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Migration, tourism and the HIV-Drug use syndemic in the Dominican Republic


The Caribbean region has the second highest prevalence rates of HIV in the world following sub-Saharan Africa and is one of the region's most affected by illicit drug use and drug trafficking. Focusing on men's changing work, migration, and sexual and drug use behavior in the Dominican Republic, the proposed mixed- methods collaborative study examines how HIV risk and drug use among migrant men are related to (1) patterns of migration and (2) the social environments of tourism areas. We relate contemporary demographic changes to HIV and drug use practices through the notion of tourism ecologies - geographically constrained areas in which five ecological features (social isolation; social stigma; business norms; touristic escapism; and drug and alcohol availability) are hypothesized to contribute to high risk behaviors. Our research relies fundamentally on a long-standing multisectoral Community Advisory Board involving private tourism representatives, government, public health officials, and civil society. Data collection consists of: (1) semi- structured interviews with 36 systematically selected male migrant workers in two coastal tourism areas (two interviews per subject = 72 sessions); (2) ethnographic mapping and spatial analysis using Arc-GIS in two tourism areas; (3) a cross-sectional survey with 400 male migrant workers in two research sites; and (4) the implementation of a pilot intervention with 40 migrant male tourism workers. This study contributes to public health knowledge and health promotion in three key ways. First, it identifies the factors in tourism areas that most contribute to HIV risk and drug use, contributing to the development and piloting of an evidence-based intervention. Second, it draws on an extensive literature to systematically analyze the health effects of tourism environments in high-risk settings for HIV and drug use. Finally, it incorporate a participatory process to research that will strengthen local relevance, research translation, and the impact on health policies and programs.


INVESTIGADOR: 

Nelson Varas, Ph.D. - nvaras@mac.com




Testing a Latino web- based parent-adolescent sexual communication intervention


Latino adolescents, especially those living in Puerto Rico, are at high risk for HIV/AIDS, other sexually transmitted infections (STIs), and unintended pregnancies. A web-based parent communication intervention provides an opportunity to benefit adolescents by providing additional support for safer sex decisions, and to increase parents' involvement in sexual health by decreasing barriers that keep them from participating in these interventions. The purpose of this proposed study is to evaluate a brief, theoretically informed, culturally appropriate, and linguistically tailored web-based parental communication program, Cuídalos ("Take care of them"), designed to improve parent-adolescent sexual communication and reduce adolescent sexual risk behavior. Recent findings from an R21 RCT testing a brief computer-based version of the Cuídalos program indicated that the program increased parent-adolescent general communication and sexual risk communication with English and Spanish speaking U.S. Latinos.7 In this proposed study, we plan to modify the Cuídalos intervention by changing to a web-based format, increasing the amount of content related to sexual communication and adding a module on HIV/AIDS stigma. In this RCT, we will recruit parents (n=680) and one of their adolescents (n=680) from community-based agencies in Puerto Rico, and will be randomly assigned to receive either the parent-based Cuídalos intervention or a web-based health promotion control condition. Parents and adolescents will complete measures at pre-intervention and at 3-(parents only), 6-, and 12-month follow-ups. We will address the five following specific aims: 1) Does the Cuídalos intervention increase parents' comfort with, as well as the amount of, communication with adolescents and decrease stigma at 3-,6-, and 12- month follow-ups as compared to the general health promotion control intervention; 2) Does the Cuídalos intervention decrease self-reported adolescent intercourse and unprotected intercourse at the follow-ups as compared to the general health promotion control intervention; 3) Do theory-based variables(attitudes, subjective norms, perceived behavioral control, intentions) mediate the intervention effects of Cuídalos on parents' communication with their adolescents; 4) Are the effects of the Cuídalos intervention on adolescent sexual behavior and parent-adolescent communication moderated by individual (adolescents: sexual experience, gender, age, stigma; parents: gender, age computer access/experience, frequency and time engaged in the program), and microsystem (adolescents: parent-adolescent communication) variables; and 5) Puerto Rican and Latino youth, the lack of culturally and linguistically effectiv interventions for Latino parents and adolescents, and the absence of web-based interventions for Latinos. If the program is efficacious, the web-based format will accelerate the translation of this program into public health practice and will be an important contribution in supporting safe adolescent sexual health behaviors. Is the intervention cost-effective? 


