Substance Use and HIV Risk in a Sample of Severely Mentally Ill Puerto Rican Women

Latinos, and Puerto Ricans in particular, have been disproportionately impacted by HIV/AIDS. Severe mental illness (SMI) is associated with an increase in HIV risk. Relatively little research has focused on the role of SMI among Puerto Rican injection drug users (IDUs) and non-IDUs in susceptibility to and transmission of HIV and there are few published reports on HIV risk among Latina SMI. We conducted a longitudinal mixed methods study with 53 Puerto Rican women with schizophrenia, bipolar disorder, or major depression to examine the cultural context of HIV risk and HIV knowledge, beliefs, and behaviors among a larger study with Puerto Rican and Mexican women with serious mental illness (SMI). There was a high prevalence of past and current substance use and a high prevalence of substance use-associated HIV risk behaviors, such as unprotected sexual relations with an IDU. The violence associated with substance use frequently increased participants’ HIV risk. Choice of substance of abuse depended on cost, availability, and use within the individual participant’s network. Participants attributed their substance use to the need to relieve symptoms associated with their mental illness, ameliorate unpleasant feelings, and deaden emotional pain. HIV prevention interventions for poorer Puerto Rican women with SMI must target the individuals themselves and others within their networks if the women are to be supported in their efforts to reduce substance use-related risk. The content of any intervention must address past and current trauma and its relationship to substance use and HIV risk, as well as strategies to prevent HIV transmission.     

Locus of control and HIV risk among a sample of Mexican and Puerto Rican women

The disproportionate impact of HIV/AIDS on Hispanic women in the United States has been variously attributed to a failure to utilize protective measures due to low levels of HIV knowledge, a denial or minimization of risk, and conflicts with cultural norms. It has been hypothesized that women's relative lack of power in relationships may be associated with higher risk sexual behavior. We examined the relationship between higher risk sexual behavior and perceived locus of control in sexual relationships among a sample of Puerto Rican and Mexican women. We interviewed 71 women of self-reported Mexican ethnicity in San Diego, California, and 79 women of self-reported Puerto Rican ethnicity in Cleveland, Ohio, to examine the relationship between HIV risk, HIV knowledge, and locus of control. Univariate logistic regression indicates that among Puerto Rican women, the perception that locus of control in a sexual relationship resides in the male partner was significantly associated with increased HIV risk, while younger age was significantly associated with increased risk among Mexican women only. In a combined sample of both Puerto Rican and Mexican women, multiple logistic regression analysis indicates that younger age, increased length of residence in the United States, and an other-focused locus of control are significantly associated with increased HIV risk. Women who have been in the United States for relatively longer periods of time may be more likely to integrate U.S. sexual norms into their own behavior and may, as a consequence, be at higher risk of HIV infection. Increased HIV prevention efforts must be made available to Mexican and Puerto Rican women born outside of the United States. These prevention efforts must necessarily focus not only on HIV prevention strategies, but also on the dynamics within male-female intimate relations. Increased attention to younger Puerto Rican and Mexican women is also needed.     

Spirituality, Coping, and HIV Risk and Prevention in a Sample of Severely Mentally Ill Puerto Rican Women

Hispanics have been disproportionately impacted by HIV/AIDS. Although HIV risk is significantly elevated among severely mentally ill persons (SMI), the risk of infection appears to be even greater among those SMI who are Hispanic, reflecting the increased risk of HIV among Hispanics. We report on findings from the first 41 participants in a qualitative study examining the context of HIV risk and risk reduction strategies among severely mentally ill Puerto Rican women residents in northeastern Ohio. Individuals participated in a baseline interview, two follow-up interviews, and up to 100 hours of shadowing. Interviews and shadowing activities were recorded and analyzed using a grounded theory. The majority of individuals reported using identification with a religious faith. A large proportion of the participants reported that their religious or spiritual beliefs were critical to their coping, had influenced them to reduce risk, and/or provided them with needed social support. Several participants also reported having experienced rejection from their faith communities. The emphasis on spirituality among Puerto Rican SMI is consistent with previous research demonstrating the importance of spirituality in the Hispanic culture and reliance on spiritual beliefs as a mean of coping among SMI. Our results support the incorporation of spiritual beliefs into secular HIV prevention efforts. Loue is with the Department of Epidemiology and Biostatistics, Center for Minority Public Health, School of Medicine, Case Western Reserve University, Cleveland, OH, USA; Sajatovic is with the Department of Psychiatry, School of Medicine, Case Western Reserve University, Cleveland, OH, USA.     

