Hep-Safe Hollywood

Homeless, stimulant-using gay/bisexual men and transgender women are at high risk for hepatitis B virus (HBV), hepatitis C virus (HCV), and HIV infection due to high rates of injection drug use and high-risk sexual behaviors. Thus, use of stimulants threatens to intensify homeless persons’ risk of exposure to hepatitis B, C viruses and HIV; therefore, research focused on this group is critical. A contingency management (CM) intervention may be particularly well suited for this high-risk population. CM is an intervention that attempts to modify a targeted behavior by providing incentives for changing that behavior (in simple terms, positive reinforcement). CM interventions have been successfully implemented among stimulant-using gay and bisexual men to reduce drug use and concomitant sexual risk behaviors.

The Hep-Safe Hollywood study will implement a CM intervention to increase successful HAV/HBV vaccination completion programs among homeless, stimulant-using gay/bisexual men and transgender in Hollywood. This randomized, control trial will assign 500 homeless, stimulant-using gay and bisexual men to either an enhanced nurse case managed program, which includes specialized education and CM, or a standard program, which includes brief education and CM. This study is innovative in that it will allow us to look at the effect of an enhanced nurse case management and CM program versus a standard brief education and CM program. The study will evaluate the effectiveness of homeless, stimulant-using gay/bisexual men and transgender women on completion of the HAV/HBV vaccine and, secondarily, on reduction of risk for hepatitis and HIV. Additionally, the study will assess the relative cost of these programs in terms of completion of the vaccine series. The study combines best strategies to approach, engage and intervene with this hidden and high-risk population and to assess the feasibility and efficacy of interventions that may prove beneficial in preventing hepatitis A, B, C and HIV infections.

This study is a collaboration between UCLA School of Nursing and Friends Research Institute, with Dr. Adeline Nyamathi, as the principal investigator.

 

Collaborative Evaluations with the Sonagachi/Durbar Community-Led Structural Intervention (CLSI) with Sex Workers in India.

The Sonagachi Project was initiated in 1992 in the Sonagachi red light area of Kolkata (Calcutta) as a health education and condom promotion program targeting sex workers.  Responding to barriers and needs expressed by sex workers led the program to evolve into Durbar (www.durbar.org), a multi-component community-led structural intervention (CLSI) that targets both risk behaviors and broader structural factors that marginalize sex workers and increases their vulnerability to HIV.  The Sonagachi model intervenes at multiple levels through education, community organizing, advocacy, micro-credit, STI/HIV testing and treatment, anti-trafficking and other activities.  These are all designed to restructure risk environments and empower sex workers to protect themselves by reducing both their marginalization in society and their vulnerability to HIV/AIDS and STDs (see Jana, Basu, Rotheram-Borus, Newman, 2004 for a review).  This project, funded by the World AIDS Foundation, builds research capacity among the India team while conducting a study of HIV prevention among commercial sex workers in three communities in India.

UCLA CHIPTS & Durbar Collaborative Evaluation Trial

In 1999 the Center for Community Health began a program of collaborative research with Durbar.  A quasi-experimental intervention trial was conducted in two towns in West Bengal from 2000-2001 to evaluate the Durbar/Sonagachi model CLSI’s impact on condom use, STD infection, and empowerment outcomes linked to program activities (see Jana, Basu, Rotheram-Borus, Newman, 2004 for intervention details; see Basu, Jana, Rotheram-Borus, Swendeman, et al., 2004 for study design details).  Female sex workers were selected through two-stage random selection of houses and residents in two towns’ sex work neighborhoods, or red-light areas (n=110 in each).  Women were recruited to participate with informed consent and interviewed four times over 16 months.  Follow-up rates were high with 90% average retention and 80% completing all four assessments.

Both neighborhoods received a reproductive health clinic that provided STI diagnosis and treatment, as well as in-clinic peer education and condom promotion as standard care. The intervention town also received the Durbar/Sonagachi model CLSI led by sex worker community leaders and high-status project staff that intervened with power brokers and stakeholders (i.e., police, political leaders, landlords, madams, etc.), led community building and organizing activities, and coordinated peer-led condom promotion and STI treatment follow-up

The study examined condom use and “empowerment” outcomes either directly targeted by the model CLSI, or indirectly targeted as suggested by the underlying theory of the community empowerment approach.  Overall, sex workers reporting any condom use in recent sex acts increased significantly in the intervention community (39%) compared with the control community (11%).  The proportion of consistent condom users increased 25% in the intervention community compared with a 16% decrease in the control community (Basu et al., 2004).

