Young adult males’ perceptions about gender equity in La Romana, Dominican Republic
Baez P, Messina L, Halpern M, Amesty S (2024) Young adult males’ perception about gender equity in La Romana, Dominican Republic. Discovery Global Society, Volume 2, 42 doi.org/10.1007/s44282-024-00074-4
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Objective: To assess adolescent and young adult males’ perceptions regarding gender equity in La Romana, Dominican Republic. Methods: We used the Gender Equitable Men (GEM) scale among males aged 15–24, who reported level of agreement with gender equity attitudes, establishing 0.01–0.5 = “low gender equitable”, 0.51–0.79 = “medium gender equitable” and 0.8–1 = “high gender equitable”. We established p < 0.05 for statistical significance, using Chi square for bivariate analysis and binary logistic regression to analyze predictors. Results: A total of 358 males participated; one-fourth (n = 95, 26.5%) reported high GEM scores. The reproductive health and violence subscales presented higher distribution of high GEM scores (69.3% and 66.2%). Predictors for high GEM scores included high school or higher education for self (OR: 6.1 CI 2.9–12.7, p < 0.01) or mother (OR 14 CI 1.8–11.8 p = 0.01), being married/cohabitating predicted lower gender equitable scores (OR: 0.1 CI 0.1–0.7 p = 0.01). Conclusion: Male Dominican adolescent and young adults present mixed attitudes about gender equity, reporting gender equitable mindset for violence and reproductive health. Further research should explore how perceptions of gender roles impact family planning decisions, pregnancy prevention, STIs, and gender-based violence.

 

Comparison of evaluation methods for improving the usability of a Spanish mHealth tool
Alexandria L. Hahn a, Claudia L. Michaels a b, Gabriella Khawly a b, Tyler K. Nichols a, Pamela Baez c, Sergio Ozoria Ramirez a, Janeth Juarez Padilla d, Samantha Stonbraker e, Susan Olender MD, MS f, Rebecca Schnall a b April 2024 Comparison of evaluation methods for
improving the usability of a Spanish mHealth tool. International Journal of Medical Informatics. doi:10.1016/j.ijmedinf.2024.105355.
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Objective: Mobile health (mHealth) technology is now widely used across health conditions and populations. The rigorous development of these tools has yielded improved health outcomes, yet the ideal approach for developing mHealth tools continues to evolve, indicating the need for rigorous usability evaluation methods. This study compares two usability evaluation methods – cognitive interviews and usability assessments employing a think-aloud approach – for adapting an evidence-based mHealth tool from English into Spanish. Methods: We conducted cognitive interviews and usability assessments using a think-aloud protocol to evaluate the usability of an HIV mHealth application among 40 Spanish-speaking adults with HIV in New York City, NY, and La Romana, Dominican Republic. The Health IT Usability Evaluation Model (Health-ITUEM) was used to guide the analysis of qualitative data collected from each method. Results: Participants (N = 40) averaged 43 years old (SD = 12.26; range 20–79), identified primarily Hispanic/Latino (92.5 %), and resided in La Romana (50 %) or New York City (50 %). Both usability evaluation methods yielded similar findings, highlighting learnability and information needs as crucial components of participant feedback for the mHealth application. Cognitive interviews captured participants' perspectives on the app’s interface and design. On the other hand, results from usability assessments offered insights into participants' competency while interacting with the mHealth tool. Conclusión: Findings from this study highlight the contributions and limitations of including cognitive interviews and task-based usability assessments using a think-aloud approach in mHealth usability testing. Future research should employ a multi-method approach, incorporating complementary usability evaluation methods and engaging participants in multiple assessments. Using complementary usability evaluation methods may provide a more comprehensive understanding of the usability and participant experience aspects of a mHealth tool compared to using a single usability evaluation method.

 

A randomized controlled trial of the dissemination of an mHealth intervention for improving health outcomes: the WiseApp for Spanish-speakers living with HIV study protocol (2024). Olaya, F., Brin, M., Caraballo, P.B. et al. A randomized controlled trial of the dissemination of an mHealth intervention for improving health outcomes: the WiseApp for Spanish-speakers living with HIV study protocol. BMC Public Health 24, 201 (2024).A randomized controlled trial of the dissemination of an mHealth intervention for improving health outcomes: the WiseApp for Spanish-
speakers living with HIV study protocol. BMC Public Health. doi:10.1186/s12889-023-17538-y. 
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Background: While there is no cure for HIV, adherence to antiretroviral therapy can extend the lifespan and improve the quality of life of people with HIV. Despite the global reduction of HIV infection rates in recent years, New York City and La Romana, Dominican Republic, continue to report high infection rates among Latino populations. Many people with HIV remain virally unsuppressed in these geographic hotspots, suggesting a need for additional interventions to overcome medication adherence barriers. Tailored and culturally appropriate mobile health (mHealth) technology can be an engaging way to improve adherence. The primary objective of this trial is to test the effectiveness of an mHealth tool to improve HIV medication adherence among Spanish-speaking people living in New York City and the Dominican Republic. Methods: The WiseApp study is a two-arm randomized controlled trial among 248 people with HIV across the New York and Dominican Republic sites over the course of 12 months. Participants are randomly assigned to either receive a CleverCap pill bottle that is linked to the WiseApp (intervention) or standard of care (control). All participants complete surveys at baseline, 3-month, 6-month, and 12-month follow-up visits and the study team obtains HIV-1 viral load and CD4 count results through blood draw at each study timepoint. Discussion: The use of mHealth technologies to improve medication adherence among people with HIV has been implemented in recent years. Although some studies have found improvement in adherence to antiretroviral therapy in the short term, there is limited information about how these interventions improve adherence among Spanish-speaking populations. Disproportionate rates of HIV infection among Latinos in New York City suggest an existing inequitable approach in reaching and treating this population. Due to a lack of mHealth studies with Latino populations, and apps tailored to Spanish-speakers, the WiseApp study will not only demonstrate the effectiveness of this particular mHealth app but will also contribute to the mHealth research community as a whole. Trial registration: This trial was registered with Clinicaltrials.gov (NCT05398185) on 5/31/2022.

 

Thoughts of self-harm in adolescents: Relationship with violence in the Dominican Republic(2024).
Badger K, Baez Caraballo P, Gibbs A, Messina L, Halpern M, Amesty S (2024) Thoughts of self-harm in adolescents: Relationship with violence in the Dominican Republic.PLOS Global Public Health, 4(1), e0002711. doi:10.1371/journal.pgph.0002711.
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Violence against adolescents is a pressing health problem with long-term implications for future physical and mental well-being, such as thoughts of self-harm, which have been associated with suicidal ideation and completion. However, much of the research has been conducted only in high-income countries. This study aimed to examine the correlation between violence against adolescents and self-harm thoughts in La Romana, Dominican Republic (DR). Cross-sectional survey data was collected at a community-based clinic from participants aged 13–20. Participants were recruited through the clinic’s adolescent program and peer referral, and verbal consent was obtained. A survey solicited information about each participant’s demographics, experiences with violence, and thoughts of harm to self or others. The survey was completed by 49 adolescents. The mean age was 16.78 (SD 2.34); 65% were female. We performed t-tests and Fisher’s exact to investigate the relationship between demographics, reported violence experiences and having self-harm thoughts. About half (45%) had experienced physical violence, 76% had experienced emotional violence, and 12% had experienced sexual violence. The most common perpetrators of physical and emotional violence were classmates (12% and 24%), and the most common perpetrator of sexual violence was an ex-partner (4.1%). Ten participants (20.4%) had thought about harming themselves. Self-harm thoughts were significantly associated with being female (p = 0.025), employed (p = 0.05), and a higher number of experiences of physical (0.029) and sexual violence (p = 0.023). The results of this study suggest a high prevalence of both violence and self-harm thoughts in adolescents in the DR. Interventions that address physical and sexual violence against adolescents may be particularly important. Particular attention should also be paid to screening for self-harm thoughts in female-identifying adolescents. Further research is needed to better understand the relationship between violence and self-harm thoughts in adolescents in the DR.