INVESTIGADOR: 

Nelson Varas, Ph.D. - nvaras@mac.com




Physicians and health related services for male and female transgender persons


HIV/AIDS continues to affect the Latino community disproportionately, with more than 200,000 cases in the US attributed to this population. Puerto Ricans are US citizens residing in the Caribbean Island and are a significant part of the growing epidemic among Latinos. Due in part to social stigma, Male-to-Female Transgenders (MTF-TG) constitutes an invisible and underserved group in general, and particularly among Latino communities. Nationally, the proportion of MTF-TG infected with HIV is increasing, as evidenced by the growth from 3% to 8% in new reported cases per year. Extensive research demonstrates that MTF-TG are highly stigmatized and often overlooked in research, interventions, and services. Stigmatization of MTF-TG may have serious health implications given the fact that studies in other contexts have demonstrated that a significant proportion of MTF-TG are infected with HIV, use substances, engage in high risk sexual behaviors, and are not reached by existing health services. The emerging literature on TG health has emphasized the need to focus research and interventions on physicians, many of which have received little training on these issues and may therefore lack the knowledge, experience, and sensitivity to provide quality health care. In addition, the literature emphasizes that a lack of access to quality health care resources can have compounded negative effects on MTF-TG by: decreasing their probability of accessing such services; reducing their access to knowledge about health and HIV prevention; and increasing their perceived stigmatization and marginalization through the medical encounter. These factors highlight the need to focus research on transgender health issues, emphasizing research contributing to interventions to improve access to quality health care for MTF-TG. In order to address this gap we propose a study with the following aims: 1. Explore qualitatively four areas of physician treatment of MTF-TG among a sample of professional physicians in Puerto Rico: (1) physician knowledge of MTF-TG health; (2) competency in treating MTF-TG; (3) willingness to provide services to MTF-TG; (4) and attitudes toward MTF-TG. 2. Document quantitatively the relationship between the stigmatization of MTF-TG (i.e., negative attitudes or behaviors toward MTF-TG) and areas 1-4 identified in Aim 1 (i.e., knowledge, competency, willingness, and attitudes). 3. Identify key intervention targets and strategies to be prioritized for an effective stigma-reduction intervention aiming to improve: (1) physician knowledge of transgender health issues; (2) physician competency to implement transgender-appropriate care; (3) physician willingness to provide quality services; and (4) physician attitudes towards MTF-TG among physicians in Puerto Rico. In order to achieve these objectives, we will implement a mixed method design using qualitative in- depth interviews, focus groups and quantitative questionnaires administered via iPad technology. For aim 1, we will carry out (N = 30) in-depth interviews with physicians who work in HIV-related clinical settings in Puerto Rico. The qualitative information will be used to develop a meaningful understanding of the factors of interest (i.e. knowledge, competency, willingness to treat, and attitudes). For aim 2, we will draw on qualitative data to culturally adapt and pilot test quantitative measures to assess our variables of interest. We will then administer our survey to a purposive sample of 300 physicians in Puerto Rico, including those who work in HIV-related service delivery and those who do not. Aim 3 will draw on data from focus groups with 30 key personnel from medical schools and medical organizations, as well as 15 MTF-TG recruited by our team's transgender Community Advisory Board, to identify key intervention targets and strategies for reducing stigma and improving access and quality of care. The gathered data will contribute to developing and testing a future intervention that can foster access to quality HIV prevention and health services for MTF-TG in Puerto Rico.