Results for improvements in empowerment parallel those for condom use (Swendeman  et al., 2009).  The CLSI significantly: 1) improved knowledge of STDs, condom protection from STD and HIV, and continued STD risk despite treatment;  2) provided a frame to motivate change based on reframing sex work as valid work, increasing disclosure of profession, and instilling a hopeful future orientation reflected in desire for more education or training; 3) improved skills in sexual and workplace negotiations reflected in increased refusal, condom decision-making, and ability to change work contract, but not ability to take leave; 4) built social support by increasing social interactions outside work, social function participation, and helping other sex workers; and 5) addressed environmental barriers of economic vulnerabilities by increasing savings and alternative income, but not working in other locations, nor reduced loan taking, and did not increase voting to build social capital. This study’s results demonstrate that, compared to narrowcast clinical and prevention services alone, empowerment strategies can significantly impact a broader range of factors to reduce vulnerability to HIV/STDs.

CHIPTS Funded Mixed-Methods Pilot Research

In 2005 CHIPTS awarded a pilot grant to a group of pre- and post-doctoral trainees (Dallas Swendeman, MPH, PhD, P.I., and Co-P.I.s Toorjo Ghose, MSW, PhD., Sheba George, PhD., and Arunansu Talukdar, MD, PhD) to continue collaborative research with Durbar, specifically to explore the Social Movement and Diffusion aspects of the intervention program.  The team has conducted in-depth qualitative interviews with sex workers and community leaders, program staff, and other stakeholders (see Ghose, Swendeman, George, Chowdhury, 2008).

Following the qualitative work, a comprehensive survey was developed to more thoroughly assess power broker relations, community empowerment, collective identity, community mobilization, quality of life, and family outcomes (i.e., children’s health and education) for sex worker communities.  The CHIPTS funded research supported the use of the survey in two of Durbar’s original intervention communities in Kolkata (n=100 in each), completed in December 2007, to provide pilot data for future research as well as a baseline comparison for replication sites (the pilot survey is also being implemented in the Bill and Melinda Gate’s Foundation funded replication of the Durbar model in other states in India).

Another pilot survey is in development to assess non-sex worker community members’ attitudes and behaviors in relation to sex workers, the Durbar/Sonagachi intervention, and HIV/STDs, particularly around stigma, discrimination, and marginalization.

The long-term goal for ongoing collaboration will be to conduct community randomized trials implemented across Durbars 60+ sites in West Bengal to assess the impact of community-level factors and enhanced interventions (e.g.,, cognitive-behavioral skill building, leadership training and development) on multiple risk and empowerment outcomes.

American Institute of Indian Studies (AIIS) Funded Ethnographic Research

In 2007 the AIIS awarded Dr. Swendeman a Junior Fellowship Award to conduct ethnographic and participant-observation research on the social movement aspects of Durbar and the sex worker’s rights movement in India.  Dr. Swendeman participated in and observed Durbar’s first “All India Conference of Entertainment Workers”.  The conference had two aims targeted to both internal social movement mobilization for sex workers and external alliance building, which exemplify Durbar’s social movement strategies.  First, the conference aimed to highlight the myriad aspects of sex workers’ client interactions beyond sexual intercourse, which include singing, dancing, and conversing with clients, and with strong reference to the historical context of sex work in India. Simultaneously, the conference aimed to bridge the sex worker’s rights movement to new potential and external allies of entertainment workers (i.e., singers, dancers, actors, bar girls), who had traditionally engaged in informal sex work and currently face increasing economic pressures toward sex work as the waning caste system has de-stigmatized performance activities but enables the expanding middle class to adopt performance as hobby or profession.  Dr. Swendeman’s research documented strong support for the first aim; the idea that sex work is essentially entertainment and involves much more that sexual intercourse resonated strongly with sex workers.  Support for the second aim was mixed; while the entertainment workers participating in the conference supported the broad idea of sex work as entertainment work and supported the sex worker’s rights movement, they were not willing to embrace the sex work undercurrents of their lived experience or to join a Durbar led social movement of entertainment workers that included sex workers.  Consistent with HIV/AIDS related research findings globally, stigma remains a significant barrier to engaging at-risk populations in HIV prevention.

Intervention model: 

Community-Led Structural Intervention (CLSI).  The CLSI is a multi-level intervention framework that draws on community-based participatory and empowerment approaches while emphasizing the more recent focus in HIV prevention for structural interventions.  The CLSI incorporates multi-level interventions that span behavioral (e.g., peer education and outreach, condom promotion, STD treatment follow up) and structural (e.g., community STD clinics, local and national advocacy, community mobilization) intervention approaches.

