A youth-focused case management intervention to engage and retain young gay men of color
in HIV care
Amy Rock Wohl
a
*, Wendy H. Garland
a
, Juhua Wu
b
, Chi-Wai Au
b
, Angela Boger
b
, Rhodri Dierst-Davies
a
,
Judy Carter
b
, Felix Carpio
c
and Wilbert Jordan
d
a
Los Angeles County Department of Public Health, HIV Epidemiology Program, Los Angeles, CA, USA;
b
Los Angeles County
Department of Public Health, Office of AIDS Programs and Policy, Los Angeles, CA, USA;
c
AltaMed Health Services
Corporation, Daniel V. Lara Clinic, Los Angeles, CA, USA;
d
Los Angeles County MLK-MACC, OASIS Clinic, Los Angeles,
CA, USA
(Received 5 April 2010; final version received 18 November 2010)
HIV-positive Latino and African-American young men who have sex with men (YMSM) have low rates of
engagement and retention in HIV care. An evaluation of a youth-focused case management intervention (YCM)
designed to improve retention in HIV care is presented. HIV-positive Latino and African-American YMSM, ages
18�24, who were newly diagnosed with HIV or in intermittent HIV care, were enrolled into a psychosocial case
management intervention administered by Bachelor-level peer case managers at two HIV clinics in Los Angeles
County, California. Participants met weekly with a case manager for the first two months and monthly for the
next 22 months. Retention in HIV primary care at three and six months of follow-up was evaluated as were
factors associated with retention in care. From April 2006 to April 2009, 61 HIV-positive participants were
enrolled into the intervention (54% African-American, 46% Latino; mean age 21 years). At the time of
enrollment into the intervention, 78% of the YMSM had a critical or immediate need for stable housing,
nutrition support, substance abuse treatment, or mental health services. Among intervention participants
(n �61), 90% were retained in primary HIV care at three months and 70% at six months. Among those who had
previously been in intermittent care (n �33), the proportion attending all HIV primary care visits in the previous
six months increased from 7% to 73% following participation in the intervention (pB0.0001). Retention in HIV
care at six months was associated with increased number of intervention visits (p �0.05), more hours in the
intervention (p �0.02), and prescription of HAART. These data highlight the critical needs of HIV-positive
African-American and Latino YMSM and demonstrate that a clinic-based YCM can be effective in stabilizing
hard-to-reach clients and retaining them in consistent HIV care.
Keywords: adolescents; MSM; HIV/AIDS; Latinos; African-Americans; interventions
Introduction
National HIV and AIDS rates are elevated for
African-American and Latino youth which is consis-
tent with 2008 behavioral surveillance data in Los
Angeles County in which HIV prevalence rates were
17% for African-American and 13% for Latino
18�24-year-old young men who have sex with men
(YMSM) (Bingham & Sey, 2009;.
Social services utilization and need among a community sample .docxrosemariebrayshaw
Social services utilization and need among a community sample of persons living with HIV
in the rural south
Katharine E. Stewart, Martha M. Phillips, Jada F. Walker*, Sarah A. Harvey and Austin Porter
Fay W. Boozman College of Public Health, University of Arkansas for Medical Sciences, Little Rock, USA
(Received 7 December 2009; final version received 16 June 2010)
HIV prevalence has increased faster in the southern USA than in other areas, and persons living with HIV
(PLWHIV) in the south are often rural, impoverished, or otherwise under-resourced. Studies of urban PLWHIV
and those receiving medical care suggest that use of social services can enhance quality of life and some medical
outcomes, but little is known about patterns of social service utilization and need among rural southern
PLWHIV. The AIDS Alabama needs assessment survey, conducted in 2007, sampled a diverse community cohort
of 476 adult PLWHIV representative of the HIV-positive population in Alabama (66% male, 76% Black, and
26% less than high school education). We developed service utilization/need (SUN) scores for each of 14 social
services, and used regression models to determine demographic predictors of those most likely to need each
service. We then conducted an exploratory factor analysis to determine whether certain services clustered together
for the sample. Case management, assistance obtaining medical care, and financial assistance were most
commonly used or needed by respondents. Black respondents were more likely to have higher SUN scores for
alcohol treatment and for assistance with employment, housing, food, financial, and pharmacy needs;
respondents without spousal or partner relationships had higher SUN scores for substance use treatment.
Female respondents were more likely to have higher SUN scores for childcare assistance. Black respondents and
unemployed respondents were more likely to have SUN scores in the highest quartile of the overall score
distribution. Factor analysis yielded three main factors: basic needs, substance use treatment, and legal/medical
needs. These data provide important information about rural southern PLWHIV and their needs for ancillary
services. They also suggest clusters of service needs that often occur among PLWHIV, which may help case
managers and other service providers work proactively to identify important gaps in care.
Keywords: HIV; health services utilization; rural; south; need
Introduction
The prevalence of HIV infection has increased
rapidly in the southern USA compared to the other
areas of the country (Foster, 2007; Reif, Geonnotti,
& Whetten, 2006) and southern states are among
those with the highest AIDS-related death rates in the
country (Reif, Geonnotti, et al., 2006; Whetten &
Reif, 2006). For example, in 2006, Alabama had an
age-adjusted HIV mortality rate of 4.2 per 100,000
persons, compared to 4.0 per 100,000 persons in the
USA (Heron et al., 2009). Several issues in the south
have been considere.
Leandro Mena, MD, MPH
Chair and Professor of Population Health Science
Department of Population Health Science
University of Mississippi Medical Center
Social services utilization and need among a community sample .docxrosemariebrayshaw
Social services utilization and need among a community sample of persons living with HIV
in the rural south
Katharine E. Stewart, Martha M. Phillips, Jada F. Walker*, Sarah A. Harvey and Austin Porter
Fay W. Boozman College of Public Health, University of Arkansas for Medical Sciences, Little Rock, USA
(Received 7 December 2009; final version received 16 June 2010)
HIV prevalence has increased faster in the southern USA than in other areas, and persons living with HIV
(PLWHIV) in the south are often rural, impoverished, or otherwise under-resourced. Studies of urban PLWHIV
and those receiving medical care suggest that use of social services can enhance quality of life and some medical
outcomes, but little is known about patterns of social service utilization and need among rural southern
PLWHIV. The AIDS Alabama needs assessment survey, conducted in 2007, sampled a diverse community cohort
of 476 adult PLWHIV representative of the HIV-positive population in Alabama (66% male, 76% Black, and
26% less than high school education). We developed service utilization/need (SUN) scores for each of 14 social
services, and used regression models to determine demographic predictors of those most likely to need each
service. We then conducted an exploratory factor analysis to determine whether certain services clustered together
for the sample. Case management, assistance obtaining medical care, and financial assistance were most
commonly used or needed by respondents. Black respondents were more likely to have higher SUN scores for
alcohol treatment and for assistance with employment, housing, food, financial, and pharmacy needs;
respondents without spousal or partner relationships had higher SUN scores for substance use treatment.
Female respondents were more likely to have higher SUN scores for childcare assistance. Black respondents and
unemployed respondents were more likely to have SUN scores in the highest quartile of the overall score
distribution. Factor analysis yielded three main factors: basic needs, substance use treatment, and legal/medical
needs. These data provide important information about rural southern PLWHIV and their needs for ancillary
services. They also suggest clusters of service needs that often occur among PLWHIV, which may help case
managers and other service providers work proactively to identify important gaps in care.
Keywords: HIV; health services utilization; rural; south; need
Introduction
The prevalence of HIV infection has increased
rapidly in the southern USA compared to the other
areas of the country (Foster, 2007; Reif, Geonnotti,
& Whetten, 2006) and southern states are among
those with the highest AIDS-related death rates in the
country (Reif, Geonnotti, et al., 2006; Whetten &
Reif, 2006). For example, in 2006, Alabama had an
age-adjusted HIV mortality rate of 4.2 per 100,000
persons, compared to 4.0 per 100,000 persons in the
USA (Heron et al., 2009). Several issues in the south
have been considere.
Leandro Mena, MD, MPH
Chair and Professor of Population Health Science
Department of Population Health Science
University of Mississippi Medical Center
Running Head: COMMUNITY ANALYSIS 1
Community Analysis
The most prevalent risk factors among racial and ethnic minorities are unprotected vaginal or anal sex, inadequate sex education, improving access to prevention and care services and drug use. Jackson, MS has a population of 173,212, with median household income of $32,250. Poverty is one of the major contributing factors to the risky behaviors and the rise of HIV infections within racial/ethnic minority youths. The residents with incomes below the poverty level in Jackson, MS by 2015 was 39.9%, and those with income below 50% of the poverty level was 19.2%, the breakdown is between ages 13 to 19 years of poor residents in Jackson, MS and the percentage is below half of poverty level of 20%. The most common race or ethnicity living below the poverty line in Jackson, MS is Black or African American, followed by White and Hispanic or Latino. The state of homelessness is on the rise and many of these shelters in Jackson, MS now have waiting lists with majority of its occupants are racial/ethnic minority. Even with the waiting lists, those that need to be sheltered will have to call ahead to confirm (City Data, 2015).
Mississippi is one of the most rustic states in the United States and its population is perhaps the poorest. According to the 2010 Census, Mississippi has a population of 2,967,297 people, with a racial distribution of 59% white, 37% black, 3% Hispanic, and 2% other. Mississippi ranks second in the nation (after the District of Columbia) for the highest proportion of African Americans. Through U.S. Census Bureau 2011 American Community Surveys, Mississippi levels the first in the country for the number of people living in poverty (22.6% of the total population) and the lowest middle household revenue ($36,919) (United State Census Bureau, 2011). According to the 2011 National HIV Surveillance Report, Mississippi had the 4th highest rate of HIV infection in the United States. The state’s capital city, Jackson, had the third highest rate of HIV diagnoses within aged 13 to 19 years and the eighth highest AIDS diagnosis by metropolitan statistical area (MSA) in 2011. For the past twenty years, numbers of peoples living with HIV in Mississippi has risen yearly. By the end of December 31, 2013, there was approximately 10,473 Mississippians living with HIV (National HIV Surveillance Report, 2013).
Secondary data
Jackson, MS the state’s capital city and with the most new HIV disease cases are identified in the West Central Public Health District V, which includes the metropolitan Jackson Hinds area, where 47% of all persons with HIV disease in Mississippi reside presently (Mississippi State Department of Health, 2015). According to data for states and metropolitan areas, it’s shown that racial and ethnic minority youths aged between 13 to 19 years rank 4th in the diagnose of HIV at 44.7%. The education b ...
HIV Prevention And Health Service Needs Of The Transgender Community In San F...Santé des trans
HIV Prevention and Health Service Needs of the Transgender Community in San Francisco by Kristen Clements, MPH, Willy Wilkinson, Kerrily Kitano, Rani Marx.
Il s'agit de l'un des articles parus dans le numéro spécial de l'International Journal of Transgenderism consacré en 1999 à "Transgenders and HIV : risks, prevention and care" (référence : IJT Volume 3, Number 1+2, January - June 1999).
This webinar discussed how to educate Nurse Practitioners who have completed Community Health Center. Inc’s NP Residency or NPs who have significant experience as a Primary Care Provider on the integration of specialty care for key populations, including:
• HIV care
• Hepatitis C management
• Medication-assisted treatment for opioid use and other substance use disorders
• Sexually transmitted disease (STI) screening and management
• Lesbian, Gay, Bisexual, Transgender, Questioning, Intersex, Asexual (LGBTQIA+) health, including hormone replacement therapy and gender affirming care.
Panelists:
• Charise Corsino, MA, Program Director, Nurse Practitioner Residency Programs, Community Health Center, Inc.
• Marwan Haddad, MD, MPH, AAHIVS, Medical Director, Center for Key Populations, Community Health Center, Inc.
• Jeannie McIntosh, APRN, FNP-C, AAHIVS, Family Nurse Practitioner, Center for Key Populations, Community Health Center, Inc.
Theodoros F. Katsivas, M.D., M.A.S., of UC San Diego Owen Clinic, presents "San Diego Primary Care Providers' Attitudes to HIV and HIV Testing" at AIDS Clinical Rounds
Ce document de la National Coalition for LGBT Health américaine est le fruit du travail de son "Eliminating Disparities Working Group", publié en 2004.
Il présente les chantiers identifiés de sorte à faire reconnaître et mieux prendre en compte les enjeux de santé des trans. Il balaie un large spectre de déterminants de santé : violences, VIH/sida et des autres IST, usage abusif de produits psychoactifs, santé et bien-être mental, couverture maladie, traitements hormonaux, modifications corporelles auto-réalisées, formation des professionnels de santé, tabac etc.
Zoe is a second grader with autism spectrum disorders. Zoe’s father .docxransayo
Zoe is a second grader with autism spectrum disorders. Zoe’s father recently passed away in a tragic car accident. Zoe, her mom, and two older brothers have temporarily relocated from out-of-state and are now living in her grandparents’ house in a small, rural community.
Because the family had been living out-of state, Zoe has never interacted with her grandparents. She has challenges responding to social cues, including her name and in understanding gestures. She also engages in repetitive body movements. She is fond of her set of dolls and likes lining them up. When Zoe is agitated, her mother plays Mozart, which seems to have a calming effect. Zoe also enjoys macaroni and cheese.
Her grandparents do not understand Zoe’s attempts at communicating. Zoe does not respond well to crowded and noisy environments. Zoe’s mom is working outside the home for the first time.
Because of the move, Zoe has transferred to a new school, which does not currently have any students with ASD. Although her mom is generally very involved with Zoe’s education, she is away from the home much of the time due to a long commute for her new job is a neighboring city.
Zoe’s grandparents are eager and willing to help in any way they can.
Imagine you are serving as an ASD consultant at Zoe’s new school. Using the COMPASS model, create a COMPASS Action Plan for Zoe by complete the following tasks:
Identify the personal challenges for Zoe;
Identify the environmental challenges for Zoe;
Identify potential supports; and
Identify and prioritize teaching goals.
In addition, include a 250-500-word rationale that explains how your action plan for Zoe demonstrates collaboration in a respectful, culturally responsive way while promoting understanding, resolving conflicts, and building consensus around her interventions.
.
Zlatan Ibrahimović – Sports Psychology
Outline
Introduction:
· General Info
· Nationality, Birthplace, Parents
· Childhood What he wanted to do growing up?
· When did he start playing professionally?
· Which teams did he play for?
· Give some of his career statistics and maybe records?
· What trophies has he won with club football and national team of Sweden?
· Style of Play
· What is his personality like? How do people see him in the media?\
·
Body Paragraphs
Connect the following Sports Psychology Concepts (or even those not listed) to Zlatan Ibrahimović
What is his personality type? Type A, B C, or D?
Give examples through research of where he shows this.
CATASTROPHE THEORY… OCCURS WHEN? WHAT DOES THE GRAPH LOOK LIKE
· Arousal: is a blend of physiological and psychological activity in a person and it refers to the intensity dimensions of motivation at a particular moment. It ranges from not aroused, to completely aroused, to highly aroused; this is when individuals are mentally and physically activated.
· Performance increases as arousal increases but when arousal gets too high performance dramatically decreases. This is usually caused by the performer becoming anxious and sometimes making wrong decisions. Catastrophes is caused by a combination of cognitive and somatic anxieties. Cognitive is the internal worries of not performing well while somatic is the physical effects of muscle tension/butterflies and fatigue through playing.
· The graph is an inverted U where the x line is the arousal and the y is the performance. Performance peaks on the top of the inverted U and the catastrophe happens in the fall of the inverted U
HIGH TRAIT ANXIETY ATHLETES… HOW DO THEY PERCEIVE COMPETITION?
· Anxiety: is a negative emotional state in which feelings of nervousness, worry and apprehension are associated with activation or arousal of the body
· Trait Anxiety: is a behavioral disposition to perceive as threatening circumstances that objectively may not be dangerous and to then respond with disproportionate state anxiety.
