1 HIV in Ethnic Minority Populations John B. Jemmott III Professor University of Pennsylvania Annenberg School for Communication

2 Goals of this presentation l Provide an overview of HIV/AIDS among ethnic minority individuals. l Describe our intervention research with ethnic minority adolescents. l Highlight some directions for future research.

3 Collaborators l Loretta S. Jemmott, PhD, RN, FAAN-- University of Pennsylvania l Geoffrey T. Fong, PhD--University of Waterloo l Paula K. Braverman, MD--University of Cincinnati l Paulette M. Hines, PhD--University of Medicine & Dentistry of New Jersey

4 Funding Sources l National Institute of Mental Health l National Institute of Child Health and Human Development l National Institute of Nursing Research l American Foundation for AIDS Research

5 Objectives of our research program l Identify social psychological factors that underlie HIV/STD risk behavior. l Identify theory-based, culture-appropriate, developmentally appropriate strategies. l Evaluate strategies with scientifically sound methodology. l Address practical questions. l Disseminate effective intervention strategies.

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8 Selected facts about adolescents and HIV/STD risk l Sexual intercourse as risk behavior. l Self-reported condom use declines with age. l Adolescents and young adults are at higher risk for sexually transmitted diseases (STDs). l For biological reasons, adolescent girls are more vulnerable than are adult women. l A worldwide problem

9 A general strategy l Use a theoretical framework. l Recognize cultural and contextual factors. l Identify which factors are relevant and which are not relevant to the behavior and intervention. l Consider how the factors affect the acceptability, efficacy, and sustainability of interventions. l Integrate relevant factors into the intervention.

10 Theoretical Framework l Social Cognitive Theory l The Theory of Reasoned Action l The Theory of Planned Behavior

11 Phases of Our Research l Conduct qualitative research to identify cultural and contextual factors. l Conduct quantitative research to identify predictors of the relevant behavior. l Develop or adapt the intervention for the population. l Pilot test the intervention. l Modify the intervention. l Test the intervention in a randomized controlled trial.

12 Key research questions l Can interventions be effective when implemented by facilitators who do not share the participants’ ethnicity? l Does matching the gender of facilitators and participants enhance efficacy? l Can abstinence-based interventions be effective? l How effective are peer educators? l Can interventions reduce the STD rate in adolescents? l Are evidence-based curricula effective when implemented by likely end-users?

13 Can culturally appropriate programs be effective when implemented by facilitators who do not share the ethnicity of participants? Does matching the gender of participants and facilitators enhance intervention efficacy?

14 Jemmott, Jemmott, Fong & McCaffree (1999, AJCP): Design l Randomized controlled trial l 496 African American adolescents at a weekend program l Mean age, 13.1 years l 54% were girls l 55% were sexually experienced l 5-hour HIV/STD Intervention l Health promotion control group l Facilitator race and gender, and group gender composition l 93% retained at 6-months

15 Be Proud! Be Responsible!: Empowering youth to reduce their risk of HIV l Behavioral beliefs l Self-efficacy and skills l HIV knowledge l Culturally appropriate l Developmentally appropriate l Small group l Interactive exercises l Brainstorming l Games l Videos and video clips l Role playing

16 The “Be Proud! Be Responsible!” theme Which encourages adolescents: To be proud of themselves, their family, and their community, To behave responsibly for the sake of themselves, their family, and their community, and To consider their goals for the future and how unhealthful behavior might hamper the attainment of their goals.

17 Jemmott, Jemmott, Fong & McCaffree (1999, AJCP): Results l Reduced HIV risk-associated sexual behavior. l Reduced unprotected sexual intercourse. l Race of facilitator, gender of facilitator, and the gender composition of the group did not matter.

18 Which risk reduction messages are most effective with adolescents? Which types of individuals are likely to be the most effective in delivering those messages?