 

Reaching “covidianidad”: A qualitative study of the impact of the COVID-19 pandemic on the perceived mental health of health care workers in the Dominican Republic (2023).Báez Caraballo P, Schriger S, Escober J, Acevedo A, García Alejandro A, Halpern M, et al. (2023) Reaching “covidianidad”: A qualitative study of the impact of the COVID-19 pandemic on the perceived mental health of health care workers in the
Dominican Republic. PLOS Global Public Health. doi:10.1371/journal.pgph.0002652.
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We aimed to explore how the COVID-19 pandemic affected the lives of healthcare workers (HCWs) in the Dominican Republic. We also aimed to identify the types of resources that HCWs felt were needed to support their mental health. We used purposive and convenience sampling in four health centers in the eastern Dominican Republic to recruit 28 HCWs (doctors, nurses, psychologists, and community health workers) between April 2021 and August 2021. Through semi-structured interviews, we elicited HCWs experiences during the pandemic and how they felt these experiences impacted their mental health. Interview transcripts were analyzed using an inductive/deductive thematic approach. Main stressors experienced during the pandemic by HCWs and their sequelae included anxiety due to misinformation and uncertainty, fear of the disease, the robustness of pandemic-related changes they faced in their work and daily life, and COVID-19’s economic impact. HCWs reflected on protective factors that transformed their acute sense of crisis felt at the beginning of the pandemic into what HCWs referred to as “covidianidad [everyday COVID]”, a situation that became manageable through mechanisms including social support, professional motivation, positive work environment and resilience. Lastly, HCWs identified stigmatization of and limited access to mental health services as challenges to supporting their mental health. While Dominican HCWs were vulnerable to the challenges posed by COVID-19 in sustaining their mental health, for many, the situation became manageable through the evolution of “covidianidad.” Further research and interventions are needed to reduce stigmatization of mental health services and foment a positive environment for HCWs’ mental health, to promote resiliency to future challenges.

 

Impact of an STI Diagnosis on People Living With HIV in La Romana, Dominican Republic: A Cross-Sectional, Qualitative, Descriptive Study, J Assoc Nurses AIDS Care 2023. Sanabria G, Stonbraker S, Bateman M, Halrpern M, Amesty S.
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The objective of this study was to explore how receiving a sexually transmitted infection (STI) diagnosis affects subsequent STI knowledge and sexual risk behavior among key populations in La Romana, Dominican Republic (DR) who participated in a parent study 12 to 24 months before the current study. Nine participants, with a mean age of 37 years (range 20-54 years) and a female majority (89%), who were recruited from the parent study completed in-depth interviews, questionnaires assessing STI knowledge, and received STI testing. Interviews were analyzed using qualitative descriptive methodology and questionnaire data, comparing individual’s responses between the parent and current studies. Participants reported safer sexual behaviors after original STI diagnosis, such as more frequent condom use. Questionnaires showed improvement in STI knowledge between the parent and current studies. Three participants had an STI reinfection. Findings warrant further exploration into more comprehensive and targeted STI treatment methods for key populations in the DR.

 

High burden of sexually transmitted infections among under-resourced populations in the Dominican Republic.2023
Amesty S, Perez-Figueroa R, Stonbraker S, Halpern M, Donastorg Y, Perez-Mencia M, Lantigua F, Soriano L, Baez-Caraballo P, Gilbert J, Buccini F, Sharp J, Hernandez B, Gelfond J, Cardwell E, Nicholas C, Egan KA, Gomes A, Van Dyke E, Nicholas SW, Grodman M, Taylor BS, et al. (2023). High burden of sexually transmitted infections among under-resourced populations in the Dominican Republic. Therapeutic Advances in Infectious Disease. doi:10.1177/20499361231193561.
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High burden of sexually transmitted infections among under-resourced populations in the Dominican Republic. Background: Sexually transmitted infections (STIs) are a major health issue, exacerbated by limited financial and infrastructural resources in developing countries. Methods: Prevalence of STIs was assessed in two urban centers of the Dominican Republic (DR) among populations at high risk for STIs: pregnant youth, men who have sex with men (MSM), trans women (TG), batey residents, female sex workers, and people living with human immunodeficiency virus (HIV). We conducted a cross-sectional survey and biological specimen collection to screen for Chlamydia trachomatis, Neisseria gonorrhea, Mycoplasma genitalium, Trichomonas vaginalis (trichomoniasis), Treponema pallidum (syphilis), HIV, hepatitis B and C, and human papillomavirus (HPV) among at-risk populations between 2015 and 2018. Ureaplasma urealyticum testing was also conducted even though it is not considered a STI. A non-probability community sample was recruited. Descriptive statistics examined the prevalence of STIs by population. Results: A total of 1991 subjects participated in the study. The median age was 26years (range: 18–65). Most participants were female (65.3%), heterosexual (76.7%), and were not partnered (55.7%). Most of the participants reported unprotected vaginal sex in the last 6months (54%); among MSM and TG almost half of the participants reported unprotected anal sex in the last 6months and 17.6% reported drug use in the last 6months. Almost half of the participants (49%) tested positive for one or more STIs. The most prevalent STI was Chlamydia trachomatis (12.8%), and human papillomavirus (11.9%). Among transgender women, 65.3% tested positive for an STI, 64.8% of female sex workers tested positive for an STI, and 53.8% of pregnant adolescents tested positive for an STI. Conclusion: There is a high prevalence of STIs among key and under resourced populations in the DR. Our findings highlight the need to conduct further research to optimize prevention and care strategies for structurally vulnerable and under resourced populations in the DR.

 

Mixed method evaluation of a clinic waiting room–based health education program in the Dominican Republic(2023).S Cohen, M Halpern, S Stonbraker, Health Education Research, Volume 38, Issue 2, April 2023, Pages 177–191,Mixed method evaluation of a clinical waiting room-based health education program in the Dominican Republic. Health Education Research. doi:https://doi.org/10.1093/her/cyad001.
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Waiting rooms provide an ideal location to disseminate health information. In this mixed-methods study, we evaluated waiting room–based health education talks at two clinics in the Dominican Republic and explored recommendations for implementing this intervention in similar settings. The talks addressed noncommunicable diseases, sexually transmitted infections, family planning and gender-based violence. We conducted pre- and posttests to assess attendees’ change in knowledge and conducted semi-structured interviews with a subset of them. We conducted a semi-structured focus group with educators. Analyses included Wilcox Signed Rank Tests and McNemar tests for pre- and posttests, conventional content analysis for individual interviews and transcript coding for the focus group. Patient participants were 69.3% female aged 39.6 years (SD = 13.5) on average at one clinic (n = 127) and 100% female aged 17.4 (SD = 1.3) on average at the second clinic (n = 24). Focus group participants (n = 5) had 4.8 years (SD = 3.3) of health educator experience on average. Pre- and posttests showed significant improvement (P < 0.05) across all talks. Qualitative interviews emphasized engaging, clear and brief content delivery with visual aids. The focus group highlighted the importance of patient-centered design with culturally concordant delivery and identified implementation challenges. Findings demonstrate that waiting room–based education talks improve knowledge and provide suggestions for similar interventions.