· Somatic Trait Anxiety: the degree to which one typically perceived heightened physical symptoms (muscle tension)
· Cognitive Trait Anxiety: the degree to which one typically worries or has self doubt
· Concentration Disruption: the degree to which one typically has concentration disruption during competition
People usually with high trait anxiety usually have more state anxiety in highly competitive evaluative situations than do people with lower trait anxiety. Example two athletes are playing basketball and both are physically and statistically the same both have to shoot a final free throw to win the game. Athlete A is more laid back which means his trait anxiety is lower and he doesn't view the final shot as a overly threatening. Athlete B has a high trait anxiety and because of that he perceives the final shot as very threatening. This has an effect on his state anxiety much more than.
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Running Head: COMMUNITY ANALYSIS 1
Community Analysis
The most prevalent risk factors among racial and ethnic minorities are unprotected vaginal or anal sex, inadequate sex education, improving access to prevention and care services and drug use. Jackson, MS has a population of 173,212, with median household income of $32,250. Poverty is one of the major contributing factors to the risky behaviors and the rise of HIV infections within racial/ethnic minority youths. The residents with incomes below the poverty level in Jackson, MS by 2015 was 39.9%, and those with income below 50% of the poverty level was 19.2%, the breakdown is between ages 13 to 19 years of poor residents in Jackson, MS and the percentage is below half of poverty level of 20%. The most common race or ethnicity living below the poverty line in Jackson, MS is Black or African American, followed by White and Hispanic or Latino. The state of homelessness is on the rise and many of these shelters in Jackson, MS now have waiting lists with majority of its occupants are racial/ethnic minority. Even with the waiting lists, those that need to be sheltered will have to call ahead to confirm (City Data, 2015).
Mississippi is one of the most rustic states in the United States and its population is perhaps the poorest. According to the 2010 Census, Mississippi has a population of 2,967,297 people, with a racial distribution of 59% white, 37% black, 3% Hispanic, and 2% other. Mississippi ranks second in the nation (after the District of Columbia) for the highest proportion of African Americans. Through U.S. Census Bureau 2011 American Community Surveys, Mississippi levels the first in the country for the number of people living in poverty (22.6% of the total population) and the lowest middle household revenue ($36,919) (United State Census Bureau, 2011). According to the 2011 National HIV Surveillance Report, Mississippi had the 4th highest rate of HIV infection in the United States. The state’s capital city, Jackson, had the third highest rate of HIV diagnoses within aged 13 to 19 years and the eighth highest AIDS diagnosis by metropolitan statistical area (MSA) in 2011. For the past twenty years, numbers of peoples living with HIV in Mississippi has risen yearly. By the end of December 31, 2013, there was approximately 10,473 Mississippians living with HIV (National HIV Surveillance Report, 2013).
Secondary data
Jackson, MS the state’s capital city and with the most new HIV disease cases are identified in the West Central Public Health District V, which includes the metropolitan Jackson Hinds area, where 47% of all persons with HIV disease in Mississippi reside presently (Mississippi State Department of Health, 2015). According to data for states and metropolitan areas, it’s shown that racial and ethnic minority youths aged between 13 to 19 years rank 4th in the diagnose of HIV at 44.7%. The education b ...
HIV Prevention And Health Service Needs Of The Transgender Community In San F...Santé des trans
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This webinar discussed how to educate Nurse Practitioners who have completed Community Health Center. Inc’s NP Residency or NPs who have significant experience as a Primary Care Provider on the integration of specialty care for key populations, including:
• HIV care
• Hepatitis C management
• Medication-assisted treatment for opioid use and other substance use disorders
• Sexually transmitted disease (STI) screening and management
• Lesbian, Gay, Bisexual, Transgender, Questioning, Intersex, Asexual (LGBTQIA+) health, including hormone replacement therapy and gender affirming care.
Panelists:
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Zlatan Ibrahimović – Sports Psychology
Outline
Introduction:
· General Info
· Nationality, Birthplace, Parents
· Childhood What he wanted to do growing up?
· When did he start playing professionally?
· Which teams did he play for?
· Give some of his career statistics and maybe records?
· What trophies has he won with club football and national team of Sweden?
· Style of Play
· What is his personality like? How do people see him in the media?\
·
Body Paragraphs
Connect the following Sports Psychology Concepts (or even those not listed) to Zlatan Ibrahimović
What is his personality type? Type A, B C, or D?
Give examples through research of where he shows this.
CATASTROPHE THEORY… OCCURS WHEN? WHAT DOES THE GRAPH LOOK LIKE
· Arousal: is a blend of physiological and psychological activity in a person and it refers to the intensity dimensions of motivation at a particular moment. It ranges from not aroused, to completely aroused, to highly aroused; this is when individuals are mentally and physically activated.
· Performance increases as arousal increases but when arousal gets too high performance dramatically decreases. This is usually caused by the performer becoming anxious and sometimes making wrong decisions. Catastrophes is caused by a combination of cognitive and somatic anxieties. Cognitive is the internal worries of not performing well while somatic is the physical effects of muscle tension/butterflies and fatigue through playing.
· The graph is an inverted U where the x line is the arousal and the y is the performance. Performance peaks on the top of the inverted U and the catastrophe happens in the fall of the inverted U
HIGH TRAIT ANXIETY ATHLETES… HOW DO THEY PERCEIVE COMPETITION?
· Anxiety: is a negative emotional state in which feelings of nervousness, worry and apprehension are associated with activation or arousal of the body
· Trait Anxiety: is a behavioral disposition to perceive as threatening circumstances that objectively may not be dangerous and to then respond with disproportionate state anxiety.
· Somatic Trait Anxiety: the degree to which one typically perceived heightened physical symptoms (muscle tension)
· Cognitive Trait Anxiety: the degree to which one typically worries or has self doubt
· Concentration Disruption: the degree to which one typically has concentration disruption during competition
People usually with high trait anxiety usually have more state anxiety in highly competitive evaluative situations than do people with lower trait anxiety. Example two athletes are playing basketball and both are physically and statistically the same both have to shoot a final free throw to win the game. Athlete A is more laid back which means his trait anxiety is lower and he doesn't view the final shot as a overly threatening. Athlete B has a high trait anxiety and because of that he perceives the final shot as very threatening. This has an effect on his state anxiety much more than.
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Do You Choose to Accept?
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Ziyao LiIAS 3753Dr. Manata HashemiWorking Title The Edu.docxransayo
Ziyao Li
IAS 3753
Dr. Manata Hashemi
Working Title:
The Education Gap
Research Question:
How did the youth of Iran make up the education gap resulted from the Cultural Revolution from 1980 to 1982?
This is a critical question because it involves both education and the youth of Iran. Education and the youth are both very fundamental perspectives for a society to thrive. During the cultural revolution, the education system was shut down, which would undermine the overall quality of a generation. Research of this issue will lead us to the methods used to make up the education gap. It is possible to help other countries suffering similar issues.
Thesis Statement:
After the Iran’s cultural revolution during 1980 to 1982, the youth of Iran made up the education gap caused during the revolution by promoting student movements.
Outline:
· Introduction:
· Cultural Revolution happened in Iran during 1980 to 1982. The education institutions like universities were shut down for the 3-year period. And this gap in education brought significant influence on the youth of Iran at that time. However, the education gap was made up successfully after the revolution.
· State the thesis statement:
· The education gap is made up by the youth in Iran. They promoted the student movement to help the society recover from the revolution.
· The scars left from the revolution
· The revolution lasted 3 years, young people who were supposed to be students had to quit school. The government forced schools to close. The chain of delivering knowledge was broken. And young people cannot find proper things to do when quitting school.
· Student movements
· After the cultural revolution, people in Iran realized they need to correct the current education situation recover the damages resulted from the revolution. Since Iran’s youth has a great number in the society, their power was not to be ignored. They started to fight for their own rights and profits. They were looking for ways to make up the damage has been down. Then the student movement eventually worked for recovering Iran’s education level.
· Conclusion
· The cultural revolution in Iran hurt its education continuity. However, the youth of Iran managed to make up for the damage caused by the cultural revolution. Student movements played the dominant role in this recovering process.
Bibliography:
Khosrow Sobhe (1982) Education in Revolution: is Iran duplicating the Chinese Cultural Revolution?, Comparative Education, 18:3, 271-280, DOI: 10.1080/0305006820180304
Mashayekhi M. The Revival of the Student Movement in Post-Revolutionary Iran. International Journal of Politics, Culture & Society. 2001;15(2):283. doi:10.1023/A:1012977219524.
Razavi, R. (2009). The Cultural Revolution in Iran, with Close Regard to the Universities, and its Impact on the Student Movement. Middle Eastern Studies, 45(1), 1–17. https://doi-org.ezproxy.lib.ou.edu/10.1080/00263200802547586
ZABARDAST, S. (2015). Flourishing of Occid.
Ziyan Huang (Jerry)
Assignment 4
Brand Positioning
Professor Gaur
Target audience:
HR in Ping An Bank Co., Ltd. HRs (interviewers who hire people) from Ping An Bank are usually female, aged 30-40, who look friendly and easy-going. They are sophisticated and skeptic when checking people’s resumes and asking questions during interview. Usually, HRs care about four things: 1. Graduate school ranking. 2. Working experience in bank 3. Oral expression. 4. Personal character. They prefer people who are enthusiastic, energetic and hard-working.
Q1:
Compared to other people who also look for jobs in Ping An Bank, my points of parity would be: 1. I have earned a master degree in a Top 40 U.S. graduate school. 2. I have some intern experience in another bank. My points of differentiation would be: 1. I am confidence in speaking and self-expression. I can serve both Chinese and American clients because I speak fluent Mandarin and English. 2. I am energetic and hard-working. I always have passion in learning something new, which is a key for me to develop working skills.
Q2:
My brand essence: “Energetic, hard-working and modest.”
Q3:
Positioning statement:
Ziyan Huang is for employers from bank,
Who look for excellent employees.
Ziyan Huang is an energetic, hard-working NYU graduate student,
That has passion in developing new working skills.
Because he can speak fluent Mandarin and English,
And have one year working experience in China Merchant Bank,
So that employers can trust him as a reliable candidate.
.
Zhtavius Moye
04/19/2019
BUSA 4126
SWOT Analysis
Dr. Setliff
PORSCHE
Strengths
· Brand Recognition
Not only a brand, but a status symbol for wealth and luxury
· Lean Factory Production
Manpower is low compared to the use of raw materials and supplies
· High Profit Share
The reputation is well-known for good treatment
Weaknesses
· Small automotive manufacture
Porsche has offered the same line of cars for years before extending.
· Limited Customer Sector
Not everyone can afford a Porsche
· Location
Since beginning of time, Porsche has been in Stuttgart, Germany. No space to expand
Opportunities
· Expansion
Deliveries increased in China by 12% but needs more in Asia, Japan, and Indonesia.
· Electric Mobility
A chance to expand Porsche name to many more industries and markets with top competitors such as Tesla.
· S1, O2: Brand recognition extends the range for profitability for the 2020 fully electric Porsche Taycan.
· S3, O1: The annual profitability of the company will encourage others to become a part of the business.
· S2, O1: The cost of a Porsche effects expansion, but by expanding to China could significantly increase rates.
· S3, O1: The location in Germany is a problem for expansion due to limited space of Stuttgart.
Threats
· Technology
Modern technology is advancing to lower cost vehicles.
· Market Competition
Vehicles with similar characteristics at lower cost.
· S3, O2: Weighing heavily on the market Porsche’s reputation will continue to stand abroad its competitors.
· S2, O1: Limited labor will call for more software developers in the more modern technology, especially introducing the fully electric Porsche Taycan.
· S1, O1: Porsche is a company that believes in staying at its classic and luxury perception to their buyers. Still giving all newly updated technology certain things such as an automatic start engine will not be an asset.
· S2, O2: Combined leaves Porsche at a limitation of customers making it hard to expand the market.
VIOLATION OF CIVIL RIGHTS ACT IN ELECTIONS 1
VIOLATION OF CIVIL RIGHTS ACT IN ELECTIONS 2
Violation of Civil Rights Act in Elections
Jake Bookard
Savannah State University
Violation of Civil Rights Act in Elections
Introduction
Despite the assurance of minority voter’s rights by the constitution and the fourteenth amendment, cases of rights violation with regards to the voting process are still on the rise in the US. Minority groups are often discriminated or blocked from participating in the voting process both in ways that they can discern and through cunning plans that can involve the voting process. Some of the main reasons why minorities’ constitutional rights are violated include racial discrimination by majority races, and to manipulate the outcome of the elections so as to keep minority groups out of the political leadership structure. The fourteenth amendment and the constitution do not sufficiently safeguard the rights of minority groups during elections beca.
Zichun Gao Professor Karen Accounting 1AIBM FInancial Stat.docxransayo
Zichun Gao Professor Karen Accounting 1A
IBM FInancial Statement Analysis
Financial Ratios 2019 2018 Formula
Current Ratio 1.02 1.29 CA/CL
Profit Margin 12.22% 12.35% Net Income/Total Revenue
Receiveables Turnover 9.80 10.71 Revenue/Average AR
Average Collection Period 36.72 33.62 365/Receiveables Turnover
Inventory Turnover 25.11 25.36 COST/Average Inventory
Days in Inventory 14.53 14.39 365/Inventory Turnover
Debts to Asset Ratio 0.86 0.86 Total Debts/Total Assets
IBM's days in inventory is around two weeks and this means that goods in the inventory
as efficnetly distributed and that there is a consitantly good inventory control for the
company.
The company's debts to assets ratio is the same for two years and this means that the
company has less debt than asset. However, it is still a relatively poor ratio because this
might show that there are potential problems for the company to generate sufficient
revenue.
The current ratio of the company has decreased over the year, and this means that the
company has less liquid assets to cover its short term liabilities. Since the ratio is
currently approaching 1, the company might be having liquidation problem.
The profit margin for IBM is very stable and it has been about 12% for two years. The
company is performing the profit-generating ability at an average level and it is having
an average profit margin in the industry.
The receiveables turnover is good for the company while between these two years, there
is a decline. As the company is collecting its accounts receiveables around 10 times per
year, the collection is frequent.
The company has been collecting money from customers on credit sales approximately
once every month, and the company usually has fast credit collection, which means that
the risk for credit sales is relatively low.
Inventory turnover measures how many times a company sells and replaces inventory
during a year and for IBM, the number of times is stable and it is constantly around 25.
This means that the company has an efficient control of its goods in the inventory.
Free Cash Flow 11.90 11.90 CF_Operation-Capital Expenditures
Return on Assets 0.06 0.08 Net Income/Total Assets
Asset Turnover 0.51 0.65 Revenue/Assets
Figures From Financial Statement
From Income Statement pg.68
Net Income 9431 9828
Total Revenue 77147 79591
Cost 40657 42655
From Consolidated Balance Sheet pg.70
Current Assets 38420 49146
Current Liabilities 37701 38227
Accounts Receiveables 7870 7432
Inventory 1619 1682
Total Assets 152186 123382
Total Liabilities 131202 106452
From Cash Flow Overview pg.59
Net Cash From Op 14.3 15.6
Capital expenditures 2.4 3.7
The company currently has 11.9 billion dollars free cash flow for two years and this is a
relatively high level of free cash flow. With the high free cash flow, the company can
have more oportunity to expand, invest in new projects, pay dividends, or invest the
money into Resea.
Zheng Hes Inscription This inscription was carved on a stele erec.docxransayo
Zheng He's Inscription
This inscription was carved on a stele erected at a temple to the goddess the Celestial Spouse at Changle in Fujian province in 1431. Message written before his last voyage.
The Imperial Ming Dynasty unifying seas and continents, surpassing the three dynasties even goes beyond the Han and Tang dynasties. The countries beyond the horizon and from the ends of the earth have all become subjects and to the most western of the western or the most northern of the northern countries, however far they may be, the distance and the routes may be calculated. Thus the barbarians from beyond the seas, though their countries are truly distant, "have come to audience bearing precious objects and presents.