Research methods (brief description):

Mixed-methods – including longitudinal intervention-control surveys, semi-structured qualitative interviews, ethnography, participant observation, and cross-sectional community surveys.

Local significance (How has this project impacted the immediate population?):

The project has been expanded to 60+ sties throughout Kolkata and West Bengal, India,  transforming the power dynamics within sex work communities (red-light areas) to support HIV/STD prevention and treatment, and the health and well being of sex workers and their children and families.

International significance (How has this project impacted the global community?):

The project has been sited as a model program for replication for since 2000 and served as a model for (and its leadership advisors to) the recent Bill and Melinda Gates Foundation funded scale-up of HIV prevention targeting high-risk groups in India (i.e., Project Avahan) and for sex workers specifically (i.e., Project Parivartan). Durbar also has strong links with sex workers rights organizations globally.

Links to related web resources:

Durbar Official Website: http://www.durbar.org/

Wiki: http://en.wikipedia.org/wiki/Durbar_Mahila_Samanwaya_Committee

Brief report on UCLA MPH Summer Internship funded by the Bixby Center at UCLA:  http://bixby.ucla.edu/summerinternships/india.asp

Below, you will find videos associated with this project (which you can find on  Vimeo) as well as a press release regarding AIDS in India in 1997.

Dr. Smarajit Jana – Talk # 1 from CHIPTS, UCLA on Vimeo.

Dr. Smarajit Jana – Talk # 2 from CHIPTS, UCLA on Vimeo.

Sonagachir ek Yug: Shootings from the carnival for rights and pleasure. from CHIPTS, UCLA on Vimeo.

Listen to me: The subtle voice and new look of an emerging self. from CHIPTS, UCLA on Vimeo.

Savings, Credit and AIDS: A bank to bank on for fighting AIDS. from CHIPTS, UCLA on Vimeo.

The End Begins: Saga of a journey for a new self and sexuality. from CHIPTS, UCLA on Vimeo.

Parliament March: Sex workers’ movement against ITP(A). from CHIPTS, UCLA on Vimeo.

Journey for Existence from CHIPTS, UCLA on Vimeo.

Beyond the Barbed Wire: Addressing Human Trafficking. from CHIPTS, UCLA on Vimeo.

The Press Trust of India in 1997, reported a doubling of AIDS cases every 14 months.

India is experiencing rapid and extensive spread of HIV infection (World Health Organization, 1997). The Press Trust of India in 1997, reported a doubling of AIDS cases every 14 months. Since the first reported case of HIV infection in 1986, HIV has spread to every state and union territory in the country with 25% of infections occurring in rural areas. Gender issues and poverty are cited as major issues in the spread of the disease.

A group that continues to be at high risk is female commercial sex workers. While the degree to which commercial sex is tolerated and regulated varies across societies in India, the majority of these women are young, have low socioeconomic status, and are at immediate risk for HIV infection and other sexually transmitted diseases. The most rapid and well-documented spread of HIV has occurred in Bombay and the State of Tamil Nadu. In Bombay, home to an estimated 100,000 commercial sex workers, HIV prevalence has reached the level of 50% among sex workers, 36% in STD patients, and 2.5% in women attending antenatal clinics.

A major means of transmission for the HIV in India is married and unmarried men visiting commercial sex workers. This is exhibited through the increasing spread of HIV infection throughout the general population as their customers, often truck drivers and migrant workers, act as vectors for carrying infections back to their wives and lovers in villages all over the country. Slowing the rate of infection among sex workers and their customers is essential to protecting the spread of infection both to the general population and among these high-risk groups.

In order to meaningfully impact the spread of the epidemic, there is: 1) a need for substantial increase in the national, state, and local capacity of the Indian professional social science and biomedical community in HIV prevention program development and research evaluation; and 2) identification and demonstration of model HIV prevention programs that can be disseminated nationally and internationally.

HIV/STD Risk Behaviors in Methamphetamine User Networks

SATH-CAP stands for the Sexual Acquisition and Transmission of HIV Cooperative Agreement Program. The overall goal of SATH-CAP is to better understand how patterns of sexual and drug use behaviors along with other social and environmental factors, such as other sexually transmitted diseases, places where people gather for sex and drug activities, and types of partnerships, influence the spread of HIV/AIDS from people currently at high risk for HIV/AIDS, like drug users and men who have sex with men (MSM), to those at a lower risk.