Addressing the HIV/AIDS Epidemic Among Puerto Rican People Who Inject Drugs: The Need for a Multiregion Approach

High levels of HIV risk behaviors and prevalence have been reported among Puerto Rican people who inject drugs (PRPWID) since early in the HIV epidemic. Advances in HIV prevention and treatment have reduced HIV among people who inject drugs (PWID) in the United States. We examined HIV-related data for PRPWID in Puerto Rico and the US Northeast to assess whether disparities continue.Injection drug use as a risk for HIV is still overrepresented among Puerto Ricans. Lower availability of syringe exchanges, drug abuse treatment, and antiretroviral treatment for PWID in Puerto Rico contribute to higher HIV risk and incidence.These disparities should be addressed by the development of a federally supported Northeast–Puerto Rico collaboration to facilitate and coordinate efforts throughout both regions.Behavioral, biomedical, and structural interventions have led to significant reductions in HIV incidence in the United States. More than 30 years since HIV was first reported, the possibility of an AIDS-free generation in the United States has recently emerged. Current research and policy efforts focus on identifying those who may be unaware of their infection to engage and maintain them in antiretroviral treatment, and aim to reduce health disparities among racial/ethnic groups.Despite great advances in HIV prevention and care, insufficient progress has been made among Puerto Rican people who inject drugs (PRPWID). Research on the HIV/AIDS epidemic among people who inject drugs (PWID) has documented higher levels of risk behaviors and prevalence among individuals identified as Puerto Rican than among other groups since early in the epidemic, and these disparities persist. Although Puerto Ricans in the island and the continental United States represent about 9% of the US Hispanic population,1 nearly 23% of incident HIV cases among Hispanics in 2006 were among those born in Puerto Rico.2 Injection drug use accounted for the majority of AIDS cases in Puerto Rico early in the epidemic,3 and currently more than 20% of new infections in Puerto Rico are attributed to injection drug use, a higher percentage than for any other region of the United States 4 and for any other Hispanic subgroup.5To meet the challenge of eradicating HIV in the United States, health disparities within subgroups at high risk for HIV must be addressed. Furthermore, the HIV treatment–as–prevention paradigm6 in use to reduce HIV transmission will not suffice in reducing comorbidities associated with injection drug use (e.g., hepatitis C, overdoses), also found at disproportionately high rates among PRPWID. We focused on Puerto Rico and the northeastern United States, where the majority of Puerto Ricans live,1 to examine the history of the epidemic among PRPWID, the current state of the epidemic, and the availability of HIV prevention and treatment services. We also describe other challenges to health for PRPWID and interventions recently adopted in Puerto Rico and provide recommendations to further reduce HIV in this population.     

Preventing HIV Among U.S. Women of Color With Severe Mental Illness: Perceptions of Mental Health Care Providers Working in Urban Community Clinics

Given their knowledge of the behavioral issues related to psychiatric illness, mental health care providers are in a unique position to help prevent HIV among women with severe mental illness (SMI). We conducted in-depth interviews with providers at two New York City community clinics. We identified three major, interrelated themes pertaining to HIV prevention among women of color with SMI. Interventions that address the barriers that clinicians face in discussing sex, sexuality, and HIV with patients and train providers in the cultural considerations of cross-cultural mental health care are needed to help prevent HIV among women of color with SMI.     

Sexual risk factors for HIV and violence among Puerto Rican women in New York City

The authors examined sexual factors for HIV risk in 1,003 women of Puerto Rican heritage who attended a community-based NewYork City hospital clinic. Participants' ages ranged from 18 to 73 years. Half were born in the continental United States, and half were born in the Commonwealth of Puerto Rico. All were sexually active within the past 90 days with a male partner.The authors compared sociodemographic characteristics, experience of intimate partner violence (IPV), and HIV sexual risk factors (number of partners, history of sexually transmitted infections [STIs],condom use, and so on).Multiple regression analyses considering sociodemographic characteristics were a predictor for IPV and sexual risk behaviors. The authors found differences in sexual risk behaviors by place of birth (continental United States versus Commonwealth of Puerto Rico) and language chosen for the interview (Spanish or English).Puerto Rican women reported fewer sexual partners and STIs. Mainland-born and English-preference women reported more IPV, risky partners, and condom use. Birth in the continental United States and preference for English appear to be indicators of greater risk for IPV, risky sexual practices, and risky partners. HIV prevention intervention strategies for Puerto Rican women must address differences in heterosexual risk according to language and place of birth.     