 

The impact of expedited third semester viral load testing on the proportion of vaginal deliveries in HIV-positive pregnant women in the Dominican Republic 2022. Nimalendran R, Egan KA, Dyke EV, Amesty S, Halpern M, Hod E, Lerebours L, Nicholas SW, Spitalnik S, Whittier S, Stotler B. (2022). The impact of expedited third trimester viral load testing on the proportion of vaginal deliveries in HIV-positive pregnant women in the Dominican Republic. Integrative Gynecology and Obstetrics Journal. doi:10.31038/IGOJ.2022523

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Objective: Advances in HIV treatment have led to a significant decrease in vertical transmission. Lack of adequate viral load testing capabilities inhibited the ability to follow national and international guidelines for obstetric care in the Dominican Republic (DR). The objective of this study was to determine if expedited third trimester viral load testing in HIV-positive pregnant women led to an increase in vaginal deliveries at a clinic in the DR, thus demonstrating the ability to follow national guidelines for obstetric delivery of HIV-positive women on antiretroviral therapy (ART).
Study Design: This study enrolled pregnant HIV-positive patients at a clinic in the DR October 2014-July 2015. Viral load testing was performed 34-36-weeks gestation and results were available within 48 hours. Demographic information, clinical factors, and obstetric outcomes were collected and compared to patients in a retrospective cohort, who delivered January 2012-December 2012 when expedited viral load testing was unavailable.
Results: Of the 20 women in the study, 17 (85%) had viral loads <1000 and seven women (35%) delivered vaginally. In the comparison retrospective cohort, of 41 women, three women (7%) had vaginal deliveries. Comparing the two groups, there was a statistically significant increase in vaginal deliveries from 7% to 35% (p=0.02) after expedited viral load testing was made available. All infants born in the study were HIV-negative.
Conclusion: The study with expedited viral load testing available had an increased number of vaginal deliveries of HIV-positive women on ART. The majority of these patients were on ART with HIV viral loads.

Power and respect in global health research collaboration: Perspectives from research partners in the United States and the Dominican Republic(2023). Green C, Scharf J, Jiménez‐Bautista A, Halpern M. (2023). Power and respect in global health research collaboration: Perspectives from research partners in the United States and the Dominican Republic. Developing World Bioethics, 1–10 Journal Title TBD.
doi:10.1111/dewb.12384.
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Research partnerships between institutions in the Global North and institutions in the Global South have many potential benefits, including sharing of knowledge and resources. However, such partnerships are traditionally exploitative to varying degrees. In order to promote equity in South-North research partnerships, it is necessary to learn from the experiences of researchers collaborating internationally. This study analyzed transcripts from eleven semi-structured qualitative interviews with researchers working at Clínica de Familia La Romana, an institution in the Dominican Republic with decades of experience with research and research partnerships with institutions from the Global North. The findings of this study suggest that respect for resources invested in research, as well as for the researchers and institutions themselves, are vital components to a successful global health research partnership. These findings have implications for individual research partnerships, as well as the policies of journals and institutions providing funding that affect these partnerships.

 

Use of Multiple Methods to Measure Adherence to Antiretroviral Treatment in La Romana, Dominican Republic Rev Panam Salud Publica 2022. Báez P, Tiburcio A, Alba N, Mateo F, Grullon E, Cordero S, Fernández A, Reinoso J, Cruz D, Gómez K, Vargas N, Saint-Hilaire C, Abreu OL, Acosta G, Halpern M, Stonbraker S, et al. (2022). Medición de adherencia a antirretrovirales con métodos múltiples en La Romana, República Dominicana. Revista Panamericana de Salud Pública. doi:https://doi.org/10.26633/RPSP.2022.207.
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Objective:To develop a tool that measures levels of adherence to antiretroviral treatment (ART) in resour ce-poor settings, based on a combination of four methods for measuring adherence. Methods. Retrospective review of 500 medical records of people living with HIV, randomly selected from October 2017 to January 2020. Adherence to ART was measured by combining four measurement methods (coverage of prescribed ART, ART picked up at pharmacies, viral load, and self-reported adherence). Chi squared tests were performed with p<0.05 for statistically significant differences and logistic binary regression to identify the probability of optimal and suboptimal adherence. Spearman tests were performed for correlation of categories, and Cronbach’s alpha was used to measure the internal consistency of the tool. Results. We obtained 497 adherence scores. Of these, 307 (61.8%) users qualified as adherent, 141 (28.4%) as semi-adherent, and 49 (9.8%) as non-adherent. A higher probability of optimal adherence was found in groups aged 60 years and older (odds ratio [OR]: 1.6; CI95%: 0.8–3.5), with no difference between men and women (OR: 0.9; CI95%: 0.7–1.4). Spearman’s test reported a relationship (r = 0.8) between viral load levels and final score, and Cronbach’s alpha yielded modest internal consistency (α = 0.7). Conclusions. A tool was developed to measure adherence to ART in a resource-poor environment. The tool shows modest levels of internal consistency and a strong correlation between viral load and adherence.

If the give their mind to HIV, the don’t last long”: An explanatory model of HIV infection in a limited-resource setting informs person-centered care 2022.Stonbraker S, Sanabria G, Cunto-Amesty S, Alcantara C, Abraido-Lanza AF, Rowell-Cunsolo T, Halpern M, Bakken S, Schnall R, George M. (2022). “If they give mind to HIV, they don’t last as long”: An explanatory model of HIV infection in a limited-resource setting informs Persons-Centered care. Global Qualitative Nursing Research, doi:https://doi.org/10.1177/23333936221097112
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Explanatory models describe individuals’ perceptions of their illness experiences, which can guide culturally relevant care. We constructed an explanatory model of the experience of living with human immunodeficiency virus (HIV) in the Dominican Republic. Following qualitative descriptive methodology, we conducted interviews in Spanish using a semi-structured interview guide developed using Kleinman’s explanatory model framework. Two bilingual researchers coded interview transcripts following conventional content analysis. We used deductive codes from Kleinman’s framework and inductive codes external to the framework to construct the codebook. We arranged codes by shared meaning into categories and constructed themes that reflected shared findings from inductive categories and deductive codes. Twenty-six persons living with HIV participated. They provided rich descriptions of their experiences represented by four cross-cutting themes, which informed the explanatory model. By incorporating this in-depth understanding of patients’ illness experiences into care delivery, nurses can cultivate culturally meaningful and trusting patient-centered partnerships that improve health.

HIV pre-exposure prophylaxis: assessment of acceptability among members of HIV serodiscordant/serostatus unknown couples. International Journal of STD & AIDS, Vol 0(0) 1-7, 2022. Bracho-Sanchez E, Stonbraker S, Halpern M, Wood S, Lowenthal E. (2022). HIV pre-exposure prophylaxis: assessment of acceptability among members of HIV serodiscordant/serostatus unknown couples. International Journal of STD &amp; AIDS. doi:10.1177/09564624221097753.
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Background: Pre-exposure prophylaxis (PrEP) is effective in preventing HIV infection but is not yet widely available in resource-limited settings such as the Dominican Republic. We aimed to ascertain PrEP acceptability among people living with HIV in the Dominican Republic who are part of HIV serodiscordant partnerships and understand relationships between PrEP acceptability, HIV stigma, and intimate partner violence.
Methods: A cross-sectional survey of people in care for HIV infection included acceptability-related questions and assessments of HIV stigma and intimate partner violence. We also explored the expected impact of PrEP on HIV disclosure rates and fertility intentions.
Results: Of the 100 participants, 74% had been in their current partnership for >1 year; 38% had not disclosed to their partner; 29% reported condomless sex, and 23% reported sex with multiple partners. PrEP was highly acceptable with 84% of participants saying they were “very likely” to offer PrEP to their partner if available and 21% stating it would allow them to have more children. Of those who had not disclosed to their partner, 71% stated PrEP would help them do so. No relationship was found between PrEP acceptability, HIV stigma, and intimate partner violence. However, higher than expected rates of PrEP acceptability limited the power of these analyses. 
Conclusion: Pre-exposure prophylaxis was considered to be highly acceptable among people living with HIV in the Dominican Republic who are part of serodiscordant partnerships.

