Transcript Powerpoint

Eileen V. Pitpitan,2 Thomas L. Patterson1, Shirley J. Semple1,
Claudia V. Chavarin1, Carlos Magis-Rodriguez3,
& Steffanie A. Strathdee2
1
Department of Psychiatry, University of California, San Diego (UCSD), California, U.S.A.;
2 Division of Global Public Health, Department of Medicine, UCSD;
3 Centro Nacional para la Prevención y Control del VIH/SIDA (CENSIDA), Mexico City, D.F., Mexico
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Background
• 6,000-10,000 FSWs in Tijuana Mexico
• Male clients of FSWs are at high risk of
transmitting HIV/STIs
• Clients are a “bridge population”
-originate mostly from both Tijuana and
San Diego
• Tijuana’s HIV prevalence is double Mexico’s
national average
• HIV prevalence is highest among:
•
•
•
•
MSM (~20%)
PWID (5%)
FSWs (~6%)
Male clients of FSWs (~5%)
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Sex Work in Mexico
• Quasi legal in Mexico
– Zone of tolerance (zona roja)
– Work permit
• Sex tourist destination
• Work environments complex
– Bar girls
– Street (“paraditas”)
– Beauty/massage parlors
– Table dancers
– In-call services
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Study Aims
• Few intervention designed to promote safer sex
among clients
• ‘Hombre Seguro’ developed based on qualitative
interviews and previous intervention experience with
high risk men and FSWs.
• AIM 1. Test a brief theory based intervention designed
for U.S. and Mexican clients of FSWs in Tijuana
• AIM 2. Determine if clients experiencing syndemics
experience greater benefit from the intervention
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Syndemics (Singer, 1999)
• Co-occurrence of substance use, experiences of
violence, poor mental health, and other factors
that have an additive effect on HIV risk behavior
• Hypothesis: More psychosocial and health
problems (e.g. substance use, depression)
more likely to engage in higher sexual risk
behavior (dose-response relationship)
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Syndemic Risk Factors
Measures
•
Drug Use
Alcohol Use
•
Depression
•
Abuse
•
Incarceration
Primary Outcome
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•
•
Recent (past 4 mo) and frequent use (≥ 1x per
week) marijuana, heroin, inhalants,
methamphetamine, ecstasy, and 9 others
(including “any other drug”
Alcohol Use Disorders Identification Test (AUDIT)
(score of ≤8 = “hazardous drinker”)
Center for Epidemiological Studies–Depression
(CES-D) scale (10 items, mood over last week,
scale of 0 to 3. Cutoff = 11 or greater)
Three items queried lifetime emotional, physical or
sexual abuse
Any incarceration in past 4 months? (1=yes, 0=no)
AIM 1 OUTCOME: Total recent (past 4 months)
unprotected sex acts with FSWs at baseline
Hombre Seguro Participants
• Recruited in Tijuana Zona Roja
• N = 400 (half reside in U.S., half in
Tijuana)
• Eligibility criteria:
biologically male
>18 years old
obtained sex from an FSW in
exchange for money, drugs, shelter
or goods
unprotected vaginal or anal sex with
FSW
test HIV-negative at baseline
agree to receive treatment for a
active STIs
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Study Design
Baseline Assessment
Hombres Seguro
Didactic Safer Sex
(200 clients: 100 U.S., 100 Mexican)
(200 clients: 100 U.S., 100 Mexican)
One 60-minute one-on-one
Counseling Session
One 60-minute one-on-one
Counseling Sessions
6- 12-Month Assessment
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Hombre Seguro Intervention:
Theory Based
• Social Cognitive Theory
– Knowledge
– Self-Efficacy
– Outcome expectancies
• Theory of Reasoned Action
– Intention to change
• Transtheoretical or “Stages of
Change” Model
– Readiness to change
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Mujer Segura Counseling
Topics*
Topic
Description
Context of
unsafe sex.
Develop insights into motivations/triggers of
Unsafe sex. Set plan and goals for safer sex
Condom Use
MI and skill-building to induce behavior change.
Match counseling to individual’s stage of change
Negotiation of
Safer Sex
MI and skill-building to teach negotiation skills to
move participants into action
*incorporating motivational interviewing (MI) and social cognitive theory
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Results Aim 1: Was Hombres
Seguro efficacious?
• Both groups significantly reduced unsafe
sex acts with FSWs.
• BUT …Intervention and Control conditions
did not differ (i.e., both benefited).
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Photo By: Oralia Loza
Results Aim 2:
Did clients with more syndemic
exposures benefit more from
the intervention?
Source: Wikipedia Commons,
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2009
Source: Wikipedia Commons, 2007
Figure 1 . Total Unprotected Sex Acts with
FSWs at Baseline by Syndemic Risk
18
16
14
12
10
8
6
4
2
0
0 (n= 32)
1 (n= 89) 2 (n= 125) 3 (n= 97)
4 (n= 39)
5 (n= 16)
Num b er of Syndem ic Risk s
GEE significantly and positively associated with more unprotected sex acts
with FSWs in the past 4 months (B = 0.20, p = 0.01, 95% CI 0.05, 0.35).
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Total Unprotected Vaginal and Anal Sex
Acts with FSWs in past 4 months
(reported at 12 months)
Change in unprotected sex with FSWs by Syndemic Group
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Conclusions
• Both Hombres Seguro and the didactic control
condition resulted in significant decreases in risk
behavior.
• At baseline, more syndemic problems were associated
with more unprotected sex in both Hombres Seguro
and the information only control condition
• At 12-months post intervention:
• Among Hombres Seguro participants, syndemic
risk moderated the effect of the intervention on
sexual risk behavior.
• Among control participants, the syndemic
relationship was no longer significant
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Conclusions, Continued
• First study to demonstrate an intervention “buffering” the
negative impact of syndemic problems on HIV risk.
• Hombre Seguro aimed at reducing sexual risk.
–Counseling session was tailored to the specific
individual’s issues and risk profile
–Appeared to alleviate the composite negative impact of
drug use, alcohol use, violence, depression, and
incarceration on sexual risk.
• Psychosocial problems do not exist in silos and thus
integrated combination interventions are needed.
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Acknowledgments
This study was funded by the National Institute
on Drug Abuse (NIDA) (R01DA029008). This
work was also supported by Diversity
Supplement (R01 DA029008-04S1) and a K01
Award (K01 DA036447-01) to Dr. Pitpitan.
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Thanks
• Project staff and co-investigators
• Most importantly, the participants who
gave of their time and seldom have a
voice
• San Diego Department of Health
• Others
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Patronato ProComusida
Tijuana, AC
Source: Shira Goldenberg
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The table above shows the intercorrelations between the risk factors. We found that
out of ten possible associations, 5 were statistically significant (p < .05) and 1 was
marginally significant (p < .10).
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