Understanding the Barriers that Reduce the Effectiveness of HIV/AIDS Prevention Strategies for Puerto Rican Women Living in Low-income Households in Ponce,PR: A Qualitative Study

Background The HIV/AIDS epidemic has been strongly felt in Hispanic/Latino communities. Estimates of AIDS prevalence among Latinos in the US reveal that just nine States and the Commonwealth of Puerto Rico account for 89% of the Latinos living with AIDS in 2004. Previous research reveals social and cultural factors play an important role in HIV prevention. Methods Four focus groups were conducted, with 39 women, ages 21–67, participating in the discussions. The objectives of this research were to assess knowledge regarding HIV transmission among women living in low-income households, to ascertain barriers to safe sex in this population, and to elicit opinions about effective prevention strategies. Results Our results suggest that participants recognized HIV/AIDS modes of transmission and risk behaviors, as well as their barriers to practicing safe sex. They identified promiscuity, unprotected sex, infidelity, drug and alcohol use, and sharing syringes as behaviors which would place them at risk of HIV/AIDS transmission. They specifically identified lack of negotiating skills, fear of sexual violence, partner refusal to use condoms, and lack of control over their partner’s sexual behavior as barriers to practicing safe sex. Finally results also indicate that current HIV/AIDS prevention strategies in Puerto Rico are inadequate for these women. Discussion To address these issues the authors suggest cultural and social factors to be considered for the development of more effective HIV/AIDS prevention programs.     

Migrant Drug Users: Predictors of HIV-Related Sexual and Injection Risk Behaviors

Background Puerto Rican drug users recruited in NY who previously used drugs in Puerto Rico (PR) have been found to have higher HIV injection and sex-related risk behaviors than those who had not used in PR. This study examined predictors of risk among migrant Puerto Rican drug users. (For the purpose of this paper, the term “migrant” was used to designate Puerto Rican drug users who had used drugs in Puerto Rico and were recruited in New York or New Jersey). Methods A total of 290 drug users who had previously used drugs in PR were recruited in NY and New Jersey and interviewed regarding drug use history and HIV risk behaviors. Results Participants engaged in high risk behaviors, e.g., 39% shared injection paraphernalia and 62% reported unprotected sex. Multivariate analyses found that predictors of injection-related risk included being born in PR and purchasing drugs jointly with other drug users; predictors of sex-related risk included younger age and homelessness. Discussion Addressing risk reduction among those drug users who were born in Puerto Rico and are younger or homeless was indicated, and efforts to reach those at highest risk through NEPs was recommended.     

HIV risk among a sample of Mexican and Puerto Rican men and women

HIV/AIDS has disproportionately affected the Hispanic communities in the United States. Consequently, Hispanic communities at risk for HIV infection should be considered a high priority for prevention and education efforts. Although such efforts ideally consider variations across subpopulations, including differences in high-risk behaviors and routes of transmission by national origin, gender, and acculturation levels, relatively few studies of risk behavior have considered such differences. This paper reports on an interview-based study of HIV knowledge, risk behavior, and protective behaviors among a sample of 143 men and women of Mexican ethnicity in San Diego County, California and 189 men and women of Puerto Rican ethnicity in Cuyahoga County, Ohio. The authors' findings indicate that individuals who have been in the United States for longer periods of time and who are younger in age are at increased risk of HIV infection. Increased perceived risk may also be predictive of increased actual risk.     

Research with Severely Mentally Ill Latinas: Successful Recruitment and Retention Strategies

Individuals from minority groups in the United States have been found less likely than non-Hispanic whites to participate in research studies. The recruitment and retention of individuals from minority groups has also proved challenging. We describe the challenges that we encountered in recruiting and retaining a sample of severely mentally ill Mexican and Puerto Rican ethnicity for a study of the context of HIV risk. We recruited women in San Diego County, California and northeastern Ohio who were between the ages of 18 and 50 and who had diagnoses of schizophrenia, bipolar disorder, or major depression. We identified challenges to recruitment and retention at the macro, mediator, and micro levels. We were able to retain 81.1% of the Puerto Rican cohort and 26.7% of the Mexican cohort over a 5-year period. The vast majority of barriers to recruitment and retention within the Puerto Rican cohort occurred at the micro (individual) level. Macro level barriers occurred more frequently and impacted retention to a greater extent within the cohort of Mexican women. Our experience underscores the importance of outreach to the community and the interaction between staff and individual participants. Diverse strategies are required to address the impact of migration on follow-up, which may vary across groups.     