The Emperor, approving of their loyalty and sincerity, has ordered us (Zheng) He and others at the head of several tens of thousands of officers and flag-troops to ascend (use) more than one hundred large ships to go and confer presents on them in order to make manifest (make it happen) the transforming power of the (imperial) virtue and to treat distant people with kindness. From the third year of Yongle (1405) till now we have seven times received the commission (official permission) of ambassadors to countries of the western ocean. The barbarian countries which we have visited are: by way of Zhancheng (Champa Cambodia), Zhaowa (Java), Sanfoqi (Palembang- Indonesia) and Xianlo (Siam/Thailand) crossing straight over to Xilanshan (Ceylon- Sri Lanka) in South India, Guli (Calicut) [India], and Kezhi (Cochin India), we have gone to the western regions Hulumosi (Hormuz Between Oman and Iran), Adan (Aden), Mugudushu (Mogadishu- Somalia), altogether more than thirty countries large and small. We have traversed more than one hundred thousand li (distance of 500 meters) of immense water spaces and have beheld in the ocean huge waves like mountains rising sky-high, and we have set eyes on barbarian regions far away hidden in a blue transparency of light vapours, while our sails loftily unfurled like clouds day and night continued their course (rapid like that) of a star, traversing those savage waves as if we were treading a public thoroughfare. Truly this was due to the majesty and the good fortune of the Court and moreover we owe it to the protecting virtue of the divine Celestial Spouse.
The power of the goddess having indeed been manifested in previous times has been abundantly revealed in the present generation. When we arrived in the distant countries we captured alive those of the native kings who were not respectful and exterminated those barbarian robbers who were engaged in piracy, so that consequently the sea route was cleansed and pacified (to make someone or something peaceful) and the natives put their trust in it. All this is due to the favours of the goddess.
We have respectfully received an Imperial commemorative composition (essay/piece of writing) exalting the miraculous favours, which is the highest recompense and.
Zhou 1Time and Memory in Two Portal Fantasies An Analys.docxransayo
Zhou 1
Time and Memory in Two Portal Fantasies: An Analysis of Alice’s Adventure in Wonderland and "Windeye"
Life is a collection of moments, and some memories last forever. Brian Evenson
demonstrated this in “Windeye,”a story of a man who faces mental challenges because of the
life-long memory of his sister. In spite of the fact that his mother insists that the sister did not
exist, the protagonist stuck to this belief until his old age. The basis of the protagonist’s
problems is the intense love and unforgettable memories he shared with his imagined sister.
A great portion of his childhood memories is centered around his sister and their exploration
of the windeye. Windeye, the corruption of the word window, is a portal that causes the
disappearance of the protagonist’s sister. The popular portal fantasy, Alice’s Adventure in Wonderland, illustrates a similar story in the same sub-genre where a girl travels through a
rabbit hole and experiences a fantasy world which chronicles her changes from naive child-
like responses to more adult-like problem solving reactions. In “Windeye,” Brian Evenson
utilizes the portal trope to develop conflict and outcomes while exploring the themes of time
and memory. In both stories, the use of the portal trope creates a distinct world that is
separate from reality; however, the outcomes are different, and ultimately, Alice’s Adventure in Wonderland presents the theme of growth while “Windeye” explores time and memories.
The use of time factors allows the reader to travel back to the origin of the story in “Windeye” and experience the beginning of the central conflict. It is in his past that the
protagonist develops strong childhood memories of a sister, which is the cause of his future
mental challenges. In the present, the narrator is old and rickety as he uses a cane to walk but
is still reminiscent of the past (Evenson). He holds firm to the belief that he might have a
chance of meeting his sister again and thus contemplates the future and the sister’s
appearance. The plot of “Windeye” is composed of distinctive life moments: the past, the
present, and the future, which offer a clear and complete description of the events. The theme
Zhou 2
of time allows the reader to understand why the protagonist profoundly feels that his sister exists. In essence, it is time travel that gives the story a picture of the events that lead to the current situation.
The portal fantasy is a fictional literary device where a character enters into a
fantastical world through a portal or a hole. In Alice’s Adventures in Wonderland, Carroll
uses a rabbit hole as a physical portal to move through time. Comparably, Evenson utilizes
the windeye, a window that can only be seen from one side, as a physical portal. When the
sister touches the windeye, her brother believes that she enters into another reality through
the portal as Alice does. In contrast, the protagonist also experiences a new reality as he is.
Zhang 1
Yixiang Zhang
Tamara Kuzmenkov
English 101
June 2, 2020
Comparing Gas-Powered Cars and Electric Cars
Electric cars have become increasingly popular in the past century. These cars use
electric motors instead of conventional gasoline engines. Electric cars pollute less and utilize
energy more efficiently than gas-powered vehicles; therefore, modern research is focusing on
improving electric vehicles, such as increasing the storage capacity of the batteries. This essay
seeks to identify the differences and similarities between the two types of cars focusing on their
performance, price, and convenience.
An electric car is a car that is primarily powered by electricity. The conventional gas-
powered cars require diesel or gasoline to power the engines. These cars have gas tanks that store
fuel and the engine converts the gas to the energy that powers the motor. Similarly, electric cars
have batteries, or fuel cells that store and convert electricity to energy used to propel electric
motors (What Are Electric Cars?). Four components present in electric cars distinguish it from
the gas-powered cars (Alternative Fuels Data Center: How Do All-Electric Cars Work?). The
first is the charge port. Since electricity powers an electric car, there has to be a port to connect
to an external power source when charging the battery. The second is an electric traction motor
that propels the vehicle. The third is a traction battery pack. This battery serves the same purpose
as the gas tank; thus, it stocks electric power to propel the motor. The forth is a direct current
converter. This component converts the current to low voltage power that is needed to power the
electric engine.
Tamara Kuzmenkov
90000001730094
You need to watch the panapto session for this paper assignment and FOLLOW the instructions I give there. Your topic sentence must follow the patterns set forth by your thesis. So, this first paragraph must have a topic sentence about GAS POWERED cars and PRICE. That is what you have set forth in your thesis. Watch the panapto session. And ask me questions if you do not understand what I mean.
Tamara Kuzmenkov
90000001730094
No, you cannot 'announce' what your essay will do. And this is NOT the thesis I approved. What I approved:"Both gas-powered cars and electric cars are now in use, but their price, performance and convenience may vary, which may influence people's decisions about which type to use."
Zhang 2
Differences between gas-powered cars and electric cars
The initial purchase price of an electric car is much higher than that of a gas-powered car.
Consumers intending to own a vehicle have the option of buying or leasing. The initial cost of a
car depends on an individual's disposable income and savings. Knez et al. noted that "When it
comes to financial features, the most important thing seems to be the total price of the vehicle"
(55). The difference in price between electr.
Zhang �1
Nick Zhang
Mr. Bethea
Lyric Peotry
13 November 2018
Reputation by Taylor Swift
After Taylor Swift fell into disrepute, she was truly reborn. As a creative singer
who reveals a lot of real life emotions and details in her works, she constantly refines
and shares her emotional connection with her audience. In her new album, people find
resonance in her work, connect it with their own lives. "Reputation" is not only the
original efforts of Taylor Swift, but also means that she turned gorgeously and
dominated. This album is like a swearing word from her to the world. Revenge fantasy,
sweet love, painful growth... all the good and bad things that happened in these stages
of life, her music seems to have gone through with us all over again.
But last August, the now 28-year-old singer declared that "the old Taylor is
dead" in her eerie single "Look What You Made Me Do," the beginning of a new era for
Swift (Weatherby). The disclosure of the society, the accusations of rumor makers,
these straight-forward lyrics shred the ugly face of those unscrupulous people. Taylor
Swift did not endure the rumors in the society, but created this rock album after the
silence. If 1989 is still what Taylor hopes to gain the understanding of the public, this
album is really a matter of opening up the past concerns, saying goodbye to the past
as well as being a true Taylor Swift. No longer caring about the so-called "reputation ",
preferring to be burned to death by those ridiculous "images." This air of newfound
jadedness is one of the many ways in which Swift broadcasts her long-overdue loss of
Zhang �2
innocence on “Reputation,” an album that captures the singer during the most
turbulent but commercially successful period of her career. (Primeau)
The cover is black and white, the picture is Taylor's head, and the side is the
newspaper's article and title words. The cover of the album may be a metaphor, it
reveals that Taylor can no longer stand the report of the gossip media, and the chain on
the neck represents depression and breathlessness. The theme and style of the album
are all refined from their own lives. The emotions and themes interpreted in her songs
make the audience feel more deeply that her album is her life. Without even using any
real words, fans can surmise what this means — a reference to the endless headlines
and stories the singer has spurred in recent years. (Primeau) Reputation, come to diss
the past and all opponents.
The lyrics and MV are full of real stalks in Taylor Swift's life , with Taylor's
resentment for circles and industry since his debut. In the era of streaming singles, she
is the rare young star who still worships at the altar of the album, an old-fashioned
instinct that serves her surprisingly well. (Battan) "Look What You Made Me Do" is a
counterattack against Kanye West and Kim Kardashian, Katy Perry and numerous
online "black mold". And .
Zero trust is a security stance for networking based on not trusting.docxransayo
Zero trust is a security stance for networking based on not trusting any users, devices, or applications by default, even those that are already on the network. The zero trust model uses identity and access management (IAM) as a foundation for an organization’s security program. For this assignment:
Research the zero trust model.
Write a report that describes the following:
The purpose of zero trust and what differentiates it from other security models
An overview of how zero trust works in a network environment
How zero trust incorporates least privilege access through role-based access control (RBAC) and/or attribute-based access control (ABAC)
Need 2 pages around 600 words
.
Zero plagiarism4 referencesNature offers many examples of sp.docxransayo
Zero plagiarism
4 references
Nature offers many examples of specialization and collaboration. Ant colonies and bee hives are but two examples of nature’s sophisticated organizations. Each thrives because their members specialize by tasks, divide labor, and collaborate to ensure food, safety, and general well-being of the colony or hive.
In this Discussion, you will reflect on your own observations of and/or experiences with informaticist collaboration. You will also propose strategies for how these collaborative experiences might be improved.
Of course, humans don’t fare too badly in this regard either. And healthcare is a great example. As specialists in the collection, access, and application of data, nurse informaticists collaborate with specialists on a regular basis to ensure that appropriate data is available to make decisions and take actions to ensure the general well-being of patients.
Post
a description of experiences or observations about how nurse informaticists and/or data or technology specialists interact with other professionals within your healthcare organization. Suggest at least one strategy on how these interactions might be improved. Be specific and provide examples. Then, explain the impact you believe the continued evolution of nursing informatics as a specialty and/or the continued emergence of new technologies might have on professional interactions.
.
Zero plagiarism4 referencesLearning ObjectivesStudents w.docxransayo
Zero plagiarism
4 references
Learning Objectives
Students will:
Develop diagnoses for clients receiving psychotherapy*
Analyze legal and ethical implications of counseling clients with psychiatric disorders*
* The Assignment related to this Learning Objective is introduced this week and
submitted
in
Week 4
.
Select a client whom you observed or counseled this week. Then, address the following in your Practicum Journal:
Describe the client (without violating HIPAA regulations) and identify any pertinent history or medical information, including prescribed medications.
Using the
Diagnostic and Statistical Manual of Mental Health Disorders
, 5th edition (DSM-5), explain and justify your diagnosis for this client.
Explain any legal and/or ethical implications related to counseling this client.
Support your approach with evidence-based literature.
.
Zero Plagiarism or receive a grade of a 0.Choose one important p.docxransayo
Zero Plagiarism or receive a grade of a 0.
Choose one important police function: Law enforcement, order maintenance or service, etc.
OR
Choose one important police strategy: Traditional Policing, Community Policing, Data Driven Policing, etc.
Write a research paper describing the strateugy or function in detail and discussing the significance of the strategy or function with respect to the roles in society.
Format: Title Page, Outline, Text, and References
Must have 3 sources
You can use your textbook: Cox, Steven M., et al. (2020). Introduction to Policing. Fourth Edition. Thousand Oaks, CA: SAGE Publications, Inc.
Paper must by 6 pages long
APA Style
.
ZACHARY SHEMTOB AND DAVID LATZachary Shemtob, formerly editor in.docxransayo
ZACHARY SHEMTOB AND DAVID LAT
Zachary Shemtob, formerly editor in chief of the Georgetown Law Review, is a clerk in the US District Court for the Southern District of New York. David Lat is a former federal prosecutor. Their essay originally appeared in the New York Times in 2011.
Executions Should Be Televised
Earlier this month, Georgia conducted its third execution this year. This would have passed relatively unnoticed if not for a controversy surrounding its videotaping. Lawyers for the condemned inmate, Andrew Grant DeYoung, had persuaded a judge to allow the recording of his last moments as part of an effort to obtain evidence on whether lethal injection caused unnecessary suffering.
Though he argued for videotaping, one of Mr. DeYoung’s defense lawyers, Brian Kammer, spoke out against releasing the footage to the public. “It’s a horrible thing that Andrew DeYoung had to go through,” Mr. Kammer said, “and it’s not for the public to see that.”
We respectfully disagree. Executions in the United States ought to be made public.
Right now, executions are generally open only to the press and a few select witnesses. For the rest of us, the vague contours are provided in the morning paper. Yet a functioning democracy demands maximum accountability and transparency. As long as executions remain behind closed doors, those are impossible. The people should have the right to see what is being done in their name and with their tax dollars.
This is particularly relevant given the current debate on whether specific methods of lethal injection constitute cruel and unusual punishment and therefore violate the Constitution.
There is a dramatic difference between reading or hearing of such an event and observing it through image and sound. (This is obvious to those who saw the footage of Saddam Hussein’s hanging in 2006 or the death of Neda Agha-Soltan during the protests in Iran in 2009.) We are not calling for opening executions completely to the public — conducting them before a live crowd — but rather for broadcasting them live or recording them for future release, on the web or TV.
When another Georgia inmate, Roy Blankenship, was executed in June, the prisoner jerked his head, grimaced, gasped, and lurched, according to a medical expert’s affidavit. The Atlanta Journal-Constitution reported that Mr. DeYoung, executed in the same manner, “showed no violent signs in death.” Voters should not have to rely on media accounts to understand what takes place when a man is put to death.
Cameras record legislative sessions and presidential debates, and courtrooms are allowing greater television access. When he was an Illinois state senator, President Obama successfully pressed for the videotaping of homicide interrogations and confessions. The most serious penalty of all surely demands equal if not greater scrutiny.
Opponents of our proposal offer many objections. State lawyers argued that making Mr. DeYoung’s execution public raised safety concerns..
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Zeng Jiawen ZengChenxia Zhu English 3001-015292017Refl.docxransayo
Zeng
Jiawen Zeng
Chenxia Zhu
English 3001-01
5/29/2017
Reflective Essay
Becoming a good writer is a challenging and continuous process that need to constantly improving your writing skills in different area as same as constructive reflection for identification of both progress and directions for further development. My writing competence has improved significantly during the ten weeks of English 3001 Writing Proficiency course in such areas as grammar, use of verb tenses, and content quality.
The most serious problems I faced in writing process previously were grammar issues and poor content of the essays. To be more precise, I used to lack empirical competence in proper use of verb tenses. My confusions of tense forms destroyed all the sense of the essay, and often improper sentence structure made the result of the writing process insufficient to meet the University Writing Skills Requirements. Initially, when I tried to improve my skills in the given area, I only paid attention to the highlighted mistakes and comments of the tutor. Nonetheless, I realized it was not enough. Therefore, I changed this strategy to a more constructive one. To be more precise, I started reading more books in English and wrote essays diverse topics apart from the course tasks. It was an effective type of training since in several weeks my essays revealed particular progress which I took into consideration and continued.
I realize that it does not suffice to finally meet the University Writing Skills Requirements since this is only a fraction of real competence in writing. The next step of self-improvement the given sphere is editing that also has numerous issues and challenges to be dealt with. It means that there are two domains within the notion of writing competence, and both of them have no limits and require constant self-improvement. Therefore, my goal to meet academic requirements is only one more step in the course of acquisition of linguistic competence and capacity to master English in terms of writing essays and academic papers.