19 Jemmott, Jemmott, & Fong (1998, JAMA)—Design l Randomized controlled trial l 659 African American adolescents at a weekend program l Mean age, 11.8 years l 53% were female l 25% were sexually experienced l Abstinence-based, safer- sex, or health promotion control intervention l Adult facilitator or peer co-facilitators l 93% retained at 12-month follow-up

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23 Can behavioral interventions reduce the rate of STD among adolescents?

24 Jemmott, Jemmott, Braverman, & Fong (In Press, Arch Ped & Adol Med): Design l Randomized controlled trial l Teen Clinic at an Adolescent Medicine Department l Skill-building HIV/STD, information-based HIV/STD, or health promotion control intervention l Mother’s interventions

25 Jemmott, Jemmott, Braverman, & Fong: Participants l 682 sexually experienced adolescent girls l Informed consent l 68% African American and 32% Latina l 93% of Latinas were Puerto Rican l Mean age, 15.5 years l 87% had coitus in previous 3 months l 22% had a STD at baseline l 89% retained at 12-month follow-up

26 Adjusted mean frequency of unprotected sexual intercourse in the previous 3 months 8,9

27 Adjusted Mean Number of Sexual Partners in Previous 3 Months 8

28 Adjusted mean frequency of sexual intercourse while high in the past 3 months 2,3,5

29 Adjusted rate of STD 8

30 CDC’s Dissemination Project “Research to Classrooms: Programs that Work” Scientifically valid evidence of effectiveness User-friendly Dissemination to educators and other advocates for youth Good news/bad news

31 “Programs that Work” l “Reducing the Risk” (Kirby et al.) l “Be Proud! Be Responsible!” (Jemmott et al.) l “Get Real About AIDS” (Main et al.) l “Becoming a Responsible Teen” (St. Lawrence et al.) l “Focus on Kids” (Stanton et al.) l “Making a Difference: An Abstinence-Based Approach” (Jemmott et al.) l “Making Proud Choices: A Safer Sex Curriculum” (Jemmott et al.)

32 Are evidence-based HIV/STD interventions effective when implemented by likely end-users?

33 Phase IV Trial of the “Be Proud! Be Responsible!” HIV Intervention l Randomized controlled trial l 86 community-based organizations in Philadelphia and New Jersey l Be Proud! or health promotion control intervention l Intensity of facilitator training l 3,448 adolescents 13 to 18 years of age l Follow-up sample, N = 1,707 l Adolescents’ sexual behavior l Fidelity of implementation

34 CBO Facilitators l Facilitators 20 to 70 years of age (M = 37.6) l 82% Black, 9% Latino, 7% White l 73% Women l 5% high school degree, 28% some college, 47% bachelor’s degree, 21% some graduate education

35 Adolescent Participants l 57% girls l Mean age, 14.8 years l 83% Black, 13% Latino, 1% White l 57% ever had sexual intercourse l 40% had sexual intercourse in past 3 months l 53% did not use condoms consistently in the past 3 months

36 Main findings l Proportion protected sexual intercourse l Percentage consistent condom use l No significant effects on sexual intercourse l Condom-use knowledge l Self-efficacy to use condoms l Condom-use hedonistic beliefs l Intensity of training did not matter

37 Implications l CBOs can achieve sexual-risk-behavior change using an evidence-based curriculum. l Training of facilitators need not be extraordinarily extensive or expensive to achieve desired results.

38 Questions of current interest l Adaptability/generalizability to adolescents in developing countries l Implementation by teachers in classrooms l Long-term effects and maintenance of behavior change l Effects on rates of sexually transmitted diseases, including HIV

39 A Final Word l Adolescents are at high risk of HIV/STD in the US and worldwide. l Interventions can be efficacious. l Behavior-change theory and tailoring to the population. l Efficient ways to provide effective interventions to the diverse populations in need. l Important questions are unanswered. l Still, considerable progress has been made. l We are optimistic about yield of future studies.

40 Thank you!