HIV/AIDS Misconceptions may be Associated with Condom Use among Black South Africans: an Exploratory Analysis

In South Africa; approximately 20of 15-49-year-olds are infected with HIV. Among black South Africans; high levels of HIV/AIDS misconceptions (e.g. HIV is manufactured by whites to reduce the black African population; AIDS is caused by supernatural forces or witchcraft) may be barriers to HIV prevention. We conducted a cross-sectional study of 150 young black adults (aged 18-26; 56males) visiting a public clinic for sexually transmitted infections; to investigate whether HIV/AIDS misconceptions were related to low condom use in main partner relationships. We assessed agreement with HIV/AIDS misconceptions relating to the supernatural (e.g. witchcraft as a cause of HIV) and to genocide (e.g. the withholding of a cure). In multivariate models; agreement that `Witchcraft plays a role in HIV transmission' was significantly related to less positive attitudes about condoms; less belief in condom effectiveness for HIV prevention; and lower intentions to use condoms among men. The belief that `Vitamins and fresh fruits and vegetables can cure AIDS' was associated with lower intentions among men to use condoms. Women who endorsed the belief linking HIV to witchcraft had a higher likelihood of unprotected sex with a main partner; whereas women who endorsed the belief that a cure for AIDS was being withheld had a lower likelihood of having had unprotected sex. Knowledge about distinct types of HIV/AIDS misconceptions and their correlates can help in the design of culturally appropriate HIV-prevention messages that address such beliefs

It's not just what you say: relationships of HIV dislosure and risk reduction among MSM in the post-HAART era.

In the post-HAART era, critical questions arise as to what factors affect disclosure decisions and how these decisions are associated with factors such as high-risk behaviors and partner variables. We interviewed 1,828 HIV-positive men who have sex with men (MSM), of whom 46% disclosed to all partners. Among men with casual partners, 41.8% disclosed to all of these partners and 21.5% to none. Disclosure was associated with relationship type, perceived partner HIV status and sexual behaviors. Overall, 36.5% of respondents had unprotected anal sex (UAS) with partners of negative/unknown HIV status. Of those with only casual partners, 80.4% had >1 act of UAS and 58% of these did not disclose to all partners. This 58% were more likely to self-identify as gay (versus bisexual), be aware of their status for <5 years and have more partners. Being on HAART, viral load and number of symptoms were not associated with disclosure. This study - the largest conducted to date of disclosure among MSM and one of the few conducted post-HAART - indicates that almost 1/5th reported UAS with casual partners without disclosure, highlighting a public health challenge. Disclosure needs to be addressed in the context of relationship type, partner status and broader risk-reduction strategies.

Assessing sexual risk behaviour with the Timeline Followback (TLFB) approach: continued development and psychometric evaluation with psychiatric outpatients.

This paper describes a series of 4 studies, designed to provide evidence of the feasibility, reliability, and validity of the Timeline Followback (TLFB) method when used to assess sexual risk behaviour with psychiatric outpatients. This population was selected because patients often have difficulty completing assessments of sexual risk behaviours due to deficits in attention, memory, and communication skills. All 4 studies demonstrated the feasibility of the HIV-risk TLFB. Study 1 also demonstrated that it can be completed in 20 min, and scored in less than 10 min. Qualitative data revealed that both patients and assessors found the features of the TLFB helpful. Study 2 provided evidence that the HIV-risk TLFB can be reliably scored by interviewers whereas Study 3 demonstrated that this measure can be completed reliably by patients and that TLFB of sexual behaviour were consistent over time. Study 4 provided initial evidence for the validity of the HIV-risk TLFB but also suggested that the TLFB may yield frequency estimates that are slightly less than those obtained with single-item measures. We conclude that the TLFB is feasible, reliable, and valid, even in a population known to have difficulty with self-report measures.

The relation of alcohol use to HIV-risk sexual behavior among adults with a severe and persistent mental illness.

The authors examined the relationship between alcohol use and HIV-risk sexual behavior and tested whether alcohol use immediately prior to sex is related to decreased condom use. The participants were 159 adults living with a severe and persistent mental illness. Each participated in a structured interview to assess all sexual and drug-use behavior over a 3-month period. Analysis of 3,026 sexual behaviors reported by 123 sexually active participants indicated that at the global level, participants who drank more heavily were more likely to have engaged in sexual risk behavior. At the event level, however, alcohol use was not related to condom use during vaginal or anal intercourse; that is, participants who used condoms when sober tended to use them to the same extent when drinking.

Generalization of training effects in schizophrenia.