Moreover, I know that currently I need to focus more on content issues, persuasive capacity and proper use of diverse materials employed to support evidence which are crucial elements of writing papers per University requirements. On the other hand, I see that all the core problems with linguistic competence which I have faced earlier, are solved, which means that I need to focus on further self-improvement and keep constructive work in order to achieve my next targets in the field of concern. Furthermore, I have considerable progress in such important dimensions of academic paper construction as thesis development, use of testimony and personal observations, and alignment of different ideas into a coherent, justified and credible academic entity. Now I do not permit run-ons, excessive use of articles or comma splices to emerge in my works. It means that flaws of basic and medium level are dealt with, and further self-de.
zClass 44.8.19§ Announcements§ Go over quiz #1.docxransayo
z
Class 4
4.8.19
§ Announcements
§ Go over quiz #1
§ Practice listening quiz
§ Lecture on social organization of Hindustani music
z
Announcements
§ Aashish Khan recital on April 28
§ Assignment #1 will be posted this week
§ Summer course on Indian rhythm
z
Practice listening quiz
z
Terms
§ Socio-musical identity – the connection of social rank to musical
status; prevalent throughout musical communities in South and
Central Asia
§ Soloist – the lead musical role
§ Accompanist – the supporting musical role(s)
§ Heterophony – style of music in which a melody is closely
imitated by another instrument or voice
z
Questions to keep in mind
§ What does social class have to do with music performance?
§ How is authority created and controlled?
§ How is it challenged?
§ What is the relationship between soloist and accompanist?
§ How does this affect music performance?
§ What is the relationship between student and teacher?
z
Social class and caste in South Asia
§ Societies were stratified in a social hierarchy
§ High caste – rulers, priests, elite
§ Low caste – manual laborers
§ Dalits – “untouchables”
§ Caste specialization of artisan trades common among Muslim communities
§ Carpentry, pastoralism, leather making, jewelry making, and music!
§ The community to which you were born determined your social rank and the
opportunities that would be available to you
§ People could ”change” their class through certain strategies
§ Marriage, contesting the hegemony of the upper classes
z
Organization of specialist knowledge
§ Music is a practice of specialized communities
§ Music is your life!
§ No word for “musician”
§ Rather, terms denoting the specialty of the performer are used
§ This categorization indicates musical identity (the instrument one
performs) as well as that person’s social rank and roles
z
Organization of specialist knowledge
§ Dhrupadiya – singer of dhrupad
§ Gawaiya – vocalist
§ Binkar – bin (veena) player
§ Khayalia – singer of khyāl
§ Sitariya – sitar player
§ Sarodiya – sarod player
§ Tabliya – tabla player
§ Sarangiya – sarangi player
§ Rubabi – rubab player
§ Qawwal - singer of Qawwali
z
Instrument association
Soloist
Vocal
Sitar
Rudra veena
Sarod
Dance
Rubab
Surbahar
Bansuri
Accompanist
Sarangi
Tabla
Harmonium
z
Social roles and ranks
§ Relationship between occupation and social identity is very
close
§ Soloists are venerated and have great prestige
§ Accompanists have lower social and musical status
§ They are subservient to soloists in both roles
z
Performance structure
§ Soloist (Dhrupad, khyāl, thumri, ghazal
§ Vocal
§ Instrumental
§ Accompanist
§ Melodic
§ Sarangi
§ Harmonium
§ Student
§ Heterophony
§ Rhythmic
§ Tabla
§ Dholak
§ Drone
§ Tanpura
z
Social roles and ranks
§ Soloists and accompanists belonged to different social class
§ Never intermarried
§ Cousin marriages
§ Soloist class – kalawant
§ Accompanist classes – mirasi, dhari (dhadhi).
zClass 185.13.19§ Announcements§ Review of last .docxransayo
z
Class 18
5.13.19
§ Announcements
§ Review of last class
§ Finish lecture on Qawwali, begin intro to Pakistan
z
Announcements
§ Keshav Batish senior recital, June 5 – Extra credit
§ Exam #1 results posted
§ 2 perfect scores, 25 A’s, 46 B’s, 37 C’s, 17 D and lower
§ Summer course on Indian rhythm (second session)
§ Learn tabla and dholak!
§ Enrollment open now!
z
Last class review
§ Qawwali – “Food for the soul”
§ Sufi devotional poetry set to music
§ Performed at dargah
§ ‘Urs
z
Terms
§ Mehfil – small, intimate gatherings that involve entertainment of
various sorts, including music, poetry, dance etc.
z
Tum Ek Gorakh Dhandha Ho
§ “You are a baffling puzzle”
§ Written by Naz Khialvi (1947-2010)
§ Pakistani lyricist and radio broadcaster
§ Popularized by Ustad Nusrat Fateh Ali Khan (1948-1997)
z
Tum Ek Gorakh Dhandha Ho
kabhi yahaan tumhein dhoonda
kabhi wahaan pohancha
tumhaari deed ki khaatir kahaan
kahaan pohancha
ghareeb mit gaye paamaal ho
gaye lekin
kisi talak na tera aaj tak nishaan
pohancha
ho bhi naheen aur har ja ho
tum ik gorakh dhanda ho
At times I searched for you here,
at times I traveled there
For the sake of seeing You, how
far I have come!
Similar wanderers wiped away
and ruined, but
Your sign has still not reached
anyone
You are not, yet You are
everywhere
You are a baffling puzzle
z
Bhar Do Jholi Meri
§ Traditional song
§ Popularized in movie “Bajrangi Bhaijaan” (2015)
z
Bhar Do Jholi Meri
Tere Darbaar Mein
Dil Thaam Ke Woh Aata Hai
Jisko Tu Chaahe
Hey Nabi Tu Bhulata Hai
Tere Dar Pe Sar Jhukaaye
Main Bhi Aaya Hoon
Jiski Bigdi Haye
Nabi Chaahe Tu Banata Hai
Bhar Do Jholi Meri Ya Mohammad
Lautkar Main Naa Jaunga Khaali
They come into Your court
clenching their hearts
Those people whom You desire to
see , O Prophet!
I’ve also come to Your door with
my head bowed down
You’re the One who can fix
broken fates, O Prophet!
Please fill my lap, O Prophet!
I won’t go back empty handed
z
Ustad Nusrat Fateh Ali Khan
(1948-1997)
§ Pakistani vocalist
§ Sang classical (khyāl) but more famous as a Qawwali singer
§ Brought classical performance techniques to Qawwali
§ Visiting artist at University of Washington from 1992-93
§ Legacy carried on through his nephew, Rahat Fateh Ali Khan
z
Introduction to Pakistan
Badshahi Mosque, Lahore
Built in 1671 by Emperor Aurangzeb
z
Pakistan
§ Prominent Bronze Age (3000-1500BCE) settlements of Mohenjo
Daro and Harrapa along Indus River Valley
§ Hinduism widespread during Vedic Age (1500-500BCE)
§ Ruled by series of Hindu, Buddhist, and eventually Muslim
(Persian) dynasties
§ Islam introduced by Sufi missionaries from 7th to 13th centuries
§ Ethnically and linguistically diverse
z
Indus Valley civilization
z
Pakistan ethnicities
z
Modern India and Pakistan
§ By the end of 19th century British rule was in effect over much of
old Mughal Empire territory
§ The Hindu and Muslim divide among this territory was be.
The French Revolution, which began in 1789, was a period of radical social and political upheaval in France. It marked the decline of absolute monarchies, the rise of secular and democratic republics, and the eventual rise of Napoleon Bonaparte. This revolutionary period is crucial in understanding the transition from feudalism to modernity in Europe.
For more information, visit-www.vavaclasses.com
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The Roman Empire A Historical Colossus.pdfkaushalkr1407
The Roman Empire, a vast and enduring power, stands as one of history's most remarkable civilizations, leaving an indelible imprint on the world. It emerged from the Roman Republic, transitioning into an imperial powerhouse under the leadership of Augustus Caesar in 27 BCE. This transformation marked the beginning of an era defined by unprecedented territorial expansion, architectural marvels, and profound cultural influence.
The empire's roots lie in the city of Rome, founded, according to legend, by Romulus in 753 BCE. Over centuries, Rome evolved from a small settlement to a formidable republic, characterized by a complex political system with elected officials and checks on power. However, internal strife, class conflicts, and military ambitions paved the way for the end of the Republic. Julius Caesar’s dictatorship and subsequent assassination in 44 BCE created a power vacuum, leading to a civil war. Octavian, later Augustus, emerged victorious, heralding the Roman Empire’s birth.
Under Augustus, the empire experienced the Pax Romana, a 200-year period of relative peace and stability. Augustus reformed the military, established efficient administrative systems, and initiated grand construction projects. The empire's borders expanded, encompassing territories from Britain to Egypt and from Spain to the Euphrates. Roman legions, renowned for their discipline and engineering prowess, secured and maintained these vast territories, building roads, fortifications, and cities that facilitated control and integration.
The Roman Empire’s society was hierarchical, with a rigid class system. At the top were the patricians, wealthy elites who held significant political power. Below them were the plebeians, free citizens with limited political influence, and the vast numbers of slaves who formed the backbone of the economy. The family unit was central, governed by the paterfamilias, the male head who held absolute authority.
Culturally, the Romans were eclectic, absorbing and adapting elements from the civilizations they encountered, particularly the Greeks. Roman art, literature, and philosophy reflected this synthesis, creating a rich cultural tapestry. Latin, the Roman language, became the lingua franca of the Western world, influencing numerous modern languages.
Roman architecture and engineering achievements were monumental. They perfected the arch, vault, and dome, constructing enduring structures like the Colosseum, Pantheon, and aqueducts. These engineering marvels not only showcased Roman ingenuity but also served practical purposes, from public entertainment to water supply.
Read| The latest issue of The Challenger is here! We are thrilled to announce that our school paper has qualified for the NATIONAL SCHOOLS PRESS CONFERENCE (NSPC) 2024. Thank you for your unwavering support and trust. Dive into the stories that made us stand out!
Biological screening of herbal drugs: Introduction and Need for
Phyto-Pharmacological Screening, New Strategies for evaluating
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Instructions for Submissions thorugh G- Classroom.pptxJheel Barad
This presentation provides a briefing on how to upload submissions and documents in Google Classroom. It was prepared as part of an orientation for new Sainik School in-service teacher trainees. As a training officer, my goal is to ensure that you are comfortable and proficient with this essential tool for managing assignments and fostering student engagement.
Honest Reviews of Tim Han LMA Course Program.pptxtimhan337
Personal development courses are widely available today, with each one promising life-changing outcomes. Tim Han’s Life Mastery Achievers (LMA) Course has drawn a lot of interest. In addition to offering my frank assessment of Success Insider’s LMA Course, this piece examines the course’s effects via a variety of Tim Han LMA course reviews and Success Insider comments.
Operation “Blue Star” is the only event in the history of Independent India where the state went into war with its own people. Even after about 40 years it is not clear if it was culmination of states anger over people of the region, a political game of power or start of dictatorial chapter in the democratic setup.
The people of Punjab felt alienated from main stream due to denial of their just demands during a long democratic struggle since independence. As it happen all over the word, it led to militant struggle with great loss of lives of military, police and civilian personnel. Killing of Indira Gandhi and massacre of innocent Sikhs in Delhi and other India cities was also associated with this movement.
Acetabularia Information For Class 9 .docxvaibhavrinwa19
Acetabularia acetabulum is a single-celled green alga that in its vegetative state is morphologically differentiated into a basal rhizoid and an axially elongated stalk, which bears whorls of branching hairs. The single diploid nucleus resides in the rhizoid.
A youth-focused case management intervention to engage and ret.docx
1. A youth-focused case management intervention to engage and
retain young gay men of color
in HIV care
Amy Rock Wohl
a
*, Wendy H. Garland
a
, Juhua Wu
b
, Chi-Wai Au
b
, Angela Boger
b
, Rhodri Dierst-Davies
a
,
Judy Carter
b
, Felix Carpio
c
and Wilbert Jordan
d
2. a
Los Angeles County Department of Public Health, HIV
Epidemiology Program, Los Angeles, CA, USA;
b
Los Angeles County
Department of Public Health, Office of AIDS Programs and
Policy, Los Angeles, CA, USA;
c
AltaMed Health Services
Corporation, Daniel V. Lara Clinic, Los Angeles, CA, USA;
d
Los Angeles County MLK-MACC, OASIS Clinic, Los Angeles,
CA, USA
(Received 5 April 2010; final version received 18 November
2010)
HIV-positive Latino and African-American young men who
have sex with men (YMSM) have low rates of
engagement and retention in HIV care. An evaluation of a
youth-focused case management intervention (YCM)
designed to improve retention in HIV care is presented. HIV-
positive Latino and African-American YMSM, ages
18�24, who were newly diagnosed with HIV or in intermittent
HIV care, were enrolled into a psychosocial case
management intervention administered by Bachelor-level peer
case managers at two HIV clinics in Los Angeles
County, California. Participants met weekly with a case
manager for the first two months and monthly for the
3. next 22 months. Retention in HIV primary care at three and six
months of follow-up was evaluated as were
factors associated with retention in care. From April 2006 to
April 2009, 61 HIV-positive participants were
enrolled into the intervention (54% African-American, 46%
Latino; mean age 21 years). At the time of
enrollment into the intervention, 78% of the YMSM had a
critical or immediate need for stable housing,
nutrition support, substance abuse treatment, or mental health
services. Among intervention participants
(n �61), 90% were retained in primary HIV care at three
months and 70% at six months. Among those who had
previously been in intermittent care (n �33), the proportion
attending all HIV primary care visits in the previous
six months increased from 7% to 73% following participation in
the intervention (pB0.0001). Retention in HIV
care at six months was associated with increased number of
intervention visits (p �0.05), more hours in the
intervention (p �0.02), and prescription of HAART. These data
highlight the critical needs of HIV-positive
African-American and Latino YMSM and demonstrate that a
clinic-based YCM can be effective in stabilizing
hard-to-reach clients and retaining them in consistent HIV care.
Keywords: adolescents; MSM; HIV/AIDS; Latinos; African-
Americans; interventions
Introduction
National HIV and AIDS rates are elevated for
African-American and Latino youth which is consis-
tent with 2008 behavioral surveillance data in Los
4. Angeles County in which HIV prevalence rates were
17% for African-American and 13% for Latino
18�24-year-old young men who have sex with men
(YMSM) (Bingham & Sey, 2009; Centers for Disease
Control and Prevention [CDC], 2008). Youth are also
known to test late for HIV, delay seeking care for an
HIV infection following a positive HIV test, are at high
risk for dropping out of HIV care and have poor
adherence to antiretroviral treatment regimens (Cen-
ters for Disease Control and Prevention [CDC], 2005;
Johnson, Sorvillo et al., 2003; Rao, Kekwaletswe,
Hosek, Martinez, & Rodriguez, 2007; Rudy, Murphy,
Harris, Muenz, & Ellen, for the Adolescent Trials
Network for HIV/AIDS Interventions, 2009; Valleroy
et al., 2000). In addition, among a national sample of
HIV-positive 15�22-year-old YMSM, only 15% were
receiving HIV medical care and 8% were on antire-
troviral medications (Valleroy et al., 2000).
Given the difficulties faced by HIV-positive
youth, targeted interventions are needed to help
5. YMSM access and attend regularly scheduled pri-
mary HIV care appointments. The successful man-
agement of HIV disease requires frequent lifelong
appointments with an HIV primary care provider and
uninterrupted medication use, requirements that im-
pose substantial lifestyle changes for all HIV-positive
persons (Department of Health and Human Services
[DHHS], 2008). Given the many competing chal-
lenges that HIV-positive minority YMSM face in
their daily lives including cultural and community
stigma toward their sexual orientation and HIV
status, sexual identity issues, substance abuse, mental
illness, and basic subsistence concerns regarding
employment, education, transportation, and housing,
*Corresponding author. Email: [email protected]
AIDS Care
Vol. 23, No. 8, August 2011, 988�997
ISSN 0954-0121 print/ISSN 1360-0451 online
# 2011 Taylor & Francis
6. DOI: 10.1080/09540121.2010.542125
http://www.informaworld.com
http://www.informaworld.com
it is not surprising that additional support is needed
to help them manage their HIV infection (Eastwood
& Birnbaum, 2007; Mustankski, Garafalo, Herrick, &
Donenberg, 2007; Rao et al., 2007; Swendeman,
Rotheram-Borus, Comulada, Weiss, & Ramos,
2006; Valleroy et al., 2000).