Specifically, the study seeks to answer these primary questions:

  • To what extent do HIV infections among drug-using populations spread to uninfected drug users and non-drug users through drug-related and/or sexual transmission behaviors?
  • What individual (behavioral, biological), network, and structural characteristics influence the speed, extent and path of the spread?

The SATH-CAP includes five research centers, a scientific and logistical coordinating center at RAND, and the funder, the National Institute on Drug Abuse (NIDA). The research centers are:

  • Research Triangle Institute (RTI)
  • University of California, Los Angeles (UCLA)
  • University of Illinois, Chicago (UIC)
  • Yale University
  • The Biomedical Center (BMC), St. Petersburg, Russia, Andrei Kozlov

Rectal Transmission of STIs/HIV among Women

While the prevalence and epidemiology of rectal sexually transmitted infections (STIs) are well characterized among men who have sex with men (MSM), little is known about rectal STIs in women. Evidence demonstrates that women also practice anal intercourse (AI) and are therefore at risk for these infections. The proposed study will investigate contextual factors as well as the prevalence and correlates of rectal STIs among women attending public sexually transmitted disease (STD) clinics in Los Angeles County (LAC) and determine if women who report substance use have differing risks for rectal STIs as compared to women who do not report substance use.

The specific aims of the project are to:
(1) identify contextual factors, which influence AI and the acquisition of rectal C. trachomatis and/or N. gonorrhoeae infection among women, comparing the particular context of substance use;
(2) measure the prevalence and correlates of rectal C. trachomatis and/or N. gonorrhoeae infection among women and determine whether this varies by substance use status.

Unprotected AI is recognized as one of the most efficient modes of HIV sexual transmission and is a commonly practiced behavior with opposite sex partners, with estimates of AI ranging from 7-40% in the United States. It is well established that HIV transmission probabilities are increased in the presence of STIs and there is evidence to suggest that among heterosexuals who report recent AI, about 60-80% report never using condoms suggesting they are likely to also be exposed to other STIs. Although it is clear that AI is a sexual practice with a high probability of transmission of HIV, data on the prevalence and incidence of rectal STIs among women reporting recent anal intercourse is limited. The proposed study will use both qualitative and quantitative methods to examine contextual and individual level factors associated with the acquisition of rectal STIs in women who report AI. Specifically, we will use the Theory of Gender and Power as a framework to examine AI and rectal STI-related exposures and risk factors among women attending the 12 public STD clinics in LAC (Aim 1). We will interview both women who are diagnosed with rectal C. trachomatis or N. gonorrhoeae infection and women who are not diagnosed with these infections, in order to identify key differences, particularly by substance use status. Concurrent to the qualitative assessment we will collect quantitative information available as part of the standard of care within the STD clinics. Currently, all clinics collect demographic and risk behavior information and conduct vaginal screening and rectal screening for C. trachomatis and N. gonorrhoeae among women who report AI. The laboratory testing results, along with medical record information will be used to provide estimates of the prevalence and correlates of rectal STIs and determine the extent to which this varies by substance use status (Aim 2).

The findings from this study will be one of the first to describe the prevalence and factors associated with rectal STIs among a relatively high risk group of women. At the end of the award period, these results will not only help inform overall rectal screening guidelines for women but will be used to develop a proposal designed to test a prevention intervention aimed at reducing the acquisition of rectal STIs/HIV among women.

HIV Counseling & Texting Program

The HIV Counseling and Texting (HCT) program utilizes social networks testing methodology, specifically designed to work with HIV infected and high-risk gay and bisexual men of color and transgender women. HIV infected or high-risk negative participants who either come to the Friends Community Center site for services or are contacted through street outreach and meet eligibility are invited to serve as recruiters. The engagement of new recruiters will be an active and ongoing part of the program. Potential recruiters attend a group orientation, which explains the social network methodology and informs potential recruiters that they will be requested to recruit individuals from their social, sexual or drug-using networks whom they believe to be at high-risk of HIV infection. Following the training period (brief identification, group orientation, individual interview), the recruiter begins to locate network associates to be referred to our testing site. Confirmatory HIV tests and STI testing (syphilis, Chlamydia, gonorrhea) are also available at the Friends Community Center site. Participants (both those who test HIV negative and positive) are then linked to appropriate medical, social, psychological, CRCS and other needed services. Network associates who wish to become recruiters are be assessed for eligibility and appropriateness.

This program is funded by the Los Angeles County, Department of Health Services, Office of AIDS Programs and Policy (OAPP).