The primary goal of this study was to investigate transfer of training (generalization) in patients with schizophrenia. We randomly assigned 33 schizophrenia subjects to one of three conditions: training on the Wisconsin Card Sort Test (WCST-T), training on the Halstead Category Test (CAT-T), or no training (No-T). The WCST and CAT were administered to all subjects at baseline. Subjects in the WCST-T and CAT-T groups then received training on the respective test, while the No-T group received additional untrained trials. All participants were subsequently retested on the WCST and CAT, and completed a brief neuropsychological battery. As hypothesized, the WCST-T and CAT-T groups exhibited large improvements on the trained test and moderate improvement on the untrained test, while the No-T group failed to show improvement on either test. These results suggest that the training paradigm did produce generalization, and that the changes were not due to practice effects. The extent of generalization across both training groups was strongly associated with neuropsychological test performance (Spearman's rho=0.56, P<0.05). The implications of these findings for rehabilitation programs were discussed, and recommendations were made for future research.

HIV risk sensitization following a detailed sexual behavior interview: a preliminary investigation.

We administered a detailed structured interview of sexual HIV risk behavior to 110 college students (46% women; mean age = 19.7 years; range = 18-41 years) and assessed their perceived risk of HIV infection before and after the interview. The sexual behavior assessment consisted of 29 single-item frequency questions, followed by a 90-day Timeline Followback interview. Results indicate that sexually active participants experienced HIV risk sensitization during the interview, whereas participants who were not sexually active did not. Among the sexually active participants, those who had multiple sexual partners were more sensitized to their risk than participants with only one partner, and those who engaged in vaginal sex evidenced increased risk perception, but participants who had only oral sex did not. These findings indicate that detailed sexual behavior assessments influence participants' motivation to reduce their risk behavior. This may be helpful in increasing the effectiveness of brief risk behavior interventions such as HIV counseling and testing. These findings may also have implications for the generalizability of HIV prevention interventions to contexts that do not include such detailed assessments.

Does alcohol lead to sexual risk behavior? Findings from event-level research.

The belief that alcohol use leads to sexual risk behavior is nearly ubiquitous. To determine if this belief is warranted, we identify theory and research regarding the alcohol, risky-sex link. We focus our review on studies that use the event-level methodology because this approach provides a particularly sensitive but stringent test of the situational alcohol, risky-sex connection. Overall, the data from available event-level studies indicate that people who use condoms when they are sober also tend to use them when drinking; people who fail to use condoms when drinking probably also fail to use them when sober. We recognize several empirical exceptions to this rule and provide suggestions for future research.

Effects of HIV counseling and testing on sexual risk behavior: a meta-analytic review of published research, 1985-1997.

OBJECTIVES: This study examined whether HIV counseling and testing leads to reductions in sexual risk behavior. METHODS: The meta-analysis included 27 published studies that provided sexual behavior outcome data, assessed behavior before and after counseling and testing, and provided details sufficient for the calculation of effect sizes. The studies involved 19,597 participants. RESULTS: After counseling and testing, HIV-positive participants and HIV-serodiscordant couples reduced unprotected intercourse and increased condom use more than HIV-negative and untested participants. HIV-negative participants did not modify their behavior more than untested participants. Participants' age, volition for testing, and injection drug use treatment status, as well as the sample seroprevalence and length of the follow-up, explained the variance in results. CONCLUSIONS: HIV counseling and testing appears to provide an effective means of secondary prevention for HIV-positive individuals but, as conducted in the reviewed studies, is not an effective primary prevention strategy for uninfected participants. Theory-driven research with attention given to the context of testing is needed to further explicate the determinants of behavior change resulting from HIV counseling and testing, and the effectiveness of specific counseling approaches.

Understanding HIV-related risk among persons with a severe and persistent mental illness: insights from qualitative inquiry.

We conducted focus groups with 36 men and women who were receiving treatment for a severe and persistent mental illness (SPMI) to learn more about the social context of their intimate relationships and the psychological antecedents of their sexual decision-making. Qualitative analysis of focus group transcripts indicated that a) sexual activity tended to be unplanned and occurred in social networks where HIV risk may be elevated, b) HIV-related knowledge was superficial and insufficient to guide safer sexual behavior, c) participants' HIV risk perception was often based upon factors unrelated to their sexual behaviors, and d) communication skills for HIV risk reduction were poor. We discuss how qualitative methods yielded insights not readily available through quantitative approaches and offer recommendations for HIV risk assessment and prevention among persons with an SPMI.

Reliability of the timeline follow-back sexual behavior interview.

The reliability of self-reported sexual behavior is a question of utmost importance to human immunodeficiency virus (HIV) prevention research. The Timeline Follow-Back (TLFB) interview, which was developed to assess alcohol consumption on the event level, incorporates recall-enhancing techniques that result in reliable information. In this study, the TLFB interview was adapted to assess HIV-related sexual behaviors and their antecedents, and its reliability was assessed. The interview was administered to 110 participants (46% women, M age = 19.7; range = 18-41), and 58 participants who reported sexual behavior during the previous three months returned one week later for a second interview. Test-retest intraclass correlations (rho) from the TLFB protocol showed that all sexual behaviors were reported reliably (rho range = .86 to .97, median = .96). Bootstrapping, a nonparametric statistical technique, was used for significance testing in the reliability analyses. Reliability was equivalent across each of the three months assessed with the TLFB and was equivalent to conventional assessment methods (i.e. single-item questions). These findings show that the TLFB sexual behavior interview provides reliable reports of sexual behavior over three months and yields event-level data that are extremely valuable for sexual behavior and HIV-prevention research.