Several interventions have helped at-risk youth
access and remain in general medical care and several
models of integrated medical care for HIV-positive
youth have been developed (Harris et al., 2003; Huba
& Melchior, 1998; Johnson, Sorvillo et al., 2003;
Schneir, Kipke, Melchior, & Huba, 1998; Woods
et al., 1998). There are few quantitative evaluations
of interventions, however, that target HIV-positive
Latino and African-American YMSM with the goal of
7. improving engagement and retention in HIV care. One
intervention that included primarily HIV-negative
at-risk youth (98%) used a combination of outreach,
mental health and case management services and
reported that retention in care was correlated with
more outreach and case management contacts (Harris
et al., 2003). Another case management program
found that addressing barriers related to concrete
needs helped improve retention in HIV care for a
mostly female and young African-American sample
(Johnson, Botwinick et al., 2003).
In 2004, the Health Resource and Services Ad-
ministration (HRSA) HIV/AIDS Bureau, Special
Projects of National Significance (SPNS) program
funded eight demonstration sites to identify, imple-
ment, and evaluate new models to provide outreach
and interventions for HIV-positive Latino and Afri-
can-American YMSM (Magnus et al., 2010). As one
8. of the demonstration sites, the Los Angeles County
Department of Public Health developed and evalu-
ated a clinic-based, youth-focused case management
intervention (YCM) to engage and retain Latino and
African-American YMSM in HIV primary care
services.
Methods
Participants were recruited from April 2006 through
April 2009 from HIV testing sites, sexually trans-
mitted disease clinics, support groups, community
colleges, clubs/bars, and two predominantly African-
American or Latino public HIV clinics in Los Angeles
County. Eligibility criteria included ages 13 to 23,
confirmed HIV-positive status, African-American or
Latino race/ethnicity, and biologically male. In addi-
tion, eligible participants had to be new to HIV care
or in intermittent care with less than two HIV
primary care visits in the previous six months.
9. YCM combined psychosocial case management,
treatment education/adherence support and HIV risk
reduction counseling to provide a client-centered
intervention through which care was coordinated
(Garland, Wohl, Boger, Carter, & Wu, 2006). The
clinic-based intervention was administered by two
para-professional, Bachelor-level case managers who
were trained and supervised by a licensed clinical
social worker to deliver the intervention in a non-
judgmental and culturally appropriate manner. The
participants met weekly with a case manager for the
first two months and monthly for the next 22 months.
At the first meeting, the case managers conducted
a comprehensive assessment to evaluate the partici-
pant’s medical, physical, psychosocial, environmental,
and financial needs. Using the stages of change model,
the case manager evaluated whether participants were
in one of the following stages with respect to initiation
and utilization of HIV care: pre-contemplation, con-
templation, preparation, action, or maintenance
(Coury-Doniger, Levenkron, McGrath, Knox, &
Urban, 2000; Elder, Ayala, & Harris, 1999). The
case manager and the participant developed an
individualized treatment plan to address identified
barriers to engagement and retention in HIV care
corresponding to their stage of change. To reduce
barriers to care, necessary referrals for services
were identified. Participants were provided $25 quar-
terly for their participation in the evaluation totaling
$200 for the 24-month intervention.
Participants were administered a standardized
baseline survey at enrollment by the case managers
to assess demographic and psychosocial characteris-
tics, sexual risk behaviors, substance use, depression,
10. and HIV testing and care history (Magnus et al.,
2010; Radloff 1977). Data on prescribed antiretrovir-
al therapy regimens, CD4 counts, and attendance to
HIV care appointments were abstracted from medical
records.
The primary study outcome was the proportion of
YMSM retained in HIV care at six months. For the
purposes of analysis, retention in care was defined as
attending two or more HIV care appointments in the
past six months which was based on the DHHS
treatment guideline recommendation during the study
period of at least one HIV medical care visit every
three�four months (DHHS, 2008). Odds ratios
(ORs), 95% confidence intervals (CI) and t-tests
were calculated to compare demographic and beha-
vioral characteristics for Latino vs. African-American
YMSM. Data on attendance and time in the inter-
vention, referrals provided and referrals completed
were compared using a binomial test of proportions.
Referral data were used to construct a dichotomous
composite variable to indicate whether a client had a
AIDS Care 989
critical and immediate need for housing, nutrition,
substance abuse treatment, and/or mental health
services, characteristics identified in other studies of
HIV-positive youth (Eastwood & Birnbaum, 2007;
Johnson, Botwinick et al., 2003).
11. Data on mean number of HIV care visits, missed
visits, percent of scheduled visits attended, and
retention in care were compared at three and six
months for all 61 patients. The same measures were
compared at baseline and six months for the 33
patients who had been in intermittent care prior to
enrollment in the intervention. These comparisons
were conducted using paired t-tests and McNemar’s
test for paired data. Finally, logistic regression
modeling was conducted to identify factors associated
with retention in HIV care at six months and the
unadjusted ORs and 95% CIs are presented. All
statistical analyses were performed with SAS version
9.1 (SAS 2007). The study was approved by the
institutional review boards at all of the participating
organizations and all clients provided written in-
formed consent in English or Spanish.
Results
12. The majority of the 61 participants were enrolled via
referral from friends who were in the intervention
(28%); 26% were enrolled through clinic in-reach by
the case manager to re-engage patients who had been
lost to care at the clinics; 18% were enrolled by clinic
providers and staff; 16% were enrolled by referral
from local HIV testing programs; 5% through out-
reach activities, and 7% from other programs.
As shown in Table 1, 54% of the participants were
African-American, 46% were Latino, and the mean
age at enrollment was 21. Participants identified
themselves as male (91%), transgender (3%), female
(3%), or other/refused to identify (3%). Sixty-one
percent identified as homosexual, 21% as bisexual,
and 11% as heterosexual.
Almost half (43%) of the participants reported
that they were still in school and more than three
quarters (84%) reported that they had completed at
least high school. Compared to Latinos, African-
13. Americans were significantly more likely to have
completed at least high school (OR �3.5, 95%
CI �1.03, 11.8). Overall, 42% were currently em-
ployed, with no statistical differences between Afri-
can-Americans and Latinos. Most participants
reported living with their family (57%) or friends
(29%) and African-Americans were significantly
more likely to report living with friends compared
to Latinos (OR �6.4, 95% CI �1.6�25.4).
Based on the CES-D screening tool administered
at time of enrollment, 66% of participants had
depressive symptoms, with CES-D scores of 16 or
more. In addition, African-Americans were three
times more likely to have depressive symptoms at
time of enrollment compared to Latinos (OR �3.5,
95% CI �1.01, 12.4).
Among African-Americans, 52% reported life-
time drug use and 54% of Latinos reported any
lifetime drug use. Although not shown in Table 1,
46% of the overall sample reported lifetime marijua-
na use, 13% stimulant use, 8% inhalant use, and 23%
other drugs.
As shown in Table 2, one (2%) participant exited
the study early and seven (11%) were lost to follow-
up. The participant who left the study early changed
his primary HIV care to another location; the seven
participants who were lost to follow-up were also lost
14. to care at the clinic and included five who moved out
of the area, one in jail and one whose whereabouts
was unknown.
Participants attended an average of 5.1 scheduled
YCM appointments, had on average 1.1 drop-in
visits, 0.9 telephone contacts, and 2.3 missed YCM
appointments. Overall, participants attended 61% of
scheduled YCM appointments. Participants received
a mean of 7.3 hours of the intervention with
Latino YMSM receiving statistically more hours of
the intervention compared to African-Americans
(p �0.001). The average YCM appointment lasted
67 minutes and the length of the appointment was
significantly longer for Latinos compared to African-
Americans (p �0.0003).
There were 238 total referrals provided in the first
six months of the intervention. The majority of
referrals were for housing (29%), mental health
services (13%), risk reduction education (11%), and
transportation assistance (8%). By the end of
six months, 163 of the 238 (68%) referrals were
completed. Of these, 78% of the housing, 65% of the
mental health, 77% of risk reduction education, and
68% of transportation referrals were completed.
African-Americans were more likely to receive
referrals for housing (pB0.0001) and transportation
(pB0.0001) compared to Latinos, and Latinos were
more likely than African-Americans to receive refer-
rals for risk reduction services (p �0.007), support
groups (p�0.03), and substance abuse services
(p �0.03).
At time of enrollment into the intervention, 86%
15. of the African-Americans and 71% of the Latinos
had a critical need for housing, nutrition, substance
abuse treatment, or mental health services.
From months 1�3, participants attended an
average of 2.2 HIV primary care appointments,
990 A.R. Wohl et al.
Table 1. Demographic characteristics of HIV-positive 18�24-
year-old men who have sex with men who participated in a
youth-focused case management intervention (N �61).
African-
Americans
(N�33)
Latinos
(N�28)
Total
(N�61)
N (%) N (%) N (%) OR (95% CI)
Sexual orientation
Homosexual/gay 20 (61) 17 (61) 37 (61) Referent
Heterosexual 1 (3) 6 (21) 7 (11) 0.2 (0.02�1.5)
Bisexual 10 (30) 3 (11) 13 (21) 2.5 (0.7�9.2)
Other/refused 2 (6) 2 (7) 4 (7) 1.0 (0.1�7.7)
Gender identity
Male 29 (88) 26 (93) 55 (91) Referent
16. Female 2 (6) 0 (0) 2 (3) �
Transgender 1 (3) 1 (4) 2 (3) 1.0 (0.6�16.2)
Other/refused 1 (3) 1 (4) 2 (3) 1.0 (0.1�16.2)
Education
a
Less than high school 5 (16) 11 (39) 16 (27) Referent
High school or more 27 (84)* 17 (61)* 44 (84)* 3.5
(1.03�11.8)*
Currently in school
b
No 17 (55) 16 (59) 33 (57) Referent
Yes 14 (45) 11 (41) 25 (43) 1.2 (0.4�3.4)
Currently employed
c
No 20 (67) 13 (48) 33 (58) Referent
Yes 10 (33) 14 (52) 24 (42) 0.4 (0.2�1.4)
Housing status
d
Family 17 (53) 15 (63) 32 (57) Referent
Friends 13 (41)** 3 (12)** 17 (29)** 6.4 (1.6�25.4)**
On own 2 (6) 5 (21) 7 (12) 0.5 (0.1�3.1)
Homeless/shelter 0 (0) 1 (4) 1 (2) �
Depression � CES-De
No 6 (22) 10 (50) 16 (34) Referent
Yes 21 (78)*** 10 (50)*** 31 (66)*** 3.5 (1.01�12.4)***
17. History of drug use
f
No 16 (48) 13 (46) 29 (48) Referent
Yes 17 (52) 15 (54) 32 (52) 0.9 (0.3�2.5)
Mode of HIV exposure
MSM 32 (100) 22 (78) 55 (90) Referent
MSM-IDU/IDU 0 (0) 1 (4) 1 (2) �
Heterosexual 0 (0) 3 (11) 3 (5) �
Other/NIR 0 (0) 2 (7) 2 (3) �
HIV care history
Previously in care 21 (64) 13 (46) 34 (56) Referent
New to care 12 (36) 15 (54) 27 (44) 2.0 (0.7�5.6)
Disclosed HIV status to friends
g
No 7 (23) 10 (36) 17 (29) Referent
Yes 24 (77) 18 (64) 42 (71) 1.9 (0.6�5.9)
Disclosed HIV status to family
h
No 14 (44) 15 (54) 29 (48) Referent
Yes 18 (56) 13 (46) 31 (52) 1.5 (0.5�4.1)
Disclosed HIV status to no one
i
No 25 (81) 20 (71) 45 (76) Referent
Yes 6 (19) 8 (29) 14 (24) 0.6 (0.2�2.0)
18. Mean (SD) Mean (SD) Mean (SD) t-Test p
Mean age (SD) 21 (1.4) 22 (1.7) 21 (1.6) �1.67 0.10
Mean age at first sexual intercourse (SD)
j
14.2 (2.5) 14.2 (2.6) 14.3 (2.5) 0.05 0.96
Mean number of partners in past 3 months (SD)
k
2 (2.2) 2 (2.2) 2 (3.1) �0.3 0.76
AIDS Care 991
attended 76% of scheduled HIV care appointments,
and 90% were retained in care (Table 3). During
months four through six, participants attended an
average of 1.7 HIV care appointments, attended 51%
of scheduled appointments, and 70% were retained in
care. There were statistically significant decreases in
all of the HIV care measurements between three and
six months.
Among the 33 participants who had been in
intermittent care, the average number of HIV care
visits increased from 0.2 to 5.5 between baseline and
six months (pB0.0001) (Table 4). In addition, the
percentage of scheduled HIV care visits attended
increased from 7% to 73% between baseline and
six months (pB0.0001) and 82% of those who had
been in intermittent care were retained in consistent
primary HIV care at six months.
19. The main factors associated with retention in HIV
care at six months was prescription of HAART,
increased number of intervention appointments and
more hours in the intervention (Table 5). A signifi-
cant dose-response trend was observed between
retention in HIV care and increasing number of
hours in the intervention (p �0.02) and increasing
number of intervention appointments (p �0.05).
Discussion
This is one of the first studies to evaluate the impact
of a youth-focused clinic-based intervention on
retention in HIV care for HIV-positive Latino and
African-American YMSM. Not only was the inter-
vention effective in engaging YMSM in consistent
HIV care, but two of the main factors associated with
retention in HIV care at six months were related to
the quantity or dose of the intervention received.
These data suggest that a time-intensive intervention
delivered by a non-judgmental and culturally compe-
tent peer is very effective in engaging at-risk Latino
and African-American YMSM in consistent HIV
care, particularly during the early months of HIV
care. Our findings are consistent with a study of
primarily HIV-negative at-risk youth that found that
more case management contact was associated with
improved retention in care (Harris et al., 2003).
The finding that YMSM who were prescribed
HAART were more likely to be retained in care is
20. a new finding as there are few similar interventions
that have been evaluated with respect to retention in
care. Given that the intervention was associated with
retention in care, intervention participants were also
probably more likely to be prescribed HAART by a
physician. Several studies have noted the difficulties
and challenges that youth face with adherence to
HAART, and it is likely that the skills needed for
YMSM to adhere to HAART are the same as those
needed to adhere to HIV care (Rao et al., 2007; Rudy
et al., 2009). It is notable that the percentage of
intervention participants on HAART (69%) was
considerably greater than that reported among
a national sample of HIV-positive YMSM (8%)
(Valleroy et al., 2000).
A large proportion of the YMSM were in a state
of crisis at time of entry into the intervention,
underscoring the strong need for youth-focused
21. interventions to help address barriers to engagement
and retention in HIV care. The severe subsistence and
psychosocial needs of the study group are consistent
with data from other studies of HIV-positive YMSM
in which a critical need for housing, substance abuse,
and mental health treatment were identified (East-
wood & Birnbaum, 2007; Johnson, Botwinick et al.,
2003; Mustankski et al., 2007; Valleroy et al., 2000).
Housing referrals were most common for the YMSM
which is consistent with other research in adolescent
and general HIV patient populations that has shown
that housing challenges are an obstacle to retention in
consistent HIV care and that housing assistance can
result in improved medical outcomes (Aidala, Lee,
Abramson, Messeri, & Siegler, 2007; Eastwood &
Birnbaum, 2007).
Table 1 (Continued )
Mean (SD) Mean (SD) Mean (SD) t-Test p
22. Average months between HIV diagnosis and
intervention enrollment (SD)
l
11.6 (19.5) 20.0 (29.9) 15.3 (24.7) �1.16 0.23
Mean CD4 cell count at enrollment (cells/mm
3
)
d
381 (180) 419 (213) 397 (194) �0.7 0.43
a
Data missing on one participant;
b
Data missing on three participants;
c
Data missing on four participants;
d
Data missing on five participants;
e
Data missing on 14 participants;
f
Includes marijuana, methamphetamine, amyl nitrate, and other
drugs;
g
Data missing on two participants;
h
23. Data missing on one participant;
i
Data missing on two participants;
j
Data missing on nine participants;
k
Data missing on six
participants; and
l
Data missing on nine participants. *p-value�0.04; **p-
value�0.009; ***p-value�0.046
Note: OR, odds ratio; CI, confidence interval; MSM, men who
have sex with men; IDU, injection drug use; NIR, no identified
risk; IQR,
interquartile range.