High prevalence of rectal chlamydia among pregnant adolescents in La Romana, Dominican Republic warrants extragenital STI testing. International Journal of STD & AIDS, Vol 0(0) 1-7, 2021. Bancalari P, Nicholas C, Halpern M, Stonbraker S, Taylor B, Soriano L, Ljubicic D, Amesty S. (2021). High prevalence of rectal chlamydia among pregnant adolescents in La Romana, Dominican Republic warrants extragenital STI testing. International Journal of STD &amp; AIDS. doi:10.1177/09564624211043082.
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To our knowledge, there are no studies estimating the prevalence of extragenital sexually transmitted infections (STIs) among pregnant adolescents in the Caribbean. This study sought to fill this gap by assessing the prevalence and correlates of oral, genital, and rectal chlamydia (CT) among a sample of pregnant adolescents in La Romana, Dominican Republic. Two hundred pregnant youths, aged 15–24 years, were recruited by systematic sampling during their first prenatal visit to a maternal care unit. A sociodemographic and behavioral questionnaire was administered and urine and oral/anal swabs were collected and tested for CT. Descriptive analyses and Fisher’s exact tests were performed. The prevalence of oral, genital, and rectal CT was 6%, 15%, and 23%, respectively, although less than 5% of participants reported ever engaging in receptive anal intercourse. This discrepancy could be explained by autoinoculation, concurrent transmission during sex, undertreatment of rectal CT, or underreporting of anal sex. Almost half of CT infections would have been missed if only genital samples were collected, as current protocol dictates. More research is needed to understand sexual behaviors and rectal STI risk factors among heterosexual adolescent women. STI screening procedures for pregnant and sexually active adolescents should include routine testing of extragenital sites.

Clinician use of HIV-related infographics during clinic visits in the Dominican Republic is Associated with Lower Viral Loads and other improvements in Health Outcomes. AIDS and Behavior, 2021.Stonbraker S, Liu J, Sanabria G, George M, Cuanto-Amesty S, Alcantara C, Abraído-Lanza A, Halpern M, Rowel-Cunsolo T, Bakken S, Schnall R. (2021). Clinician use of HIV-related infographics during clinic visits in the Dominican Republic is Associated with Lower Viral Loads and other improvements in Health Outcomes. AIDS and Behavior. doi:https://doi.org/10.1007/s10461-021-03331-8.
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We designed an infographic intervention to help clinicians provide health information to persons living with HIV. In this study, we assessed the extent to which our intervention may improve objectively and subjectively measured health outcomes (CD4 count, viral load, and engagement with clinician among others) when integrated into routine visits in the Dominican Republic. In this pretest–posttest study, we followed participants for 9 months at 3-month intervals. Physicians administered the intervention during participants’ first 3 visits. Outcome measures, selected using a conceptual model, were assessed at 4 time points. We assessed changes in outcomes over time with general linear regressions and Wilcoxon Signed-Rank tests. Participants (N = 50) were mostly female (56%) and had been living with HIV for a mean of 6.3 years (SD = 6.1). All outcomes, except CD4 count, demonstrated statistically significant improvements by study end. This provides preliminary evidence our intervention may improve outcomes, but further testing is needed.

Barriers to HIV treatment adherence among adults living with HIV in the eastern Dominican Republic. International Journal of STD & AIDS. VOL0(0) 1-6, 2021. Bast E, Stonbraker S, Halpern M, Lowenthal E, Gross R. (2021). Barriers to HIV treatment adherence among adults living with HIV in the eastern Dominican Republic. International Journal of STD &amp; AIDS, 2021. doi:10.1177/09564624211014102.
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Despite access to nationally supplied antiretroviral treatment, viral load suppression rates remain suboptimal in the Dominican Republic. Counseling and support services are available but mainly targeted to those identified as having the most need. At Clínica de Familia La Romana (CFLR) in La Romana, all patients undergo a structured baseline interview including exploration of expected barriers to care. We conducted a retrospective cohort study of a random sample of patients at CFLR with treatment initiation between 1 January 2015 and 1 December 2017 to determine if self-identified barriers to HIV care predict viral load suppression. Viral load suppression occurred in 63% of the 203 patients evaluated. Lack of food (n = 19) was significantly associated with lack of viral suppression (OR 3.0, 95% CI 1.14–7.87). Nondisclosure of HIV status (n = 24) showed evidence for a protective effect (OR 0.33; 95% CI 0.11–1.0). Further steps should be taken to address food insecurity as well as to understand associated barriers to care among individuals with food insecurity.

Feasibility and acceptability of using information visualizations to improve HIV-related communication in a limited-resource setting: a short report. AIDS Care, 2021.Stonbraker S, Flynn G, George M, Cunto-Amesty S, Alcántara C, Abraído-Lanza A, Halpern M, Rowell-Cunsolo T, Bakken S, Schnall R. (2021). Feasibility and acceptability of using information visualizations to improve HIV-related communication in a limited-resource setting: a short report. AIDS Care. doi:https://doi.org/10.1080/09540121.2021.1883517.
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Infographics (visualizations that present information) can assist clinicians to offer health information to patients with low health literacy in an accessible format. In response, we developed an infographic intervention to enhance clinical, HIV-related communication. This study reports on its feasibility and acceptability at a clinical setting in the Dominican Republic. We conducted in-depth interviews with physicians who administered the intervention and patients who received it. We conducted audio-recorded interviews in Spanish using semi-structured interview guides. Recordings were professionally transcribed verbatim then analyzed using descriptive content analysis. Physician transcripts were deductively coded according to constructs of Bowen et al.’s feasibility framework and patient transcripts were inductively coded. Three physicians and 26 patients participated. Feasibility constructs endorsed by physicians indicated that infographics were easy to use, improved teaching, and could easily be incorporated into their workflow. Coding of patient transcripts identified four categories that indicated the intervention was acceptable and useful, offered feedback regarding effective clinical communication, and recommended improvements to infographics. Taken together, these data indicate our intervention was a feasible and acceptable way to provide clinical, HIV-related information and provide important recommendations for future visualization design as well as effective clinical communication with similar patient populations.