INVESTIGADOR: 

Nelson Varas, Ph.D. - nvaras@mac.com



HIV/Stigma behaviors in clinical encounters


The proposed K02 Independent Scientist Award application to the National Institute on Drug Abuse (NIDA) is an extension of my ongoing commitment to research aiming to address HIV/AIDS stigma among Latino populations, specifically Puerto Ricans. Puerto Rico is a Caribbean Island linked to the United States, where HIV infection prevalence has been estimated at 1% (more than 35,000 reported cases). The Island's epidemic is mainly driven by unclean needle sharing for injected drug use (IDU) and is embedded in the Caribbean region which has the second highest rates of HIV/AIDS in the world. Therefore, the need for stigma- free health services is ever-growing. My research career has been characterized by an ongoing commitment to addressing the role of stigmatization on access to quality health services for people with HIV/AIDS (PWHA) in this setting. In my previous NIH funded studies I have focused on the identification and reduction of HIV/AIDS stigma attitudes among health professionals. The proposed K02 will allow me to extend this research agenda to address the behavioral components of HIV/AIDS stigma as manifested in clinical interactions. My long-term career goals include: 1) advancing the understanding of the interrelation between HIV/AIDS stigma attitudes and behaviors (i.e. verbal and non-verbal) manifested by health professionals in Puerto Rico, 2) documenting the underlying predictors and cultural correlates of HIV/AIDS stigma attitudes and behaviors in the Puerto Rican setting, and 3) developing scientifically tested stigma measurement guidelines and interventions to reduce both HIV/AIDS stigma attitudes and behaviors among this population. As part of the proposed K02 application I propose several career development strategies to foster my long-term career goals. These include: 1) the acquisition of new skills related to the use of Standardized Patient Simulation Technology for use in research via extended contact with the University of Puerto Rico's Standardized Patient Program, and 2) collaborations with experts in the field of visual methodologies and observational data analysis at the University of Rochester, Florida International University and the University of California at San Francisco. With the skills acquired through these interactions, I will be better positioned to implement the proposed research plan in which I propose to study the dynamics of physician/patient interaction that may contribute to stigmatization of PWHA, through an observational study of simulated interactions using a standardized patient (SP) program in Puerto Rico. The proposed study has the following aims: Aim 1 - To document HIV/AIDS stigma attitudes and their role on behavioral manifestations of stigma during physician/patient interactions in a sample of medical residents in Puerto Rico; Aim 2 - To document variations of HIV/AIDS stigma behaviors during physician/patient interactions when providing services to clients with different modes of HIV transmission; and Aim 3 - To determine the role of cultural factors (i.e., traditional gender roles religiosity, homophobia, and stigmatization of drug users) on attitudinal and behavioral manifestations of HIV/AIDS stigma among medical residents in Puerto Rico. To achieve these aims I propose an experimental design using mixed method techniques (structured observations, quantitative questionnaires, and SP simulations). The study will be conducted through the SP program at the University of Puerto Rico's Medical Sciences Campus. I will recruit a sample of 154 medical residents in Puerto Rico to participate in an experiment embedded within their ongoing SP training, and assign them to engage in all of the following patient conditions, with randomized order of presentation: 1) HIV-infected through intravenous drug use, 2) HIV-infected through unprotected heterosexual relations, 3) HIV-infected through unprotected homosexual relations, 4) HIVinfected through unprotected heterosexual relations or intravenous drug use, 5) HIV-infected through unprotected homosexual relations or intravenous drug use, 6) HIV-infected through unprotected homosexual or heterosexual relations, and 7) the common cold as a stigma- free comparison control. Interactions will be video-recorded and subsequently coded for behavioral expressions of stigma using a preliminary developed and pilot-tested measure from my NIH funded studies. After participation in the simulation, all participants will complete quantitative questionnaires addressing HIV/AIDS stigma attitudes and adherence to cultural factors of importance in the Puerto Rican setting. The study will be the first to document behavioral manifestations of HIV/AIDS stigma among medical residents in Puerto Rico, thereby extending the scientific literature that has focused almost exclusively on their stigmatizing attitudes. Furthermore, it will be the first study to address the role of cultural factors on the manifestations of HIV/AIDS stigma among this population in Puerto Rico and variations related to means of infection. The findings from the study have the potential to inform the development of guidelines for stigma measurement and stigma reduction interventions for this population, taking into consideration both attitudinal and behavioral manifestations of stigma, and the role of local culture on these indicators.


INVESTIGADOR: 

Nelson Varas, Ph.D. - nvaras@mac.com



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