992 A.R. Wohl et al.
Other research has described the impact that an
HIV diagnosis can have on the mental health of gay
youth and given all of the psychosocial challenges
related to sexual identity, stigma and alienation by
friends and family, and the general vulnerabilities
attached to YMSM, it is not surprising that the
24. high rates of depression were observed (Donenberg
& Pao, 2005). The high prevalence of depression in
the African-Americans in the study group is con-
sistent with other research and underscores the
critical need for mental health interventions for
YMSM of color (Flicker et al., 2005; Johnson,
Botwinick et al., 2003; Lam, Naar-King, & Wright,
2007).
The prevalence of any lifetime drug use among
this group of YMSM was high (52%), but consistent
with the prevalence of lifetime substance use reported
in an adolescent HIV clinic population in Los Angeles
(44%) (Schneir et al., 1998). The proportion of
YMSM in the current study reporting marijuana
and methamphetamine use is also consistent with
individual drug use reported for HIV-positive YMSM
in California, however it was lower than lifetime drug
use reported from the eight sites participating in this
25. Table 2. Participation and referrals for 18�24-year-old HIV-
positive Latino and African-American MSM who participated in
a youth-focused case management intervention (YCM).
African-Americans
n �33
Latinos
n �28
Total
n�61 p-Valuea
Six month study status, n (%)
Completed 28 (85) 25 (89) 53 (87) 0.52
Exited study 1 (3) 0 (0) 1 (2) 0.32
Lost to follow-up 4 (12) 3 (11) 7 (11) 0.72
Six month YCM attendance (mean) n �33 n �28 n �61 p-
Valueb
Scheduled appointments attended 4.0 5.8 5.1 0.15
Drop-in visits 1.7 0.4 1.1 0.02
Telephone contacts 0.2 1.5 0.9 0.01
Missed appointments 1.2 3.5 2.3 0.003
Percent of scheduled appointments
attended
60% 63% 61% 0.77
Total hours of YCM received (mean) 5.1 9.7 7.3 0.001
Average duration of YCM appointment (mean
26. minutes)
52 84 67 0.0003
Total referrals provided, n (%) N�73 N�165 N�238 p-Value
b
Mental health services 6 (8) 26 (16) 32 (13) 0.12
Substance abuse services 0 (0) 10 (6) 10 (4) 0.03
Nutrition/food counselling 3 (4) 13 (8) 16 (7) 0.28
Housing 40 (55) 29 (18) 69 (29) B0.0001
Transportation 14 (20) 5 (3) 19 (8) B0.0001
Family/child related issues 0 (0) 2 (1) 2 (B1) 0.34
Financial/benefits 3 (4) 5 (3) 8 (3) 0.67
Employment assistance 0 (0) 5 (3) 5 (2) 0.13
Legal issues 0 (0) 5 (3) 5 (2) 0.13
Risk reduction education 2 (3) 24 (15) 26 (11) 0.007
Treatment advocate/pharmacy 2 (3) 12 (7) 14 (6) 0.17
Support groups 0 (1) 10 (6) 10 (4) 0.03
Dental services 1 (1) 2 (1) 3 (1) 0.92
General education 0 (0) 1 (B1) 1 (B1) 0.50
Other HIV care services 0 (0) 3 (2) 3 (1) 0.25
Other needs 2 (3) 14 (8) 16 (7) 0.23
Referrals completed at 6 months,
n (%)
55 (75) 108 (65) 163 (68) 0.13
Critical need for housing, nutrition, substance
abuse and/or mental health services at time
27. of enrollment, n (%)
30 (86) 24 (71) 54 (78) 0.13
Prescribed HAART during intervention, n (%) 25 (76) 17 (61)
42 (69) 0.21
a
Proportions compared using a binomial test of proportions.
b
Means compared using a t-tests.
AIDS Care 993
SPNS initiative (Magnus et al., 2010; Ruiz, Facer, &
Sun, 1998). Although substance use was common
among this study group of YMSM, drug use was not
associated with retention in primary HIV care once a
client was enrolled in the intervention.
The intervention was designed to include weekly
visits for the first two months followed by monthly
visits for the subsequent four months for a total of 12
case management visits. The average number of visits
was seven, however, suggesting that weekly visits are
not feasible for YMSM and that monthly visits are
more realistic for this population, given that many of
the YMSM were employed or in school. However, the
HIV care measures were statistically worse at
six months compared to three months, suggesting
that the intervention was most effective when the
contact with the case manager was most intense
during the early months of the intervention, lending
support for weekly visits up to at least six months. To
28. facilitate YCM attendance, the case managers had to
be flexible with intervention appointment times and
the clinics became flexible with HIV care visit
appointments as the YMSM would often miss
scheduled appointments and show up when no
appointment had been scheduled. Flexible scheduling
has been reported as a strategy to help YMSM
keep their appointments to clinical care and case
management (Johnson, Botwinick et al., 2003;
Magnus et al., 2010). These data suggest that clinic
scheduling flexibility will improve clinical care atten-
dance and health outcomes.
In addition to having flexible appointment times,
the case managers had multiple strategies for staying
in contact with their clients. They conducted a large
part of their communication with the YMSM using
cell phones and text messaging which was the most
effective communication strategy. While these meth-
ods of communication were not specifically evaluated
in this study, they have been found to be effective in
improving clinic attendance among general clinic
populations (Chen, Fang, Chen, & Dai, 2008; Leong
et al., 2006; O’Brien & Lazebnik, 1998). The $25
incentive was also helpful in motivating clients to
come to the appointments and incentives have been
demonstrated to improve retention in a variety of
health care interventions (Giuffrida & Torgerson,
1997).
The limitations to this study include the relatively
small sample of YMSM which prevented the calcula-
tion of adjusted OR estimates. Identification of HIV-
positive Latino and African-American YMSM both
locally and nationally for this SPNS initiative was
29. extremely challenging, even when using multiple
outreach strategies. Second, the YMSM in this study
Table 3. Retention in HIV care at 3 and 6 months among HIV-
positive 18�24-year-old MSM in a youth-focused case
management intervention (n �61).
3 months 6 months p-Value
Mean number of HIV care visits in the past
3 months
2.2 1.7 0.04
a
Mean missed HIV care visits in past 3
months
0.6 1.0 0.06
a
Percent of scheduled HIV care visits
attended in the past 3 months
76% 51% B0.0001
b
Percent retained in HIV care in past 3
months
90% 70% 0.0005
b
a
p-Value for paired t-test;
30. b
p-Value for McNemar’s test for paired data.
Table 4. Retention in HIV care at 6 months among 18�24-year-
old HIV-positive MSM in a youth-focused case
management intervention who had been in intermittent care (n
�33).
Baseline (n �33) 6 months (n �33) p-Valuea
Mean attended HIV care visits in
past 6 months
0.2 5.5 B0.0001
Mean missed HIV care visits in past
6 months
0.4 2.0 0.0001
Percent of scheduled HIV care visits
attended in past 6 months
7% 73% B0.0001
Percent retained in HIV care at
6 months
0% 82% �
a
p-Value from results of paired t-test.
994 A.R. Wohl et al.
31. were recruited using a convenience sampling ap-
proach and the findings may not be representative
of all HIV-positive African-American and Latino
YMSM. In addition, while there was no control
group for comparison, participants served as their
own controls when the analyses of outcomes pre and
post intervention were conducted. Finally, the sus-
tainability of the intervention beyond the 6 months of
follow-up is important but has not been evaluated to
date.
Given the growing number of HIV-positive
YMSM and the challenges that they face in testing
early for HIV and accessing and staying in consistent
care, innovative, culturally appropriate care retention
interventions are necessary. The data presented here
demonstrate that it is possible to create an effective,
clinic-based intervention to address the barriers that
32. YMSM encounter in engaging in consistent HIV care.
Acknowledgements
This study was supported by the Health Resources and
Services Administration (HRSA) Special Projects of Na-
tional Significance Initiative H97HA03783-04-00 and
California HIV/AIDS Research Program grant CH05-
LAC-617. The authors would like to acknowledge the
study staff who delivered the project intervention: Amin
Lewis, Christopher Moore, and Kathy Bouch. In addition,
the authors would like to acknowledge and thank the study
participants and medical providers for their time.
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AIDS Care 997
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Section 1: Background Information
Across the United States, vast numbers of young children are
influenced by one or more hazard variables that have been
connected to scholastic disappointment and weakness. Among
them is a family financial hardship, which is reliably related to
negative results. Children in low-wage families have been found
to show less in psychological and behavioral improvement
contrasted with their associates in higher-pay families. There
are about 24 million children under age 6 in the United States.
Many young kids are experiencing childhood in families
encountering financial hardship. 11.4 million children live in
low-pay or low-income households. This incorporates 12
percent, almost three million children, who live with a
compelling need. Between 3 and 16 percent of young children
are influenced by destitution mixed with another dangerous
element, including guardians without a secondary school degree
(1.7 million), high schooled mother (very nearly 0.7 million)
and living in a family without English speakers (0.9 million).
Almost four million kids (16 percent) reside in families or
underneath the government destitution level and headed by a
single guardian. Scholarly difficulties are often profoundly
seeded and start in essential and optional school, which when
left unaddressed, regularly prompts remediation at the
postsecondary level. There are a few components that add to
low-pay children entering school with poor math and reading
abilities. Without a head start program, kids face many risk
factors such as school dropout, teen pregnancy, and crime. This
paper aims to focus on some of the many risk factors facing
these kids including, language barrier, socioeconomic status,
transportation, and lack of health education.
Risk Factors:
Language barrier is met when children from low-pay families
hear upwards of 30 million fewer words by the age of four than
45. their higher-wage peers. In homes where instruction is not
needed, particular requirements should set for children from
birth where dialect abilities, dialect introduction, perusing
desires, an affection for learning, and an association can make
between scholarly achievement and future performance. English
Language Learners are characterized as having English as a
second dialect and predominately a dialect other than English at
home. While there are much prosperous and advantaged English
dialect learners in schools, 66 percent of English dialect
students originate from low-wage families, and part of English
dialect learners in evaluations pre-K to fifth grade have
guardians who did not move on from secondary school. Around
8 percent of children selected in U.S. schools are English
dialect learners. Research demonstrates that English dialect
learner children are substantially less liable to score at or above
proficient levels in both math and perusing/dialect expressions.
Socioeconomic status is one factor that guarantees that
each kid has the chance to exceed expectations in both
scholastics and life. Be that as it may, many elements keep
preventing from serving this part. One of the principle variables
is the disparity of early adolescence training got by kids in
various financial status, which is to a significant degree critical
in molding a child’s prosperity scholastically and monetarily in
later years. Financial status is regularly measured as a mix of
training, wage, and occupation. This implies the individuals
who are from lower financial foundations experience the ill
effects of low-level instruction, little pay, and have low-paying
employments. Subsequently, children from lower financial
foundations don't have access to quality early youth education,
making them fall behind scholastically. Top notch early
adolescence instruction, or preschool for kids between the ages
three and five, can altogether affect a child's prosperity
scholastically and monetarily in their grown-up years.
Transportation also plays a major role in this because, in
low-wage regions of the nation, even neighborhood schools
might be a long way from children because of school
46. terminations for poor execution, low enlistment, or spending
issues. Whenever separation or wellbeing concerns block
schedule to class, it can be hard to organize exchange
transportation. The transportation itself, for example, paying for
a taxi or transport can be costly. Additionally, it can be
troublesome or outlandish for families who are tending to
family obligations to leave their homes unattended. Some low-
wage guardians penance higher-paying, longer-hour
employments with a specific end goal to set aside a few minutes
to take their children to and from school, which adds to an
absence of intergenerational versatility.
Lack of health education is where lower pay and fewer
assets imply that individuals with less instruction will probably
live in low-wage neighborhoods that do not have the assets for
good education wellbeing. These areas are regularly monetarily
underestimated and isolated and have more hazard elements for
weakness, for example, less access to general stores or different
wellsprings of solid sustenance and an oversupply of fast food
eateries and outlets that advance undesirable nourishments.
Provincial and low-pay territories, which are more populated by
individuals with less instruction, regularly experience the ill
effects of deficiencies of essential consideration doctors and
other social insurance suppliers and offices.
Other successful programs at Head Start:
The program that has managed to do this is early childhood
program what they do is they offer help for low-income
families. This program is a government supported system which
is controlled by non-benefit offices, for example, group activity
offices, neighborhood training organizations and others. It's
offered to children of 3 to 5 years of age from those families
who have little pay and can't permit themselves to pay for
instruction. Guardians are additionally required to be present
during the time spent teaching. They may act both as the
teachers and as the members in the system. The early childhood
program gives early adolescence instruction, which will help to
establish the framework of getting new information at school. It
47. is much less demanding for those children who have a few
abilities in early age to make their insight more significant in
school. To give kid’s availability for school as well as physical,
social and emotional improvement, to help guardians be better
instructors for their children. I observed this program, and I can
say that every one of the kids is separated by age from 3 to 5.
There are a few age bunches. There are a few idiosyncrasies in
the educational programs arrangement in each of the gatherings.
The staff in the Head Start Program goes about as accomplices
to guardians who take a dynamic part in the instructional
procedure of their kids. The team incorporates the instructors as
well as different experts, for example, a dialect discourse
advisor and physical preparing teachers. The guardians are
welcome to wind up Head Start volunteers with a specific end
goal to take in more about the improvement of their youngster
and to raise their fearlessness.
Family child care partners aim to help family kid care
suppliers to give brilliant child care administrations, with an
emphasis on moving them toward social accreditation models.
By satisfying this reason, it is the vision of Family child care
partners to guarantee that family child care suppliers create and
apply their insight, and get to be mindful of and use accessible
backings, in ways that cultivate the sound development and
improvement of the newborn children, babies, and preschoolers
in their consideration. They also give one-on-one, home-based
instruction and help individualized to the particular needs and
quality change objectives of the supplier. Guardians’
contribution is expected to show trustees about instructive
exercises they can do at home. Social help signifies group
outreach, referrals; family requires evaluations, giving data
about available group assets.
Section 2: Purpose of the Grant
The Administration for Children and Families (ACF)
reports the accessibility of $5,372,757 to be intensely granted
with the end goal of extending access to top notch, thorough
early learning administrations for low-salary transient and
48. occasionally qualified babies and little children and their
families. This subsidizing opportunity is being made accessible
under the Consolidated Appropriations Act, 2016 (Pub. L. 114-
113). ACF requests applications from open substances,
including states; private, non-benefit associations, including
group-based or religious associations; or revenue was driven
offices that meet the qualification for applying as expressed in
Section 645A of the Head Start Act. Particular objectives
include:
Deciding qualification, enlisting, selecting, enlisting, and
checking participation, guaranteeing the most defenseless
youngsters are served. Giving far-reaching early adolescence
instruction and advancement benefits that advance the physical,
social, passionate, intellectual, and dialect improvement of
youthful kids and families amid the early years by giving
proper: EHS bunch sizes and instructor/guardian to-youngster
proportions; Qualified and prepared staff to guarantee warm and
constant connections between guardians, kids, and families that
are vital to learning and advancement for babies and little
children; Parent contribution in their kids' learning and
advancement; Learning open doors for newborn children and
little children to develop and create in warm, sustaining, and
comprehensive situations; Culturally and phonetically
responsive administrations that bolster congruity of
consideration between the home environment of the child and
the project; Health and wellbeing of enlisted kids; Health
advancement by giving exhaustive wellbeing, psychological
wellness, and oral wellbeing administrations for kids, and
helping families to recognize and get to a therapeutic home to
guarantee continuous consideration; Nutrition, incorporating
investment in the Child and Adult Food Care Program and
courses of action for nursing moms who bosom nourish in focus
based projects and family tyke care homes; Inclusion of at-
danger kids with handicaps by guaranteeing: Services address
the issues of kids with inabilities and their families, including
the foundation and execution of methods to distinguish such
49. kids and plans to facilitate with projects giving administrations
as depicted in Section 645A(b)(11) of the Head Start Act;
Providing family organizations to guardians with
administrations that: Ensuring people group associations
Providing regulatory and budgetary administration, including
Working with families to address their transportation needs.