Increasing assertiveness skills to reduce HIV risk among women living with a severe and persistent mental illness.

This study examined whether training women living with a severe mental illness to be assertive in sexual situations would decrease their risk for HIV infection. Twenty female outpatients were randomly assigned to either a 10-session assertiveness training intervention or a waiting-list control condition. All participants completed measures of HIV-related information, motivation, skills, and sexual risk behavior pre- and postintervention and at 2- and 4-month follow-ups. Compared with controls, women in the intervention group increased their assertiveness skill, HIV knowledge, and frequency of condom-protected intercourse. It is concluded that assertiveness training for women living with a severe mental illness can serve as 1 part of a comprehensive HIV-risk-reduction program for this vulnerable population.

HIV-risk behavior and the public health context of HIV/AIDS among women living with a severe and persistent mental illness.

We documented HIV-risk behavior and the public health context of AIDS in women living with a severe and persistent mental illness. Sixty-one women were recruited from outpatient clinics and day-treatment programs at a state psychiatric hospital. They completed a survey that included measures of HIV-related risk behavior, the perceived importance of 11 public health and social problems including AIDS, HIV/AIDS-related knowledge, perceived risk, and behavioral intentions. Thirty-eight percent of participants engaged in at least one type of HIV-risk behavior during the 2 months before assessment, 23% reported two or more risk factors, and 16% reported three or more risk factors. Consistent condom use was rare. Participants reporting 1 or more risk factors were more likely than those reporting no risk to report histories of alcohol or drug treatment, sexually transmitted diseases, HIV testing, and more perceived risk of HIV infection. Poverty and unemployment were viewed as more serious problems than HIV infection and AIDS. HIV-prevention interventions that are tailored to the needs and priorities of women with a severe mental illness are urgently needed to prevent further infections.

Reliability and validity of self-report measures of HIV-related sexual behavior: progress since 1990 and recommendations for research and practice.

The trustworthiness of self-reported sexual behavior data has been questioned since Kinsey's pioneering surveys of sexuality in the United States (Kinsey et al., 1948, 1953). In the era of HIV and AIDS, researchers and practitioners have employed a diversity of assessment techniques but they have not escaped the fundamental problem of measurement error. We review the empirical literature produced since Catania et al.'s (1990) review regarding reliability and validity of self-administered and automated questionnaires, face-to-face interviews, telephone interviews, and self-monitoring approaches. We also provide specific recommendations for improving sexual behavior assessment. It is imperative that standardized self-report instruments be developed and used for sexual risk-behavior assessment.

HIV risk reduction for the seriously mentally ill: pilot investigation and call for research.

Research indicates that people with serious mental illnesses (SMI; e.g., schizophrenia, schizoaffective disorder, bipolar disorder) are at enhanced risk for infection with the human immunodeficiency virus (HIV). To decrease this risk, we piloted a six-session HIV-risk reduction intervention for two single-gender groups (nine women, eight men; M age = 39.8 years) of SMI outpatients. The intervention and assessment were based on the Information-Motivation-Behavioral Skills model of HIV-preventive behavior (Fisher & Fisher, 1992, Psychological Bulletin, 111, 455-474) and employed activities designed specifically for people with a SMI. Data were collected at pre- and post-interventions and at a one-month follow-up. Results indicated that this brief intervention resulted in enhanced HIV-related knowledge, and trends toward enhanced skill at condom use negotiation and condom use self-efficacy. Overall, a modest decrease in risk behavior among participants was observed. Thus, this pilot investigation revealed that HIV-related risk of the SMI can be reduced through traditional behavioral skills and education methods. Future research employing control groups, more intensive interventions, and baseline screening for high risk is encouraged.

Behavioral risk for HIV infection among adults with a severe and persistent mental illness: patterns and psychological antecedents.

Behaviors associated with transmission of the human immunodeficiency virus (HIV) were measured in a sample of 60 adults with a severe and persistent mental illness (SPMI). Results revealed that 68% had sex in the last year; 13% of men and 30% of women reported two or more male partners, and 24% of men also reported two or more female partners. Condom use was inconsistent. Sex partners were often met in a psychiatric clinic or bar, and a substantial number were injection drug users or known to be non-monogamous. Overall, 48% of men and 37% of women reported at least one risk factor. Hypothesized psychological antecedents of HIV-related risk behavior were also measured, including knowledge, motivation for risk reduction, and self-efficacy regarding risk-reduction. Many participants were misinformed regarding HIV-transmission and risk reduction. Motivational indices indicated that attitudes toward condoms were slightly positive, and that social norms were generally supportive of condom use. However, participants tended to rate themselves at only slight risk for infection, undermining their motivation for condom use. Participants indicated only modest levels of self-efficacy in situations requiring sexual assertiveness. These findings, coupled with the elevated seroprevalence of HIV among persons having a SPMI, point to the need for risk assessment and counseling by mental health care providers.