Digital Educational Support Groups Administered through WhatsApp Messenger Improve Health-Related Knowledge and Health Behaviors of New Adolescent Mothers in the Dominican Republic: A Multi-Method Study. Informatics. 2020; 7(4):51. Stonbraker S, Haight E, Lopez A, Guijosa L, Davison E, Bushley D, Aquino Peguero K, Araujo V, Messina L, Halpern M. (2020). Digital Educational Support Groups
Administered through WhatsApp Messenger Improve Health-Related Knowledge and Health Behaviors of New Adolescent Mothers in the Dominican Republic: A Multi-Method Study. Informatics. doi:https://doi.org/10.3390/informatics7040051.
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 (1) Background: In limited-resource settings such as the Dominican Republic, many factors contribute to poor health outcomes experienced by adolescent mothers, including insufficient support and/or health knowledge. In response, we designed a digital educational support group, administered through WhatsApp Messenger, for new adolescent mothers. The purpose of this study was to assess if participation in this digital support group could improve health outcomes and health behaviors. (2) Methods: Participants completed questionnaires with a health literacy screener, demographic items, knowledge questions, the Index of Autonomous Functioning, and five Patient Reported Outcomes Measurement Information System scales before and after the moderator-led intervention. Differences between pre- and post-intervention scores were calculated and perceptions of the intervention were explored through in-depth interviews analyzed with content analysis. Participants’ well-baby visit attendance and contraceptive use were compared to that of controls and a national sample. (3) Results: Participants’ (N = 58) knowledge scores increased (p < 0.05). Participants were 6.58 times more likely to attend well-baby visits than controls (95% CI: 2.23–19.4) and their contraceptive use was higher than that of the national sample (p < 0.05). Participants indicated the intervention was enjoyable and beneficial. (4) Conclusion: This adolescent-centered digital intervention is a promising method to improve health outcomes and health behaviors of young mothers in limited-resource settings.

Establishing content for a digital educational support group for new adolescent mothers in the Dominican Republic: a user-centered design. International Journal of Adolescent Medical Health, 2020. Stonbraker S, Haight E, Soriano L, Guijosa L, Davison E, Bushley D, Messina L, Halpern M, et al. (2020). Establishing content for a digital educational support group for new adolescent mothers in the Dominican Republic: a user-centered design. International Journal of Adolescent Medical Health. doi:10.1515/ijamh-2020-0054.
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Background
As digital interventions to improve health become widespread globally, it is critical to include target end-users in their design. This can help ensure interventions are maximally beneficial among intended populations.
Objectives
To generate the content of a digital educational support group, administered through WhatsApp, for new adolescent mothers and establish participants’ cellular access and WhatsApp use.
Participants
Adolescent mothers with new babies.
Methods
We completed a two-phase user-centered design process. In phase I design sessions, participants discussed their postpartum experiences and completed an activity to elucidate their health and wellbeing information needs. In phase II sessions, participants individually identified which health information topics were important to them, then all topics were prioritized as a group. Phase II participants also completed a brief survey on cell phone access and WhatsApp use.
Results
Phase I included 24 participants, 21 of whom completed phase II. Priority health and wellbeing information topics in the postpartum period were identified as: child growth and development, understanding your baby, common childhood illnesses, breastfeeding, childhood nutrition, family planning, and self-care. Of phase II participants, 45% had cellular phone access and none had a data plan. Cellular service was inconsistently obtained with data packages or Wi-Fi. 30% of participants had no experience using WhatsApp.
Conclusions
Participants identified numerous health information needs, which will serve as the content for our planned digital support group and provides valuable insight for health care providers globally. Less than half of participants had consistent cellular phone access, and none had reliable access to cellular service.

Factors related to subsequent adolescent pregnancy in the Dominican Republic. Journal of Adolescent and Family Health, 2020; 11(1).
Fay CJ, Fay KE, Messina LA, Halpern M, Stonbraker SB, et al. (2020). Factors related to subsequent adolescent pregnancy in the Dominican Republic. Journal of Adolescent and Family Health. https://scholar.utc.edu/jafh/vol11/iss1/8.
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Objectives: Adolescents with subsequent pregnancies in the Dominican Republic represent a significant but poorly understood population with little available data to inform health care services. The objective of this exploratory study was to begin to characterize this important cohort. Methods: A survey of demographic items and a sexual and obstetrical history was administered to 50 adolescents with subsequent pregnancies in La Romana, Dominican Republic. Results: Most participants were married (78%) and exclusively economically dependent on their partner (72%) and nearly half (48%) stopped attending school. Twelve percent reported having intended their current pregnancy. Conclusions: Adolescents with subsequent pregnancies were dependent on partners in the form of living conditions and marriage, economic dependence and unemployment, and lack of education.

Perceptions and Attitudes Toward Mobile Health in Development of an Exclusive Breastfeeding Tool: Focus Group Study With Caregivers and Health Promoters in the Dominican Republic. JMIR Pediatrics and Parenting, 2020; 3(2). Casilang CG, Stonbraker S, Japa I, Halpern M, Messina L, Steenhoff AP, Lowenthal ED, Fleisher L, et al. (2020). Perceptions and Attitudes Toward Mobile Health in Development of an Exclusive Breastfeeding Tool: Focus Group Study With Caregivers and Health Promoters in the Dominican Republic. JMIR Pediatrics and Parenting. doi:10.2196/20312.Ver en línea Abstracto

Background: Despite growing interest in the use of technology to improve health outcomes in low- and middle-income countries (LMICs), local attitudes toward mobile health (mHealth) use in these settings are minimally understood. This is especially true in the Dominican Republic, where mHealth interventions are starting to emerge. This information is critical for developing effective mHealth interventions to address public health issues, such as low exclusive breastfeeding (EBF) rates, which can lead to poor outcomes. With an EBF rate of 5% in the first 6 months of life, the Dominican Republic has one of the lowest EBF rates worldwide.
Objective: This study aims to describe the current use of information and communication technology (ICT) and to analyze the attitudes and perceptions related to using mHealth interventions among caregivers of children aged ≤5 years and health promoters in the Dominican Republic. Findings can inform mHealth strategies aimed at improving EBF in this, and other, LMICs.
Methods: Participants were recruited from 3 outpatient sites: the Niños Primeros en Salud program at Centro de Salud Divina Providencia in Consuelo (rural setting) and Clínica de Familia La Romana and its program Módulo de Adolescentes Materno Infantil in La Romana (urban setting). Focus groups were conducted with caregivers and community health promoters to identify the use, attitudes, perceptions, and acceptability of mHealth as well as barriers to EBF. Discussions were conducted in Spanish, guided by semistructured interview guides. All sessions were audio-recorded and later transcribed. Thematic content analysis was conducted in Spanish by two bilingual researchers and was structured around a hybrid behavioral theory framework to identify salient themes.
Results: All participants (N=35) reported having a mobile phone, and 29 (83%) participants had a smartphone. Sources for obtaining health information included the internet, physicians and clinic, family and friends, health promoters, and television. Barriers to mHealth use included the cost of internet service, privacy concerns, and perceived credibility of information sources. Participants indicated the desire for, and willingness to use, an mHealth intervention to support breastfeeding. The desired features of a possible mHealth intervention included offering diverse methods of information delivery such as images and video content, text messages, and person-to-person interaction as well as notifications for appointments, vaccines, and feeding schedules. Other important considerations were internet-free access and content that included maternal and child health self-management topics beyond breastfeeding.
Conclusions: There is a high level of acceptance of ICT tools for breastfeeding promotion among caregivers in urban and rural areas of the Dominican Republic. As mHealth tools can contribute to increased breastfeeding self-efficacy, identifying desirable features of such a tool is necessary to create an effective intervention. Participants wanted to receive trusted and reliable information through various formats and were interested in information beyond breastfeeding.

