Concentrated HIV, STI Epidemics Stress Public Health Care Need Among Black Women

Results of a nearly 4-year randomized clinical trial of 352 Black or African American women in community supervision programs (CSPs) show how effective culturally tailored HIV and sexually transmitted infection (STI) interventions can be, according to the study findings published in JAMA Network Open.

The Empowering African-American Women on the Road to Health, or E-WORTH, group-based intervention program was tailored for Black or African American women (mean [SD] age, 32.4 [11.4] years) enrolled in probation, parole, or incarceration-alternative programs in New York City and who had substance use disorder (SUD) history. There were 2 primary outcomes:

• Incidence of any STI (biologically assayed chlamydia, gonorrhea, and Trichomonas vaginalis)at 12 months
• Total condomless acts of vaginal or anal intercourse in the past 90 days during those 12 months

In particular, the authors highlighted, close to half of women in CSPs have a SUD history, which itself is a risk factor for HIV and STIs, and E-WORTH is designed to be delivered in low-resource CSPs by Black female staff.

“These statistics indicate an urgent public health need for effective interventions to reverse the concentrated HIV/STI and SUD epidemics among Black women in CSPs,” the authors wrote. “In addition, accumulating research indicates the efficacy of culturally tailored interventions in reducing HIV/STIs among individuals from underrepresented minority groups and Black women in particular. However, there remains a dearth of HIV interventions designed for Black women in CSPs.”

Their investigation (November 18, 2015-August 20, 2019) compared outcomes between the study group (n = 172), which received the 5-session–based E-WORTH intervention with computerized self-paced modules, and the control group (n = 180), which participated in a 1-session streamlined HIV testing initiative. Among the entire study population, 22.5% also identified as Latinx.

For the 2 primary outcomes, those assigned to the E-WORTH intervention had superior results, with reduced odds for both:

• 54% lower odds of testing positive for an STI (odds ratio [OR], 0.46; 95% CI, 0.25-0.88; P = .01)
• 38% fewer condomless vaginal or anal intercourse acts (incidence rate ratio [IRR], 0.62; 95% CI, 0.39-0.97; P = .04), and 42% fewer such acts with their principal sexual partners (IRR, 0.58; 95% CI, 0.36-0.92; P = .02)

To confirm HIV and STI status, biological assays were performed at baseline and the 12-month follow-up, and participants with positive results were linked or referred to treatment. Sexual behavior data was collected at 4 time points: baseline and 3, 6, and 12 months.

Analysis also revealed:

• Most participants were high school graduates (55.8%), single (82.6%), and heterosexual (65.5%).
• In the past 90 days, all were affected by at least 1 social determinant of health (SDOH), with the top SDOHs being probation (71.2%), food insecurity (63.4%), and serving jail or prison time (22.8).
• A majority (69.5%) reported binge drinking in the past 90 days.
• Reports of ever having used an illicit drug (83.5%), crack or cocaine (37.4%), or heroin (9.1%) or having injected drugs (4.8%).
• E-WORTH group reported higher rates of always using condoms with all partners (OR, 2.11; 95% CI, 1.12-3.97; P = .02) and their main partners (OR, 1.97; 95% CI, 1.06-3.69; P = .03).

In addition, at baseline, 4.3% of participants received positive results on their HIV tests, while 36.5% of E-WORTH and 26.3% of the control participants has positive STI results.

“To consider these findings in context, the intervention effect on reducing STI incidence found in this study was stronger than the average effect from a meta-analysis of 17 HIV/STI interventions conducted among Black women, which observed a 19% reduced odds of STI incidence among intervention participants relative to comparison participants,” the authors stated.

An accompany editorial notes the strength of their results. “Black women who have a history of criminal justice system involvement, including those in community corrections (ie, probation, parole and other programs within the criminal justice system, but external to prisons and jails) are at particularly high risk,” the authors wrote. “These findings by Gilbert et al provide support for the role of comprehensive, culturally tailored behavioral interventions that tackle the complex determinants of HIV and STI risk among Black women.”

Reference

Gilbert L, Goddard-Eckrich D, Chang M, et al. Effectiveness of a culturally tailored HIV and sexually transmitted infection prevention intervention for Black women in community supervision programs: a randomized clinical trial. JAMA Netw Open. Published online April 1, 2021. doi:10.1001/jamanetworkopen.2021.5226