Designing health information delivery systems for Puerto Rican women.

Although health information is important to the prevention of much illness, the health information needs of Puerto Rican women remain unaddressed, according to the results of this phenomenological study. Through audiotaped interviews, 21 women evaluated various sources of health information. Analysis of the data revealed which health information sources they considered trustworthy and nontrustworthy. Health care providers were found to be one of the least helpful sources, as personal interactions were often hurried and inattentive to women's needs. Yet, the women were able to present a vivid portrait of a culturally sensitive community environment conducive to the presentation of health information. Implications include the importance of including cultural values in any health information setting, as well as the importance of building cultural bridges between health educators and Puerto Rican women. More research is needed to examine community efforts to enhance health information sources for this population of women.     

Income,body fatness,and fat patterns in Hispanic women from the Hispanic health and nutrition examination survey

Using data from the Hispanic Health and Nutrition Examination Survey (HHANES) (National Center for Health Statistics, 1985), we examined the relationships of income to body fatness and centralized fat patterns in Hispanic women, ages 25–74 years. There were 1,552 Mexican‐American, 451 Cuban‐American, and 654 Puerto Rican women. We used linear regression to estimate models of body fatness for weight with the covariates standing and sitting heights, and triceps and subscapular skinfolds. The indicator of central fat was the subscapular/triceps skinfold ratio. Income, estimated with the Poverty Index Ratio from the HHANES, was negatively associated with weight (p < .01) and triceps skinfold (p < .05) in Mexican‐American women and with subscapular skinfold in Puerto Rican women (p < .01). Acculturation level was inversely related to central adiposity in Mexican‐Americans (p < .07). The body fatness trends found in Mexican‐American and Puerto Rican women were consistent with those for other groups but were not apparent among the Cuban‐Americans. These groups should be targeted differently for interventions to decrease body fatness and lower the risk for chronic disease.     

Latinas and HIV/AIDS risk factors: implications for harm reduction strategies

OBJECTIVES: We examined risk factors for HIV infection among Puerto Rican and Mexican American women aged 15 through 44 years. METHODS: We used data from the 1995 National Survey of Family Growth. Analyses focused on the relation between sex role attitudes, sex education, anxiety, and consistent condom use. RESULTS: Nearly 60% of Puerto Rican and Mexican American women received no sex education from parents. Twenty-one percent of Puerto Rican and 38.3% of Mexican American women reported no sex education in schools. Women with some sex education in school, less than 13 years of education, or higher sex role attitude scores were more likely than other women to have partners who consistently used condoms. CONCLUSIONS: Harm reduction interventions must be designed to reach multiple Latino audiences by age, gender, and subgroup     

HIV knowledge among a sample of Puerto Rican and Mexican men and women

This study assessed levels of HIV knowledge and identified factors associated with HIV knowledge among a sample of heterosexual Puerto Rican and Mexican men and women, ages 18 to 45. The sample consisted of 144 men and women living in San Diego County, California, who self-identified as being of Mexican ethnicity and 209 men and women living in Cuyahoga County, Ohio, who self-identified as Puerto Rican. Interviews were conducted by trained, bilingual interviewers. Data were collected on demographic variables, attitudes towards decision-making in relationships, and HIV knowledge and risk behaviors. Puerto Rican individuals were significantly more likely than Mexican individuals to respond correctly to almost one-half of the 12 HIV knowledge items. Multiple logistic regression analysis indicated that higher levels of education, greater U.S. acculturation, legal status and birth in the United States, a self-focused locus of control in relationships, and being male were predictors of higher knowledge.     

The Puerto Rico–New York Airbridge for Drug Users: Description and Relationship to HIV Risk Behaviors

This study examined mobility on the airbridge between New York (NY) and Puerto Rico (PR) for Puerto Rican drug users and its relationship to HIV risk. Over 1,200 Puerto Rican injection drug users (IDUs) and crack smokers were recruited by outreach workers in NY and PR; interview data included questions on mobility (lifetime residences and recent trips). Two-thirds of the NY sample had lived in PR; one-quarter of the PR sample had lived in NY; the most commonly sited reasons for moving were family-related. Fewer than 10% had visited the other location in the prior 3 years. Variables related to risk were number of moves, recent travel, and having used drugs in PR (all with p < 0.05). Implications included the need to enhance risk reduction efforts for IDUs in PR and address sexual risk among mobile drug users.     