Drug use, sexual risk, and structural vulnerability among female sex workers in two urban centers of the Dominican Republic: The EPIC study. Drug and Alcohol Dependence, April 2020. Pérez-Figueroa R, Mittal I, Halpern M, Pérez-Mencia M, Donastorg Y, Taylor BS, Amesty
S, et al. (2020). Drug use, sexual risk, and structural vulnerability among female sex workers in two urban centers of the Dominican Republic: The EPIC study. Drug andAlcohol Dependence. doi:10.1016/j.drugalcdep.2020.108039.
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Background: Evidence in different countries suggest an association between sex work and drug use. In the Dominican Republic an estimated 60,000–100,000 women work in the sex industry. However, little is known about their drug use behaviors. Objective: To characterize the burden of drug use and examine correlates of these behaviors among female sex workers in the Dominican Republic. Methods: Data for this analysis comes from a cross-sectional study among key populations at risk for HIV. A community sample of female sex workers (N = 389) was recruited using passive and active recruitment strategies. Participants completed a behavioral survey between 2015 and 2016. Logistic regression models were constructed to examine predictors of drug use. Results: Protective factors against marijuana and crack or cocaine use included being heterosexual, having a higher level of education, regular employment, and fewer male sexual partners. Increased odds of crack or cocaine use were associated with incarceration, having slept in a place not meant for human habitation in the last six months, and having ever lived in a batey (a community around a sugar mill where workers and their families live). Participants that used marijuana were generally younger, while those that used crack or cocaine were older. Conclusions: Our findings highlight characteristics of the social and economic environment that require further research to optimize prevention and care strategies for this population. Public health interventions are needed that address drug use, sexual risk-taking, and helping female sex workers and their families achieve a healthy life.

Developing infographics to facilitate HIV patient-provider communication in a limited-resource setting. Applied Clinical Infographics, 2019. 10(4): p. 597-609. Stonbraker S, Halpern M, Bakken S, Schnall R, et al. (2019). Developing infographics to facilitate HIV patient-provider communication in a limited-resource setting. Applied Clinical Infographics. doi:10.1055/s-0039-1694001.
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Background: Productive patient–provider communication is a recognized component of high-quality health care that leads to better health outcomes. Well-designed infographics can facilitate effective communication, especially when culture, language, or literacy differences are present.
Objectives: This study aimed to rigorously develop infographics to improve human immunodeficiency virus (HIV)-related patient–provider communication in a limited-resource setting. A secondary purpose was to establish through participant feedback that infographics convey intended meaning in this clinical and cultural context. Methods: We adapted a participatory design methodology, developed in a high-resource setting, for use in the Dominican Republic. Initially, content to include was established using a data-triangulation method. Then, infographics were iteratively generated and refined during five phases of design sessions with three stakeholder groups: (1) 25 persons living with HIV, (2) 8 health care providers, and (3) 5 domain experts. Suggestions for improvement were incorporated between design sessions and questions to confirm interpretability of infographics were included at the end of each session. Results: Each participant group focused on different aspects of infographic designs. Providers drew on past experiences with patients and offered clinically and contextually relevant recommendations of symbols and images to include. Domain experts focused on technical design considerations and interpretations of infographics. While it was difficult for patient participants to provide concrete suggestions, they provided feedback on the meaning of infographics and responded clearly to direct questions regarding possible changes. Fifteen final infographics were developed and all participant groups qualitatively confirmed that they displayed the intended content in a culturally appropriate and clinically meaningful way. Conclusion: Incorporating perspectives from various stakeholders led to the evolution of designs over time and generated design recommendations that will be useful to others creating infographics for use in similar populations. Next steps are to assess the feasibility of using infographics to improve clinical communication and patient outcomes.

Evaluation of a comprehensive sexuality education program in La Romana, Dominican Republic. International Journal of Adolescent Medicine and Health (published online ahead of print 2019), 20190017. Richards SD, Mendelson E, Flynn G, Messina L, Bushley D, Halpern M, Amesty S, Stonbraker S, et al. (2019). Evaluation of a comprehensive sexuality education program in La Romana, Dominican Republic. International Journal of Adolescent Medicine and Health. doi:https://doi.org/10.1515/ijamh-2019-0017.
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Background: The Dominican Republic (DR) has some of the highest rates of sexually transmitted infections (STI) and adolescent pregnancy in the Caribbean. Well-designed comprehensive sexuality education programs (CSEP) can reduce risky sexual behavior. This study sought to evaluate the Módulo Anexo Materno Infantil (MAMI) adolescent clinic’s CSEP in changing knowledge of STI and pregnancy and attitudes towards risky sexual behavior following implementation. Methods: A mixed methods study was conducted among students aged 11–25 years from three schools between September 2017 and February 2018. Participants in MAMI CSEP completed questionnaires, before, immediately following, and 3 months following the CSEP. Questions assessed knowledge, attitude, and sexual experience, and obtained program feedback. There was one eight-participant focus group discussion (FGD) per school. Descriptive statistics summarized sample demographics and cross-sectional responses. McNemar’s test evaluated differences in the proportions of students selecting correct responses over time. Paired t-tests compared mean test scores across time. Result: Overall response rate was 98.7% (1414/1432), with 486 pre-tests, 448 initial post-tests, and 480 3-month post-tests. Respondents identified as 53.5% (321/600) female and 46.5% (279/600) male with mean age of 14.2 years. More males (63.4%) reported sexual experience than females (35.8%) (p < 0.001). Increases in mean scores from pre-test to post-test and pre-test to 3-month post-test were statistically significant (p < 0.001). Three themes arose from the FGDs: (1) expanding sexual and reproductive health knowledge, (2) perception of curricular content, structure and delivery, and (3) student-health educator dynamic. Conclusion: Improvement in test scores supports MAMI CSEP’s efficacy in educating students and reinforcing positive attitudes to reduce risky sexual behavior. Utilizing an interactive health educator model provided students with clear, accurate information in a safe environment with mutual trust. Selecting health educators employed by an adolescent clinic allows them to connect students to preventive and treatment services during the CSEP.

Priority topics for health education to support HIV self-management in limited-resource settings. Journal of Nursing Scholarship, 2018. 
Stonbraker S, Richards S, Halpern M, Bakken S, Schnall R, et al. (2018). Priority topics for health education to support HIV self-management in limited-resource settings. Journal of Nursing Scholarship. doi:https://doi.org/10.1111/jnu.12448.
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Purpose: The purpose of this study was to identify and prioritize the information that persons living with HIV (PLWH) in a limited-resource setting need to effectively manage their health. Design and Methods: A data sources triangulation method was used to compare data from three separate sources: (a) 107 interviews with Spanish-speaking PLWH being seen at a healthcare clinic in the Dominican Republic (DR); (b) 40 interviews with Spanish-speaking healthcare providers from the same clinic in the DR; and (c) an integrative literature review of English- and Spanish-language articles that assessed the health information needs of PLWH in Latin America and the Caribbean. We compared information needs across sources and developed a prioritized list of the topics important to provide PLWH in a clinical setting. Findings: Triangulation identified the most important topics for HIV-related health education for PLWH as medication and adherence, followed by transmission, including risks and prevention strategies, mental health management, and knowledge of HIV in general. Conclusions: The identification of evidence-based health education priorities establishes a guide that healthcare providers may use to help PLWH effectively manage their health and creates a foundation from which further studies on improving clinical interactions may be generated. Clinical Relevance: Using the priorities identified, nurses and other health educators can improve patient education, and consequently self-management, by making evidence-based choices about what information to provide to their patients.