Guaranteeing that the focuses and family childcare homes meet
wellbeing and security prerequisites and are authorized for
newborn children and little children.
Section 3: Resources
Most of the assets spent keeping up with the brilliant
educators required by the Head Start Act. Lead instructors must
have a four-year certification and aide teachers must have an
initial learning accreditation. As the wages in the field stay
much lower than likewise credentialed positions in the K-12
framework, it is progressively testing to keep remarkable
educators on board for long not to give incremental raises or
typical cost for essential items modification. Grantees are
likewise constrained in the utilization of system dollars (topped
at 15%) to cover a large number of managerial expenses. These
costs, which are generally on the ascent, include:
· Transportation- Grantees give transport administrations to
enlisted y and families where fundamental.
· Energy costs - warming/cooling, lighting; fuel costs impact
the cost of nourishment and different products.
· Health Insurance- Employee medical coverage expenses are on
a steady and soak rise.
· Capital costs - including transports, real office hardware,
utilities, working, and keeping up structures and classroom
space
· Organization- including arranging and coordination; planning,
bookkeeping, examining; and administration of acquiring,
property, finance, and staff.
Section 4: Summary
There is different in accomplishment between low-salary
family and high-pay family. Children who originate from
50. wealthy families perform higher in school compare to lower
wage families. Around 82 percent of the secondary level
graduates who originate from high-wage families go to
universities, in contrast with 52 percent of alumni from low-pay
families. A study appeared by Ludwig, J and Phillips, D. A
demonstrated that in the course of the most recent 20 years the
percent of kids from higher pay who finished school expanded
by 21 percent, while low pay expanded by just 4 percent.
The study shows that this cycle proceeds and stays with
children in school. The rate of White graduates who were school
prepared in English was 77 percent, though 35 percent of
African American were qualified. Children who originate from
families with low-salary are going to pre-K class with
instructors who are unpracticed and do not offer the courses
expected to prep them for school. These schools do not have the
assets to prepare children for education. The percentage of 3-6-
year-olds enlisted in school is 58 percent, while Hispanic is 19
percent and black at 14 percent. Changes in the legislature and
instruction framework should be made to close the gap in
schools. It is crucial to expanding scholarly accomplishment.
All children ought to be held to the same requirements and give
the same assets and devices to help them through K-12 grade.
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53. daily oral
antiretroviral pre-exposure prophylaxis (PrEP) from urban,
African-
American young men and women, ages 18–24 years, at risk for
HIV
transmission through their sexual and drug-related behaviors
participating
in eight mixed-gender and two MSM–only focus groups in
Atlanta, Geor-
gia. Participants reported substantial interest in PrEP associated
with its
perceived cost, effectiveness, and ease of accessing services and
medication
near to their homes or by public transportation. Frequent HIV
testing was
a perceived benefit. Participants differed about whether risk-
reduction be-
haviors would change, and in which direction; and whether
PrEP use would
be associated with HIV stigma or would enhance the reputation
for PrEP
users. This provides the first information about the interests,
concerns, and
preferences of young adult African Americans that can be used
to inform
the introduction of PrEP services into HIV prevention efforts
for this critical
population group.
BACKGROUNd
Recent clinical trials have demonstrated the safety and efficacy
of daily oral antiret-
roviral pre-exposure prophylaxis (PrEP) for men who have sex
with men (MSM)
(Grant et al., 2010) and heterosexual men and women (Baeten,
54. J., 2011; Thigpen
et al., 2011). An additional trial testing its efficacy for injection
drug users (IDU) is
underway. Final analyses are not yet available for two trials in
which a PrEP arm was
stopped early at an interim data safety monitoring board review
because of inability
AFRICAN-AMERICAN PrEP ATTITUDES 409
to detect efficacy of PrEP (futility) (Family Health
International, 2011; Microbicides
Trial Network, 2011).
It is timely to focus consideration of the requirements for safe
and effective
delivery of PrEP to the populations where most incident
infections are occurring
in the United States. In 2009, there were an estimated 48,100
new HIV infections
(Prejean et al., 2011) of which 64% were among MSM (2% of
the U.S. popula-
tion), 27% among heterosexuals, and 9% were attributed to
injection drug use.
African Americans (14% of the U.S. population) accounted for
44% of the new
HIV infections; Hispanics (16% of U.S. population) accounted
for 20%; and whites
for 32%. Among MSM, African Americans accounted for 37%
of new infections
while among heterosexually acquired infections African
Americans accounted for
60%. While overall, HIV incidence remained stable from 2006
to 2009, by race and
55. risk group, African-American MSM are the only group to
experience a significant
increase in new HIV infections. Specifically, among African-
American MSM aged
13–29, new infections increased 48% over that four-year period.
Although PrEP trials have shown efficacy for both MSM and
heterosexual
women and men, eight of the ten published surveys assessing
awareness and atti-
tudes toward the use of PrEP in U.S. populations were
conducted exclusively with
men who have sex with men (MSM) (Barash & Golden, 2010;
Golub, Kowalczyk,
Weinberger, & Parsons, 2010; Koblin et al., 2008; Liu et al.,
2008; Mansergh et
al., 2010; Mehta et al., 2011; Mimiaga, Case, Johnson, Safren,
& Mayer, 2009;
Voetsch, Heffelfinger, Begley, Jafa-Bhushan, & Sullivan,
2007); one with a primarily,
but not exclusively, homosexual/bisexual male population
(Kellerman et al., 2006),
and only one with a largely heterosexual STD clinic population
(Whiteside, Harris,
Scanlon, Clarkson, & Duffus, 2011). These surveys elicited
responses to discrete
choice questions about anticipated use of PrEP and awareness of
PrEP and were all
conducted while trials were underway and efficacy results were
not yet known. The
inclusion of African-American participants and younger persons
in these surveys
varied widely (Table 1).
One qualitative study conducted in New York City included
questions about
56. PrEP and other biomedical prevention methods for a subset of
72 participants in a
web-based study (Nodin, Carballo-Dieguez, Ventuneac, Balan,
& Remien, 2008) of
MSM Internet users who reported barebacking (intentional
condomless anal inter-
course). MSM of any HIV status were included, 39% of
respondents were under the
age of 30 years, 21% were African American, and 28% were
Hispanic. Results were
not analyzed by race/ethnicity. Very few had ever heard of
PrEP, and once it was
explained to them, they reported attitudes toward it that were
mixed.
Another qualitative study conducted in Los Angeles used semi-
structured in-
terviews with 25 gay and bisexual HIV-serodiscordant male
couples to learn about
motivating factors for future PrEP uptake for HIV prevention
(Brooks et al., 2011).
Couples who had been together for a minimum of twelve months
were included.
The mean age of participants was 38.2 years; 30% of
participants were Hispanic,
26% were African American. Participants identified potential
motivating factors for
adoption of PrEP as protection against HIV infection, reduced
fear about HIV in-
fection, and the opportunity to engage in unprotected sex.
Potential concerns and
barriers included the cost of PrEP, side effects, adverse effects
of intermittent use, and
accessibility of PrEP.
Because PrEP rests on the prescription of antiretroviral
57. medication to HIV-un-
infected persons, a well-targeted PrEP program will require: (1)
outreach to HIV-
uninfected persons at high risk of HIV acquisition; (2)
screening for both clinical
410 SMITH ET AL.
T
A
B
L
E
1
.
P
o
p
u
la
ti
o
n
C
h
ar
ac
te
93. antiretroviral regimen; and 4) periodic counseling to reinforce
continued HIV risk-
reduction practices as well as adherence to PrEP medication
(Centers for Disease
Control and Prevention et al., 2011). The complexity of
providing PrEP to persons
at highest risk for HIV acquisition points to the need for further
assessment of indi-
vidual and sociocultural concerns and hopes and their
incorporation into the design
and implementation of PrEP-related program services.
This is the first qualitative, focus group study to elicit attitudes
about, and pref-
erences for, PrEP services from a key group of potential users
in the United States:
inner-city, African-American young adult men and women at
risk for HIV transmis-
sion because of their sexual and drug-related behaviors.
METHOdS
PARTICIPANTS AND PROCEDURE
Three experienced social science researchers conducted focus
groups between
June and August of 2009 using a qualitative, semi-structured
interview guide. A
total of 10 focus groups were conducted. Eight focus groups
were attended by both
men and women, and two groups were composed of men who
have sex with men
(MSM) only. Focus group participants for the eight mixed-
gender focus groups were
recruited in conjunction with another ongoing study being
conducted with residents
94. of eight zip codes with high HIV and STD prevalence in
Atlanta, Georgia. Par-
ticipants for the two MSM–only focus groups were recruited
from two community-
based HIV program centers for MSM of color. To be eligible for
the study, partici-
pants must have been between the ages of 18 and 24 years and
live within one of the
eight designated zip codes. To participate in the MSM focus
group, participants had
to self-identify as MSM. Table 2 includes the demographic data
for the participants.
Outreach study staff assessed participant eligibility, described
the study, and
invited those expressing interest to a focus group session. The
focus groups were
held at a variety of locations throughout Atlanta in the
participants’ communities,
ranging from community centers to Georgia State University.
Focus groups lasted
between 1.5 and 2 hours and were audio-recorded. Georgia State
University’s Insti-
tutional Review Board granted IRB approval for the study.
Participants were asked
for verbal consent, and confidentiality was stressed at the
beginning and end of the
sessions. Waiver of signature to document informed consent
was appropriate for this
TABLE 2. Participant Demographics, PrEP Focus Group Study,
Atlanta, 2009
MSM Focus Groups Mixed Gendered Focus Groups
2 Focus Groups, N = 19 8 Focus Groups, N = 58
95. N (%) N (%)
Gender
Male 19 (100) 23 (39.7)
Female 0 35 (60.3)
Race/Ethnicity
African American 19 (100) 58 (100)
Mean Age, years 21 21
412 SMITH ET AL.
study because (1) it involved only minimal risk of harm to
participants and involved
no procedures for which written consent is normally required
outside the study, and
(2) the signature would be the only record linking the
participant to the research
and would constitute a small risk of harm resulting from an
unintended breach of
confidentiality.
DATA ANALYSIS
All focus group recordings were transcribed verbatim and
uploaded into NVivo,
a qualitative data management and analysis software (QSR
96. International Pty Ltd.
Version 8, 2008). This analysis focused on participants’
responses related to PrEP. A
general inductive approach was used to identify themes related
to attitudes toward
PrEP. One researcher was primarily responsible for developing
the codebook and
coding the transcripts. The initial codebook was reviewed by
three other researchers
familiar with the data, and all four researchers agreed upon the
final codebook. A
qualitative data analyst then applied thematic codes to the
transcribed focus group
discussions. Once coding was complete, frequently occurring
and co-occurring codes
were reviewed by interview question in order to identify
prevalent themes within
each section of the interview guide for both the mixed gendered
and MSM focus
groups. Emerging themes for the mixed gendered and MSM
focus groups were then
compared. Similar themes were discussed in all focus groups;
differences between the
MSM groups and mixed gendered groups are identified below.
RESULTS
Five main themes emerged from the discussions about PrEP:
general acceptance of
PrEP as a method of HIV prevention; potential facilitators to
taking PrEP; poten-
tial barriers to taking PrEP; the potential effects of PrEP on
sexual risk-taking; and
health care access.
GENERAL ACCEPTANCE OF PrEP
97. The majority of participants reacted positively to the idea of
taking a daily pill
to prevent HIV acquisition. One woman noted, “You might be
having sex with the
same person, you might trust them, but you’ll never know what
that person is doing,
so to be on the safe side, most definitely I’d take them pills.”
An exchange between participants in one focus group illustrates
their percep-
tion that PrEP would also be widely accepted in their
communities:
Female: I think it make a lot of people in society to come
forward to take that medicine.
Male: Yes….
Female: You’d get like everybody out here taking it.
Male: Everybody.
Female: You would have a big supply.
Female: For real. If it was free, I don’t think nobody would turn
that down.
Female: Everybody be out there trying to get them a pill.
If free, an effective pill to prevent HIV was widely accepted in
all focus groups.
Participants were also generally amenable to the requirement
that PrEP users take
98. AFRICAN-AMERICAN PrEP ATTITUDES 413
a rapid oral HIV test every three months. Most participants felt
that the testing
requirement would not be a barrier to taking PrEP, and others
mentioned that they
already participated in regular testing. One male from the MSM
focus group felt
that the quarterly testing would be an extra incentive to taking
PrEP noting, “It’d
be good because it’s good to know your status, especially if
you’re sexually active.”
FACILITATORS TO PrEP UPTAKE AND MAINTENANCE
Convenience of locations that dispense PrEP was identified as
an important fa-
cilitator to potential PrEP uptake and maintenance. Most
participants were willing
to pick up PrEP prescriptions at a variety of locations
described, including health
department clinics and community pharmacies. Some
participants were willing to go
to hospitals or hospital clinics for PrEP, but others felt the wait
time was too long at
those locations. Participants wanted to access PrEP at locations
that were familiar,
close to their normal travel routes, and could provide fast
service. Many participants
noted the convenience of pharmacies located close to public
transportation stops, as
many did not have access to cars or did not want to spend
money on gas.
Male: I’m just being honest. It’s more convenient. If it’s out of
99. the way, I’m not go-
ing bother, especially since I smoke weed…[If I had to go to]
the hospital like that, I
wouldn’t even bother because of going through all that traffic
and what you have to go
through to get there, I won’t bother.
Female: I think going to a hospital would be a disadvantage
because it would be people
waiting in line and things like that, but going to a pharmacy,
you like give them your
prescription and tell them what you need and you get out of
there. With going to a hos-
pital or a clinic, you have to wait.
Male: If it’s not within MARTA [Metropolitan Rapid Transit
Authority, public trans-
portation], I’m not going go. And if it ain’t there when I go
there, I might not come back
because I be done waste my time because I be feeling upset that
I done come down here.
Y’all know these folks want this medicine and stuff, and y’all
ain’t got it and ran out and
stuff. Y’all need to let somebody know.
Mail order prescriptions were mentioned in some groups, but
were controversial.
Some participants liked the idea of having medications
delivered to their homes
while others worried about privacy issues.
Male (MSM Group): I wouldn’t go too far because…I think they
should be able to mail
it to you. Just like these new pills like they advertise on TV,
radio—call them and they
mail it to you—[there should be] a way to call him and say “I
100. want an order of it.”
Female: Yeah, but you don’t want everybody to know, you
know what I’m saying, you
don’t want everybody to know what you get…‘cause you know,
it’s some people…they
might go in your mailbox…
BARRIERS TO PrEP UPTAKE AND MAINTENANCE
Throughout the focus groups, participants identified several
potential barriers
to taking PrEP. Barriers discussed included side effects,
medication cost, partial effec-
tiveness, low perceived personal susceptibility to contracting
HIV, burden of taking
a daily medication, reaction of peers to taking HIV medication,
and for the MSM
groups only, fear of risk compensation (decreased use of
condoms and other safer
sex practices).
414 SMITH ET AL.
Side Effects. One of the most frequently mentioned barriers to
PrEP acceptance was
possible side effects. PrEP safety studies had not been
completed at the time of the
focus groups, and moderators asked participants to assume that
PrEP would be safe
to use. Despite this, participants expressed their concern. One
man noted, “With
every drug you have a down. If I’m sick or what, and if I take
medicine and it makes
101. me feel worse than what it is and it’s supposed to make you feel
better, but if it makes
you feel weak or drowsy, or dizzy headed, I’m not going to take
it again.”
Another MSM participant shared, “I look at the TV and they
have all of these
pills for other illnesses and there’s all [of] these side effects.
That is just ridiculous
and [the side effects are] worse than…[the symptoms] you have.
Then, to make it
worse, they’ll say it could cause death. That’s what’s sticking
out in my head.”
Cost. As participants were asked about the acceptability of
taking PrEP at increasing
medication price points ($25, $50, and $75 per month), fewer
said they were willing
or able to pay for PrEP medication. Most participants felt that a
cost of $50 or more
per month would make PrEP inaccessible to them. Twenty-five
dollars was a more
acceptable price point, but would still be difficult for many of
them.
