic, Fundamental Christians, Protestants, and Unitarians). Results indicated that congregations differed in how their members responded to the spiritual needs of people living with HIV/AIDS, the level of influence AIDS had on membership participation in formal religions, and whether AIDS was seen as the result of sinful behavior or divine retribution. Concludes that the congregational differences appeared consistent with the core beliefs of the faith communities. Suggests that clergy and congregations need to take specific steps to provide spiritual support to people living with HIV/AIDS consistent with their history of caregiving to all people regardless of the crisis situation.

An empirical investigation of the relationship between spirituality, coping, and emotional distress in people living with HIV infection and AIDS.

Evaluates levels of psychological distress, coping mechanisms, and their relationship with the religious beliefs and spiritual practices of people (N=65) living with HIV and AIDS. Results of the research indicate a strong relationship for spiritual dimensions with mental health, psychological adjustment, and coping. Concludes that a blending of spiritual traditions and mental health approaches are needed to facilitate the coping of people living with HIV and AIDS.