Cervical cancer screening among transactional female sex workers in the Dominican Republic. International Journal of STD & AIDS, 2018. Richards SD, Stonbraker S, Halpern M, Amesty S, et al. (2018). Cervical cancer screening among transactional female sex workers in the Dominican Republic.International Journal of STD &amp; AIDS. doi:10.1177/0956462418779662.
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Cervical cancer is the third leading cause of cancer-related death and the second most diagnosed cancer among women in developing countries. We determined the prevalence of abnormal Papanicolaou (Pap), high-risk HPV (hrHPV), and colposcopy among transactional female sex workers (FSWs) in La Romana, Dominican Republic. The results of 144 FSWs of ages 18–54 years who completed a demographic interview and Pap testing with hrHPV detection between June 2015 and April 2016 were analyzed. Women with abnormal results were referred for colposcopy. Risk factors for abnormal Pap were assessed through bivariate and multivariate analyses. Overall, 36.1% (52/144) of Paps were abnormal and 43.4% (62/143) had hrHPV. Of all women with hrHPV and/or abnormal Pap (68/144; 47.2%), 61 (89.7%) were referred and 16 (26.2) underwent colposcopy. HPV16 and/or 18/45 was detected in 33.3% (15/45) of low-grade Paps. Binge drinking, weekly (AOR 5.1, 95% CI: 1.8–14.5) or daily (AOR 4.9, 95% CI: 1.5–16.6), and age at first sexual relation (AOR 1.2, 95% CI: 1.0–1.5) were significantly associated (p < 0.05) with abnormal Pap. Although almost half of participants had abnormal Pap or hrHPV, few underwent colposcopy. Improving access to cervical cancer screening and follow-up for FSWs is imperative.

 

Associations between health literacy, HIV-related knowledge, and information behavior among persons living with HIV in the Dominican Republic. Public Health Nursing, 2017. 35(3): p. 166-175.Stonbraker S, Smaldone A, Luft H, Cushman LF, Lerebours Nadal L, Halpern M, Larson E, et al. (2017). Associations between health literacy, HIV-related knowledge, and information behavior among persons living with HIV in the Dominican Republic. Public Health Nursing. doi:https://doi.org/10.1111/phn.12382.
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Objectives
To determine the health literacy levels of persons living with human immunodeficiency virus (HIV) (PLWH) at a health clinic in the Dominican Republic (DR) and assess associations between health literacy, HIV-related knowledge, and health information behavior (how patients need, seek, receive, and use information).
Design and Sample
Cross-sectional, descriptive. Participants were 107 PLWH attending the Clinic.
Measures
A theoretically based, 64-item survey assessing information behavior and HIV-related knowledge was administered in Spanish through individual interviews. Health literacy was assessed using the Short Assessment of Health Literacy—Spanish and English.
Results
On average, participants were 40.8 years old and had lived with HIV for 7.7 years. The majority (69.2%) had low health literacy. HIV-related knowledge and information behavior varied by health literacy level and uncertainty regarding a main indicator of disease progression, viral load, was demonstrated regardless of health literacy level. Participants with low health literacy were less likely to answer questions or answer questions correctly and many participants (39.2%) indicated viral transmission can occur through supernatural means.
Conclusions
Findings demonstrate unmet information need and that information received may not always be understood. Methods to improve health education are needed to ensure patients receive health information in an understandable way.

 

Strengthening the HIV Care Continuum in the Dominican Republic: Application of a Triadic Implementation Framework to Meet the UNAIDS 90-90-90 Treatment Goal. AIDS Patient Care and STDs, 2017. 31(10): p. 407-412. Bowman AS, Mehta M, Lerebours Nadal L, Halpern M, Nicholas SW, Amesty S, et al. (2017). Strengthening the HIV Care Continuum in the Dominican Republic: Application of a Triadic Implementation Framework to Meet the UNAIDS 90-90-90 Treatment Goal. AIDS Patient Care and STDs. doi:https://doi.org/10.1089/apc.2017.0118.
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Innovative empirical frameworks to evaluate progress in efforts addressing HIV treatment and prevention barriers in resource-limited areas are sorely needed to achieve the UNAIDS 90-90-90 goal (90% diagnosed, 90% on treatment, and 90% virally suppressed). A triadic implementation framework (TIF) is a comprehensive conceptual tool for (1) monitoring attrition, (2) evaluating operational programs, and (3) measuring the impact of specific implementation goals within the care continuum. TIF will assess the effects of enhanced programs on adherence and virologic suppression within the HIV care continuum at a regional clinic in the Dominican Republic (Clínica de Familia La Romana [CFLR]) and its program serving high-risk, migratory batey (sugarcane cultivation) communities. A retrospective cohort study completed during 2015 collected deidentified data from a CFLR chart review of adult HIV patients diagnosed in 2013. The results were quantitatively analyzed and compared to 2011 cohort data. In 2013, 310 patients were diagnosed HIV positive. The results demonstrated 73% enrolling in care, 28% adhering to care, and 16% achieving viral load suppression. Engagement increased across all steps of the care continuum compared to a 2011 cohort, culminating in a significant increase in undetectable viral load from 4% to 16% (p < 0.001). The batey program showed significant increases in patient enrollment compared to the 2011 cohort (p < 0.001). Meeting the UNAIDS 90-90-90 goal requires enhanced services in high-burden, resource-limited regions. CFLR employs TIF to assess progress and programmatic areas in need of strengthening. Data suggest enhanced CFLR services improve outcomes. Given improvements, maintenance and expansion of similar programs are warranted to achieve the 90-90-90 goal.

“… like because you are a grownup, you do not need help”: Experiences of Transition from Pediatric to Adult Care among Youth with Perinatal HIV Infection, Their Caregivers, and Health Care Providers in the Dominican Republic. Journal of the International Association of Providers of AIDS Care (JIAPAC), 2017: p. 2325957417729749.  Pinzón-Iregui MC, Ibanez G, Beck-Sagué C, Halpern M, Mendoza RM, et al. (2017). “… like because you are a grownup, you do not need help”: Experiences of Transition from Pediatric to Adult Care among Youth with Perinatal HIV Infection, Their Caregivers, and Health Care Providers in the Dominican Republic. Journal of the International Association of Providers of AIDS Care (JIAPAC). doi:https://doi.org/10.1177%2F2325957417729749.
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With the introduction of combination antiretroviral therapy (ART) worldwide, youth with perinatal HIV infection are increasingly surviving childhood and transitioning to adult care. Although a normal life span is anticipated posttransition, successful transition to adult HIV care has proven difficult, with worse outcomes posttransition than in pediatric and adult care. This study is a qualitative analysis of data from 4 focus groups of pre- and posttransition patients, caregivers, and healthcare providers in the Dominican Republic at an institution that provides comprehensive treatment including ART for HIV-infected persons of all ages. All groups discussed the problems and challenges that patients, caregivers, and providers experience while living the transition process and beyond. Five major themes emerged: the trauma of transition itself, ART adherence, experience and impact of stigma, social supports and barriers, and recommendations for improving outcomes. Participants’ insights offered approaches for a versatile structured transition process.

