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HIV/STD Prevention in Rural America

 
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Programs Tailored to Women
 

Women are the fastest growing group of people being infected with HIV. Although women account for only one-quarter of rural AIDS cases, the rate of infection is increasing, particularly among African American women living in the South. More than 80% of women diagnosed with HIV in 2008 were infected by exposure from heterosexual sex with a male partner. Over 15% of rural women diagnosed with HIV in 2008 were exposed to HIV from injecting drugs.[1] Women of color living in the South have historically had higher rates of STDs, which puts them at greater risk for HIV infection. Much of women’s vulnerability comes from their lack of power to control the behaviors of their sexual partners. Poverty, homelessness, illiteracy, substance use, and unemployment may contribute to rural women staying in unhealthy relationships for economic survival.[10] Interventions that encourage women’s empowerment and employment are more common in developing countries than the U.S. as part of HIV prevention efforts. Women benefit from having the social support and skills to negotiate safer sex practices. Women who trade sex for money or drugs are an especially vulnerable group. However, in rural America, these women may be especially difficult to identify and recruit into an intervention due to high levels of stigma, fear of arrest, and a desire to keep these behaviors “hidden.” Rural culture laden with traditional gender roles, homophobia, and racism may also contribute substantially to women of color being at heightened risk for HIV. This section presents adaptations of several evidence-based interventions that have been developed for Black women of different ages have been tested in rural areas.

SISTA for African American Women and Incarcerated Women

Target Behaviors and Behavioral Determinants
Unprotected sex with a partner who has power over the use of condoms; lack of knowledge and skills to negotiate and use condoms, negotiate relationships, make decisions; perceived lack of power; lack of racial or ethnic pride.

Description
SISTA (Sisters Informing Sisters on Topics about AIDS) (DEBI) is a group-level, gender and culturally-tailored intervention designed to increase correct and consistent condom use among African American women. Five peer-led group sessions are conducted by a trained, skilled, female facilitator. Sessions focus on racial, ethnic and gender pride, HIV/STD knowledge, and the development of condom negotiation and decision making skills. Originally designed for urban women.

Adaptation
SISTA has been adapted for use in rural communities and for women in rural county jails. In western Alabama, the local women preferred having the five 2-hour sessions in one week. They discuss and modify the time of day for the sessions throughout the week to accommodate the women’s schedules. On-site HIV testing is offered after session 2.   In the jails, the jail sets the schedule for the sessions.

Evidence
The week-long SISTA project in western Alabama is well-received enough to be conducted twice every month in different rural towns. Evaluations indicate that the vast majority of the women found the information beneficial and empowering. The participants indicated that the role plays and scenarios reflected their situations. Participants from the same housing projects have continued to meet independently as an ongoing support group after the intervention. The incarcerated women noted they felt empowered to change behaviors when released. SISTA evaluation materials for each session are administered and           reviewed by the facilitator to improve the next session but data for all programs have not been aggregated or analyzed.

Recommendations
Work with housing assistance programs in communities and directly with the jails to identify women who might benefit from SISTA. Providing relevant information, offering transportation, food, and prizes, and making the schedule flexible to fit the women’s needs all help make attending SISTA important to the women, which in turn increases participation. A thank you card after the program reminds the women about the course messages and about resources available to them.

Where Implemented
Western Alabama

Contact Information
Ann James

West Alabama AIDS Outreach

205-759-8470

 

HOPE (Helping Our People Endure) – Reinvention of SISTA for Native American Women

Target Behaviors and Behavioral Determinants
Unprotected sex with a partner who has power over the use of condoms; lack of knowledge and skills to negotiate and use condoms, negotiate relationships, make decisions; perceived lack of power; lack of ethnic pride.

Description
Reinvention of SISTA (Sisters Informing Sisters on Topics about AIDS) (DEBI)
This group-level, gender and culturally-tailored intervention, was originally designed to increase correct and consistent condom use among African American women. In this case it has been reinvented for use with Native American women. Five peer-led group sessions are conducted by a skilled, Native American female facilitator. Sessions focus on ethnic and gender pride, HIV/STD knowledge, and skills training around sexual risk reduction behaviors such as negotiating condom use and decision making. The intervention is based on Social Learning theory as well as the Theory of Gender and Power.

Adaptation
Although the five sessions and most of the core content have been retained in the reinvention, much of the intervention has been redesigned to reflect Native American culture and the power distribution in American Indian heterosexual relationships. The CDC suggests that any adaptation of a DEBI that includes the addition or subtraction of activities (such as replacing African-American poetry readings with Native American stories) be considered a reinvention and collect evaluation data to test the efficacy of the reinvented intervention.

Evidence
The original research showed that women who completed the intervention were more likely than a comparison group to use condoms. Evaluation evidence from the reinvention is in the process of being collected but is not yet available.

Recommendations
Using a facilitator who is the same gender, race/ethnicity, and age and is trained in the intervention encourages women to be engaged in the activities of this intervention. Reinvention is a time-consuming process that starts with information about the target population. It requires pilot testing and revision before implementation. Matching the cultural values in the intervention with the cultural values of the target audience is essential.

Where Implemented
Indian reservations in rural Montana

Contact Information
Montana Department of Public Health and Human Services
406-444-2457

 

Target Behaviors and Behavioral Determinants
Correct and consistent condom use with casual or non-main partners; increased communal caring behavior demonstrated by peers discussing safer sex, psychosocial issues such as low levels of self esteem, experience of discrimination, and cultural pride; reduced sex under the influence of alcohol or other drugs; self-efficacy to talk to partners about condom use; decrease in number of sexual partners.

Description
This community-level DEBI intervention uses community assessment, trained peer advocates, and the creation and distribution of culturally relevant role model stories and risk reduction materials tailored to the population’s stage of change. The intervention’s goal is to move women at high-risk for unprotected sex with casual or non-main partners toward safer behaviors. Outreach is done in bars and clubs in Anchorage and is culturally relevant for Alaska Native and multi-cultural women. Peer Advocates from the target audience distribute glossy role model stories and free condoms to friends in bars and clubs.

Evidence
The project has created and published 7 role model stories in 1.5 years of implementation and has overcome initial resistance of the target audience. All of the stories encourage these women to become more aware of their risk and contemplate behavior change. The project has been funded to conduct a rigorous evaluation of the outcomes.

Recommendations
Make role model stories small enough to fit in a woman’s purse and print with color and glossy finish to compete with other materials in a bar  setting.  Stories need to reflect the multi-cultural backgrounds of the women and have subtle suggestions for small changes, like talking to partners about using a condom. Peer Advocates should work in teams for safety. By going to the women where they congregate, the program reaches the target audience and avoids extra costs for a meeting space, transportation, and childcare.  The intervention requires a large enough town to have enough venues and at-risk population.

Where Implemented
Urban Alaska

Contact Information

Michael Covone

     Alaska Native Health Consortium

    mrcovone@anthc.org

     907 729-2907

 

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