1. Resiliency and HIV Related Decision Making Among Black Women: A Qualitative Analysis of HPTN 064 Data Jennifer M. Stewart, PhD, RN Johns Hopkins University School of Nursing Adaora Adimora, MD, MPH University of North Carolina Chapel Hill School of Medicine

2. Background Social conditions and arrangements contribute significantly to HIV vulnerability among Black women in the US. 1,2 A focus on protective factors, including resiliency, is limited in the literature. Exploring the role of resiliency and associated protective factors on HIV related decision making among Black women is a crucial approach to capitalize on assets to reduce the impact of HIV. 1.Adimora AA, Schoenbach VJ. Social Context, sexual networks, and racial disparities in rates of sexually transmitted infections. J. Infect Dis. 2005; 191 (suppl. 1): S115-S122. 2. Auerbach, Judith D., Justin O. Parkhurst, and Carlos F. Cáceres. "Addressing social drivers of HIV/AIDS for the long-term response: conceptual and methodological considerations." Global Public Health 6, no. sup3 (2011): S293-S309.

3. 1)Explore factors that protect Black women 18-44 from acquiring HIV and/or STIs 1)Elucidate the components of resiliency among a sample of high risk uninfected Black women ages 18-44. Objectives

4. Methods HPTN 064 Data 1,768 women enrolled May 2009-July 2010 from 10 communities in 6 geographic areas of the US. Inclusion criteria: women, ages 18-44 years, residing in census tracts in top 30th percentile of HIV prevalence and >25% of inhabitants living in poverty, reported at least one episode of unprotected sex with a man in prior 6 months, and also at least one additional HIV risk behavior (either personal or partner). Four of the 10 study communities (The Bronx, New York, Washington, DC, Raleigh, North Carolina, and Atlanta, Georgia) also participated in a qualitative study component (120 interviews, 31 focus groups)

5. Methods HPTN 064 Data Routine HIV testing and counseling were performed at baseline and at 6-month intervals The interviews and focus groups explored social, structural, and contextual factors that influence women’s HIV risk. Subset Data 32 interviews and 5 focus groups with Black women aged 18-44, all of whom did not acquire STIs or HIV over the course of the ISIS study.

6. Qualitative hybrid thematic analysis approach for analysis of data –Incorporated the data driven inductive approach of Boyatzis (1998) and the deductive a priori template of codes approach of Crabtree and Miller (1999). This approach used inductive coding to allow themes to emerge directly from the data. Analysis

7. Despite these negative social circumstances several protective factors emerged including: –social networks of support, –adaptability, –insulation –norms reinforcing low risk sexual practices, and –spirituality Results

8. Majority of their HIV related advice from family members or friends. Advice from family in particular was protective –“I tell my dad because my dad is like my best friend…like we talked about it and he was like ‘please just use a condom, please just use a condom….I was like why? He was like just do it…he gave them to me and if they [male partners] didn’t have one, I had one. So I’d use it…I just don’t want to hear my daddy mouth. Social Networks of Support

9. Adaptability The women adapted to challenging social and economic circumstances by maintaining and surviving. –“ I’m a survivor so I know how to survive and make ends meet. I am surviving you know… I maintain.”

10. Women responded to negative circumstances by isolating themselves and turned their focus to leaving their communities. –“The hustlers right under my window…. I done seen prostitutes out there. I done seen a whole lot and I try to act like I don’t see it like just I try to mind my business because it’s dangerous out here…. –“ I’m working on trying to better myself and get up out of there [the projects] as soon as possible. I just isolate myself from everybody until I get it right.” Protective Insulation

11. Strong statements were made against high risk sexual behaviors, particularly concurrency and exchange sex. –“stop having sex with people that you don't supposed to be having sex with just to get a little bit of cash in your pocket. That's nasty. It makes females like us look bad. There's other ways you can get money. If you graduated from high school or college, you can get that money.” Norms reinforcing reduction of risk

12. Dependence on God to cope and as a means of protection and guidance. –“well, when I'm going through some things…I used to go to beer or liquor and the problem would be still with you. That’s not the answer. You talk to the Lord on things…Prayer is the answer.” –“I’m blessed that I don’t have HIV…but that’s why I go to church on Sunday and Bible studies on Wednesdays. That’s something I do. I mean that’s the only thing that keeping me straight and strong Spirituality

13. Our results suggest several potential protective factors. Enhancing and supporting resilience among Black women is vital and can support them in their efforts to maintain their sexual health through their own mechanisms. Limitations include: original study questions were not focused on protective factors, we looked specifically at the group of women that did not acquire HIV or STIs without comparison to the group that did. Future research can focus on assets and protective factors and determine their effect on mitigating risk. Conclusion

14. ACKNOWLEDGMENTS With Profound Thanks to: NIH for funding the ISIS Study All protocol and community teams HPTN 064 (ISIS) was sponsored by Cooperative Agreement #UM1 AI068619 from the National Institute of Allergy and Infectious Diseases (NIAID), National Institute of Drug Abuse (NIDA), and the National Institute of Mental Health (NIMH). The content is solely the responsibility of the presenters and does not necessarily represent the official views of NIAID, NIDA, NIMH, or the National Institutes of Health. The primary author’s work on this manuscript was supported through the HPTN Scholars Program funded by NIAID. All ISIS participants Ada Adimora, MD, MPH – Scholar Mentor, Team Member Paula Frew, MPH, PhD Linda Vo, MPH, CHES, qualitative consultant Sally Hodder, MD –Protocol Chair Jessica Justman, MD – Protocol Co-Chair Danielle Haley, MPH – Protocol Specialist Lynda Emel, PhD SDMC Project Manager Wafaa El-Sadr, MD, MPH Domestic Prevention Susan Eshleman, MD, PhD HPTN NL Rep Cathie Fogel, PhD, WNCNP Team Member Carol Golin, MD, Team Member Bernie Lo, MD HPTN Ethics Working Group Ann O’Leary, PhD Protocol Consultant LeTanya Johnson Lewis, NL QC Rep Waheedah Shabbaz-El CHAMP Rep Lydia Soto-Torres, MD, MPH NIH Med Officer Sten Vermund MD, PhD HTPN PI Jonathan Lucas, MPH Community Manager Gina Wingood, PhD Team Member Noranik Zadeyan, MPH Community Rep