Female: If I don’t got it [the money], then no, I wouldn’t buy it
every month. I’d
probably skip a month. If I had them, I’d take them, but if I
don’t have the mon-
ey to get them, then I can’t get them, but if it’s free, of course.
I’d be the first one
in line to get them. But if I have to pay for them, I have to think
about that.
Female: And I be looking at my last $25 like, “Do I go get my
nails done? Or do I need
to go get these pills? Up, I’m about to get my nails done.”
102. Male (MSM Group): Me, personally, well, it depends on if this
was free and it wasn’t
free, if it was orderable for me because one, I don’t know if I
have insurance and ain’t
got a job, so like the money that I do get, go towards school,
but if it was free, I would
take it.
Female: Now, I can probably scrape up the 25, but I probably
couldn’t scrape up no 50
a month because the struggle is just a little too much right now.
Partial Effectiveness. Some participants doubted PrEP’s
potential to effectively pro-
tect against HIV and wanted to see the evidence before agreeing
to take PrEP. Others
wondered if PrEP would be more effective for different types of
people, or if effec-
tiveness would decline over time. When participants were asked
about the accept-
ability of PrEP at specific effectiveness rates (75% and 50%), as
the effectiveness de-
creased, fewer participants were willing to take PrEP.
Participants who rejected PrEP
at reduced effectiveness felt that the risk of failure was too
great. For example, one
female participant said, “I don’t really know, because [if you
take a 50% effective
pill], you can still get it, there’s a 50% chance to...That’s 50/50,
like, you still get it.”
A male participant shared,
Just like I said, I wouldn’t take it then because I mean, if it was
like 95% to 100%,
103. maybe [I] would. If it anything less than that, no because that’s
too big of a space, too
big of a chance of me to catch something, either way. So I
mean, I wouldn’t even put
myself at risk. Even though I said I would use protection either
way, I still wouldn’t do
it. It’d be a waste of money.
Despite reminders from moderators that PrEP should be used in
conjunction with
consistent condom use, some participants compared the
effectiveness of PrEP to that
of condoms and preferred to use the more effective method. As
one man said, “If
AFRICAN-AMERICAN PrEP ATTITUDES 415
you can’t give me the same percentage as a condom—I need that
99.9% or nothing
at all.”
In contrast, participants who were willing to take PrEP at
reduced effectiveness
rates focused on the added protection the pill would provide.
One woman explained,
However you put it…everything that they coming out with ain’t
100% anyway. The
condoms ain’t 100%, birth control, none of that…Yeah, as long
as you putting some-
thing in your body that’s helping you, regardless if it was 50
[percent effective] or 25
[percent effective], at least you trying…You got a better chance
of not catching that.
104. Low Perceived Susceptibility to Contracting HIV. Some
participants thought they
did not need PrEP because they felt their risk for acquiring HIV
infection was low,
either due to condom use or monogamy. The following quotes
illustrate this percep-
tion of low risk:
Female 1: See, I’m not in high risk, so I don’t need the pill, so I
wouldn’t take the pill
because I’m not in high risk.
Female 2: These are for girls who like all in the streets
prostituting.
Female 3: That’s what I was saying, I don’t really need them,
I’m not going to pay that
much money.
Female 2: If I’m out having sex with 25 different men every
month, then yeah, I would
take it, but right now, it’s just me and him. From what I know.
Male (MSM Group): I would not take it because I feel like…me
personally, if I’m doing
everything that I’m supposed to do and that I have to do then, I
don’t have to worry
about catching it. I feel like from using condoms or if I’m not
having sex at all or if I’m
practicing safe sex with one partner and going to the clinic and
they’re getting tested, I’m
getting tested, I won’t have to worry about anything like that,
so I wouldn’t take the pill.
Burden of Taking a Daily Medication. Many participants
105. questioned their ability to
take a daily medication for an extended period of time. For
some, recognition that
they would forget to take a pill every day discouraged them
from wanting to take
PrEP.
Female: I don’t know. I barely take my birth control every day,
so I don’t know if I could
take a pill every day. I’ll try but it’s hard to take a pill
constantly every day. Medicine for
the rest of your life? I don’t know about that.
Male: I wouldn’t take it every day…Probably like, I take it like
every week or every 2
days or something. Yeah, every day anymore can do something
else. You might drunk
and smoke and you might have a side effect, drowsiness or
something, drink or some-
thing, that too much though…I just wouldn’t feel right taking it
every day.
Reaction of Peers to Taking HIV Medication. A potential barrier
that emerged
throughout the focus group discussions was how other friends
and family members
would react to a participant taking PrEP medication. Some
participants noted that
they would avoid PrEP due to the embarrassment it could cause.
For these partici-
pants, taking PrEP could be interpreted as an admission that one
engages in risky
behaviors or lead to a perception that they have HIV.
Participants shared that HIV
stigma was prominent in their communities. One participant
even stated that he
106. almost skipped the focus group because he did not want people
to think he was
involved with AIDS research.
416 SMITH ET AL.
Male: I wasn’t going to come down here [to the focus group
today], ‘cause I’m like, shit,
someone might think that I got AIDS. I just came to show up,
but I don’t be participating
in no AIDS nothing because I don’t mean to put myself in no
category…
Male: And people are ignorant. You know what I’m saying. It’s
going put a irrelevant
stigma on you that’s not even going be there. You trying to help
yourself and help ev-
eryone else. Like say, you help that next person and if that
person get help then he’ll
help that next person and they’ll just network. But if people are
ignorant, they’ll be like,
“ooo, you taking [PrEP]. Oh, you must got it [HIV]. Why you
taking it then? You ain’t
got no reason to take [it].”
Female: I’m talking about these pills I’m a have a problem
with...these pills itself is going
to cause so much chaos…can’t nobody tell you about your
neighborhood. You going
have a problem taking them pills if everybody ain’t taking them,
[even though] you do-
ing something good. This is a positive thing. You understand
me?
107. Female: They will flip the whole story. You understand me?
Prevention don’t mean noth-
ing.
Female: [People will say,] “Oh, that girl got AIDS.”
Other participants, however, felt that taking PrEP would be a
source of pride. These
participants said they would not have a problem letting others
know they were tak-
ing PrEP because it would make them cool or because they felt
they were doing a
service to the community by preventing HIV spread.
Female: I want to say this. If I was taking the pill…I wouldn’t
be ashamed to take one.
I give [it to] my friend, hey man, like “take this” because I want
to help everybody out
around me. Especially if they ain’t got it and it going protect
them. I’m fixing to give my
friend, “Hey, y’all better take this!”
Female: You know what? I’d probably sit [my PrEP pills] on the
dresser, so those who
come can see…”This is what I’m taking so I can make sure that
I don’t get…something
bad”…Those who come in…should know. “This is what I’m
doing to make sure I don’t
get those kind of germs.”
Male: It’s sav[ing] my life. It’s pimping. I’m cool for taking
this.
Specific Fear of Risk Compensation. Although there were
participants in all groups
who anticipated some risk compensation as a result of taking
108. PrEP, only participants
in the MSM focus groups mentioned this as a reason to not take
PrEP. Some MSM
participants felt that taking PrEP would negatively influence
their current risk reduc-
tion practices and as a result wished to avoid using the pill.
Male (MSM Group): No, I wouldn’t take it to prevent myself
from getting HIV. Some
people get a little risky with it…because y’all explain it to us,
how it helps us in the long
run, but most people would use that as an excuse to say, if they
have something, we
don’t have to worry about it.
Male (MSM Group): My concern is, it might make me kind of
lax about my safe sex
practices, to be honest with you…I might just get into it one
night and be like, “oh, I
took that pill.” I’m just being honest.
EFFECTS OF PrEP ON SEXUAL RISK TAKING
In the broader context of possible changes in sexual risk
behaviors anticipated
while taking PrEP, across all focus groups, participants had
differing opinions about
whether change would occur and, if so, in which direction.
AFRICAN-AMERICAN PrEP ATTITUDES 417
When directly asked if they would be able to consistently use
condoms while
taking PrEP, the majority of participants felt that PrEP would
109. not have any positive
or negative effect on condom use: those who previously used
condoms would con-
tinue condom use and those who did not use condoms would not
start using them
as a result of using PrEP.
Female: You just asked if we participated in the program [to
take PrEP], how easy would
it be to use a condom? It’s the same, it’s no different. If we
already used the condoms
before we started taking the pill, it’s no different. It wouldn’t
be difficult. It would just
be like, I already used them before, now I have this pill and I’m
still going to take them.
Others explained that they would still want to prevent acquiring
other sexually
transmitted infections or becoming pregnant. One woman said,
“I would still use
condoms because the pill is for HIV, it’s not for trichomoniasis
and herpes and geni-
tal warts and any other STD that you could get it from. So I
would still use protec-
tion.”
A minority of participants felt that taking PrEP, especially if
highly effective,
would result in risk compensation, such as having sex without
condoms or increas-
ing their number of sexual partners. Some of these participants
saw potential simi-
larities between taking hormonal birth control and taking PrEP
and said that it
would be difficult to continue using condoms while taking
PrEP, especially if they
110. had one monogamous or primary partner.
Female: I don’t know because, that I don’t know. If you taking
a pill that’s saying you
ain’t going [to get] HIV and then you got one boyfriend. Every
time ya’ll ain’t going use
no condom, because that pill going kick in. That’s just like that
same way people feel
about birth control. When a girl on birth control, a boy don’t
want to use no condom
because they feel like you on birth control. So I think it, I don’t
know, it be easy for me
though ‘cause I still use a condom, but then again, it probably
be a little difficult.
Male: It be hard. It be more difficult because I’m taking a pill
that’s 100% effective, I’m
taking it every day, so what’s the use of a condom? ‘Cause a
condom, they say kind of
take away from the pleasure when you doing it, so if I can take
this pill to prevent what
this condom prevent, why am I even going deal with the
condom?
Only one participant expressed the belief that taking PrEP
would be a reminder
about HIV that would encourage her to use condoms more
frequently.
HEALTH CARE ACCESS
A majority of participants shared that they either had no
insurance coverage or
had some form of public insurance for themselves or their
family. Very few partici-
pants said they had private insurance through their employer or
111. through a parent.
Although most groups had participants who utilized health
departments, hospital
clinics, or community health centers for health care, a few
participants said they
consulted private physicians for health concerns. The majority
of participants said
they went to emergency rooms when ill or injured. Reasons
discussed for choosing
emergency rooms included the ability to be seen by a doctor
without having to pay
up front, proximity to one’s home, and the perception that
emergency rooms provide
high quality care and offer services not provided by health
clinics. The following
quotes represent what many participants shared about accessing
emergency rooms:
418 SMITH ET AL.
Female: I don’t get no kind of Medicaid or anything. I get like a
reduced fee if I go to a
public health center or something like that. But since I been 18,
uh-uh, nothing free. So
that’s my reasoning for going close by home, you know, or
anywhere in the area, but
[County Hospital A] is closer than anything around me.
Female: Ain’t nothing in life free. If you go to the emergency
room, they’ll see you.
They’re going to send you a bill, you know what I’m saying?
But, you know, that’s your
opportunity to get seen without…going through the process of
having to pay full price
112. to go for an appointment. That’s just your other way of getting
around, to do what
you’ve got to do. Because you’ve got to do what you’ve got to
do for yourself.
Male: They [County Hospital B] got the best doctors. They got
everything…They might
be a little slow, but they make sure you get took care of.
Infrequently, concerns about the interests for pharmaceutical
companies were ex-
pressed.
Male: I probably would try to be against it [PrEP] because if
they going get their folks
to coming up with a pill to prevent it, they pretty much have a
cure for it…they got that
close to making a pill that prevents you from getting HIV, they
damn well can have some
type of pill that can cure…I mean, y’all just need to come on
and come out with it. I
don’t advocate it. I be like, “y’all just trying to make money
with this mess.”
dISCUSSION
In these focus groups of young African-American men and
women, substantial inter-
est in PrEP was reported among both heterosexuals and MSM.
Interest in PrEP was
associated with its cost, effectiveness, and ease of accessing
services and medication
near to their homes or by public transportation.
In this young, socio-demographically disadvantaged population,
reported ac-
113. cess to private or employer health insurance was minimal while
use of publicly
funded insurance and health service providers was common.
Concerns about the
cost of PrEP were raised although some felt they could afford to
contribute a mod-
est amount (e.g., $25) as might be required for a medication or
clinic visit co-pay or
sliding-fee charge.
Rather than viewing frequent HIV testing as a barrier to its use,
several young
adults felt that PrEP would either be a stimulus for or add to
their current practice
of repeated HIV testing.
In light of the severity of the HIV epidemic among younger
African Ameri-
cans and the resulting need for expanded access to intensive
HIV prevention, it is
reassuring that there were few concerns expressed about the
safety of antiretroviral
medications for PrEP that were of specific concern for African
Americans, as has
sometimes been found with respect to treatment of HIV
infection. Similarly, there
was no expression of concerns about possible intentional harm
to the community by
making PrEP available (e.g., “conspiracy theories”).
This group may have an information network relatively distinct
from others in
which concerns about the intent of pharmaceutical companies
have been expressed.
While for some there was concern about possible HIV stigma
accruing to PrEP us-
114. ers, others felt that acknowledged PrEP use would provide a
reputational advantage.
AFRICAN-AMERICAN PrEP ATTITUDES 419
However, some reports raised serious issues that need to be
addressed in educa-
tion and counseling efforts that will accompany the introduction
of PrEP. Some par-
ticipants expressed a willingness to share their PrEP medication
with others. PrEP
users will need a clear understanding of the risks posed by
sharing or borrowing
antiretrovirals for PrEP use. These include effects on reduced
adherence and effec-
tiveness when medication supply is diminished by sharing or
other than daily use
and the increased safety risk for medication use by persons
without required screen-
ing (e.g., HIV status, renal function). In addition, for some
focus group participants,
there was overestimation of the efficacy of condoms, the
efficacy of PrEP, and the
expected duration of PrEP use (e.g., “rest of my life”)—all of
which will need to be
clarified before a fully informed decision about whether to take
PrEP can be ob-
tained by a clinical provider.
The findings of this study should be considered in light of its
limitations. Focus
groups were conducted with a relatively small number of
participants in a single
large urban community (Atlanta), and interviews were
115. completed before any efficacy
trial results were known, so participants were considering
hypothetical levels of ef-
ficacy, safety, and cost. However, the selection of African-
American young adults
from neighborhoods with high HIV and STD prevalence
addresses a deficit in our
understanding of the perceptions of a critical population that
needs increased deliv-
ery of intensive HIV prevention methods like PrEP. Now that
trial results are avail-
able and implementation is beginning in some communities,
additional studies of the
interests, concerns, and preferences of African-American young
adults in a wider set
of communities is warranted. New studies are needed to identify
the broad range of
concerns, program preferences, and opportunities that should
inform the introduc-
tion and scale-up of PrEP services into HIV prevention efforts,
especially for MSM.
All the heterosexual efficacy trials are being conducted in
Africa, and the iPrEx
efficacy trial with 2,499 MSM in six countries included 35
African Americans from
U.S. sites (Grant et al., 2010). There were two PrEP safety
studies with MSM in
the United States—Project Prepare (Eunice Kennedy Shriver
National Institute of
Child Health and Human Development (NICHD), 2011) and the
CDC TDF safety
trial (Centers for Disease Control and Prevention, 2011)—that
together included ap-
proximately 86 African-American MSM. Domestic PrEP surveys
and qualitative in-
116. terview studies underrepresent African-American MSM and
heterosexuals (see Table
1) when compared to the racial/ethnic composition of the U.S.
epidemic. This under-
representation restricts what we can know now about
acceptability, adherence, risk
behavior, and PrEP program preferences among African-
American heterosexuals
and MSM, two critical populations for reducing HIV incidence
in the United States.
The successful introduction of clinically delivered HIV
prevention methods for
African-American young adults at risk of HIV acquisition
requires an understanding
not only of their current beliefs about HIV acquisition and its
related sexual risk and
protective behaviors, but also their beliefs about medication use
and challenges and
opportunities related to their access to health care. This study
begins to inform PrEP
education and delivery strategies tailored to young African-
American heterosexuals
and MSM, a population in high need of intensive HIV
prevention.
420 SMITH ET AL.
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