Overall health and healthcare utilization among latino american women in the United States

Abstract Purpose: The purpose of this study was to examine the chronic conditions, behavioral-mental health and service utilization of Latino American women in the first epidemiologic survey in the United States. Methods: Using a national sample (n=1427) from the National Latino and Asian American Study, we assessed and compared the prevalence of overall health and service use in three major subgroups, Cuban, Mexican, and Puerto Rican, and in other Latino American women. Service use included general medical, mental health, and subspecialists. Results: In physical health, Puerto Rican American women reported the highest rate of asthma, whereas Mexican American women reported the highest rate of diabetes. Cuban American women reported the highest rate of hypertension and heart diseases. Body mass index (BMI) indicated that overweight (BMI 25-29.9?kg/m(2)) and obesity (BMI≥30?kg/m(2)) were prevalent in all three subgroups: two thirds of Mexicans and Puerto Ricans, respectively, and >50% of Cuban Americans. Of the sample, 11.6% rated their mental health status as fair or poor, and 10.8% reported at least one major depressive disorder (MDD) in the past 12 months. Puerto Rican American women had the highest rates on depression, substance abuse, and seeking mental health service, and Cuban American women saw specialists most frequently. Conclusions: Patterns of overall health issues varied among Latino American subgroup women, yet they have low rates of healthcare use. It is critical to further examine factors associated with the sex-specific health issues and with their health services underuse.     

A comparison of the fertility of Dominican, Puerto Rican and mainland Puerto Rican adolescents.

Data from three fertility surveys are used to examined the probabilities and determinants of adolescent births among Dominican and Puerto Rican women. Young women in the Dominican Republic are the most likely to have had a child by each year of age from 14 through 24, followed by young women on the Island of Puerto Rico; the probability of an early birth is lowest for Puerto Rican women on the U.S. mainland. Eighteen percent of Dominican women have had a child before their 18th birthday, compared with 13% of women living in Puerto Rico, and 10% of Puerto Rican women in metropolitan New York. The cumulative probabilities that Puerto Rican women will have borne a child before their 20th birthday are almost identical, whether the women live on the island or the U.S. mainland, but the difference between Puerto Rican and Dominican women widens. The order is reversed, however, in the analysis of premarital births: The probability of a premarital birth during adolescence is highest for Puerto Rican women in New York, and lowest for Dominican women. In a separate logistic regression analysis, education and age at first sexual intercourse are shown to be important determinants of adolescent fertility in all three populations.     

Perceiving benefits in adversity: stress-related growth in women living with HIV/AIDS

This study examines perceptions of illness-related positive of change or stress-related growth among a sample of African American, Puerto Rican, and non-Hispanic White women (n = 54) living with HIV/AIDS in New York City, USA. While these women acknowledged the negative stresses of living with HIV/AIDS, 83% reported at least one positive change in their lives that they attributed to their illness experience. A number of different domains of potential growth were identified including: health behaviors, spirituality, interpersonal relationships, view of the self, value of life, and career goals. While growth was reported by nearly all the women, some variation was found in the forms of growth reported in relation to the women's ethnic/racial background, class, and IV drug use history. These data suggest an expanded conceptualization of stress-related growth that includes behavioral aspects of growth in response to stress and illness, and which takes into account the diverse ways in which growth may be experienced.     

A qualitative study examining the perceived barriers and facilitators to medical healthcare services among women with a serious mental illness

ObjectiveThis qualitative study investigates the barriers and facilitators to accessing and utilizing healthcare services among women with a serious mental illness (SMI).MethodsA purposive sample of 30 poor, urban, predominantly African-American women with a diagnosis of an SMI was recruited. Interviews were audio-taped and transcribed verbatim. Data analysis was guided by a modified constant comparison approach.ResultsThe findings highlight a variety of nonmedical factors that serve as both barriers and facilitators to accessing and utilizing medical healthcare services, such as a trusting relationship with a mental health provider and a women’s social network.ConclusionNonmedical factors and personal circumstances seem to be important factors influencing pathways to healthcare services among women with an SMI. Efforts to better engage and retain women with an SMI into healthcare will need to better acknowledge and incorporate the larger social context of the women’s lives.