 

What the rest of the world should know about HIV: Perceptions from adults living with HIV in the Dominican Republic. Journal of the Association of Nurses in AIDS Care, 2017. 28(6): p. 977. Stonbraker S, Arcia A, Halpern M, Larson E, et al. (2017). What the rest of the world
should know about HIV: Perceptions from adults living with HIV in the Dominican Republic. Journal of the Association of Nurses in AIDS Care.
doi:10.1016/j.jana.2017.06.009.
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Evaluating the utility of provider-recorded clinical status in the medical records of HIV positive adults in a limited-resource setting. International Journal of STD and AIDS, 2016. 28(7). Stonbraker S, Befus M, Lerebours Nadal L, Halpern M, Larson E, et al. (2016).
Evaluating the utility of provider-recorded clinical status in the medical records of HIV positive adults in a limited-resource setting. International Journal of STD and AIDS. doi:10.1177/0956462416663990.
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Provider-reported summaries of clinical status may assist with clinical management of HIV in resource poor settings if they reflect underlying biological processes associated with HIV disease progression. However, their ability to do so is rarely evaluated. Therefore, we aimed to assess the relationship between a provider-recorded summary of clinical status and indicators of HIV progression. Data were abstracted from 201 randomly selected medical records at a large HIV clinic in the Dominican Republic. Multivariable logistic regressions were used to examine the relationship between provider-assigned clinical status and demographic (gender, age, nationality, education) and clinical factors (reported medication adherence, CD4 cell count, viral load). The mean age of patients was 41.2 (SD = ±10.9) years and most were female (n = 115, 57%). None of the examined characteristics were significantly associated with provider-recorded clinical status. Higher CD4 cell counts were more likely for females (OR = 2.2 CI: 1.12–4.31) and less likely for those with higher viral loads (OR = 0.33 CI: 0.15–0.72). Poorer adherence and lower CD4 cell counts were significantly associated with higher viral loads (OR = 4.46 CI: 1.11–20.29 and 6.84 CI: 1.47–37.23, respectively). Clinics using provider-reported summaries of clinical status should evaluate the performance of these assessments to ensure they are associated with biologic indicators of disease progression.

 

Evaluation of patient care cascade for HIV-positive patients diagnosed in La Romana, Dominican Republic in 2011: a retrospective cohort study. International Journal of STD & AIDS, 2016. 27(5): p. 394-401. Bowman AS, Lerebours L, Amesty S, de la Rosa M, Gil E, Halpern M, Nicholas S, Lamb MR, et al. (2016). Evaluation of patient care cascade for HIV-positive patients diagnosed in La Romana, Dominican Republic in 2011: a retrospective cohort study. International Journal of STD &amp; AIDS. doi:10.1177/0956462415584487.
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The Caribbean has the highest adult HIV prevalence in the world after sub-Saharan Africa (2011). One sub-population in the Dominican Republic is the migratory Batey community primarily comprised of Haitian immigrants with limited access to healthcare and HIV prevalence rates of between 3.0% and 9.0%, compared to 0.7% nationally. This retrospective cohort study describes the cumulative retention from diagnosis to virological suppression for newly-diagnosed HIV-infected adults presenting to the Clínica de Familia and its Batey programme in La Romana, during 2011. Of the patients diagnosed with HIV, 65% entered into care, 59% completed immunologic testing, 53% were eligible for antiretroviral therapy (ART) initiation, 36% initiated ART within three months of eligibility and 27% were retained in care. Seventeen per cent of those retained on ART with a 12-month viral load measure had undetectable viral load. Attrition primarily occurred before ART initiation. The Batey programme had a first step lost-to-follow-up of 88% compared to 20% at the clinic (p < 0.001). This retrospective study details the continuum of care and indicates where structural changes must occur to increase continuity between steps. The manuscript results are important to help implement programmes to enhance engagement and retention in HIV primary care.

Factors associated with health information seeking, processing, and use among HIV positive adults in the Dominican Republic. AIDS and Behavior, 2016. 21(6): p. 1588–1600. Stonbraker S, Befus M, Lerebours Nadal L, Halpern M, Larson E, et al. (2016). Factors associated with health information seeking, processing, and use among HIV positive adults in the Dominican Republic. AIDS and Behavior. doi:10.1007/s10461-016-1569-5..
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Effective treatment and management of human immunodeficiency virus (HIV) depend on patients’ ability to locate, comprehend, and apply health information. This study’s purpose was to identify characteristics associated with these skills among HIV positive adults in the Dominican Republic. An information behavior survey was administered to 107 participants then three logistic regressions were conducted to identify characteristics associated with information seeking, processing, and use. Never having cared for someone who was sick was significantly associated with less information seeking, processing, and use. Males were more likely to be active information seekers and those who had attended the clinic for six or fewer years were less likely to actively seek information. Younger individuals had increased odds of higher information processing and those without comorbidities had increased odds of more information use. Results may inform researchers, organizations, and providers about how patients interact with health information in limited resource settings

 

A clinical trial to introduce voluntary medical male circumcision for HIV prevention in areas of high prevalence in the Dominican Republic. PloS One, 2015. 10(9): p. e0137376. Brito MO, Lerebours L, Volquez C, Basora E, Khosla S, Lantigua F, Flete R, Rosario R, Rodriguez LA, Fernandez M, Donastorg Y, Bailey RC, et al. (2015). A clinical trial to introduce voluntary medical male circumcision for HIV prevention in areas of high prevalence in the Dominican Republic. PloS One. doi:10.1371/journal.pone.0137376.
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Background
Voluntary Medical Male Circumcision (VMMC) is an effective strategy to reduce the risk of HIV infection. Studies conducted in the Dominican Republic (DR) suggest that acceptability of VMMC among men may be as high as 67%. The goal of this clinical trial was to assess the acceptability, uptake and safety for VMMC services in two areas of high HIV prevalence in the country.
Methods
This was a single-arm, non-randomized, pragmatic clinical trial. Study personnel received background information about the risks and benefits of VMMC and practical training on the surgical technique. A native speaking research assistant administered a questionnaire of demographics, sexual practices and knowledge about VMMC. One week after the surgery, participants returned for wound inspection and to answer questions about their post-surgical experience.
Results
539 men consented for the study. Fifty seven were excluded from participation for medical or anatomical reasons and 28 decided not to have the procedure after providing consent. A total of 454 men were circumcised using the Forceps Guided Method Under Local Anesthesia. The rate of adverse events (AE) was 4.4% (20% moderate, 80% mild). There were no serious AEs and all complications resolved promptly with treatment. Eighty eight percent of clients reported being “very satisfied” and 12% were “somewhat satisfied” with the outcome at the one-week postoperative visit.
Conclusions
Recruitment and uptake were satisfactory. Client satisfaction with VMMC was high and the rate of AEs was low. Roll out of VMMC in targeted areas of the DR is feasible and should be considered.

 

Disclosure of their HIV status to perinatally infected youth using the adapted Blasini disclosure model in Haiti and the Dominican Republic: preliminary results. AIDS (London, England), 2015. 29(0 1): p. S91. Beck-Sagué CM, Dévieux J, Pinzón-Iregui MC, Lerebours-Nadal L, Abreu-Pérez R, Bertrand R, Rouzier V, Gaston S, Ibanez G, Halpern M, Pape JW, Dorceus P, Preston SM, Dean AG, Nicholas SW, Blasini I, et al. (2015). Disclosure of their HIV status to perinatally infected youth using the adapted Blasini disclosure model in Haiti and the Dominican Republic: preliminary results. AIDS (London, England. doi:10.1097/QAD.0000000000000665.
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Objectives:
To assess the safety, acceptability, and preliminary efficacy of a culturally-adapted disclosure intervention for perinatally HIV-infected combined antiretroviral therapy patients in Haiti and the Dominican Republic.
Design: 
A quasi-experimental trial was conducted comparing caregiver–youth pairs who completed the intervention [adapted Blasini disclosure model (aBDM)] to pairs who discontinued aBDM participation before disclosure. aBDM consists of five components: structured healthcare worker training; one-on one pre-disclosure intervention/education sessions for youth (describing pediatric chronic diseases including cancer, diabetes and HIV) and for caregivers (strengthening capacity for disclosure); a scheduled supportive disclosure session; and one-on-one postdisclosure support for caregivers and youth.
Methods: 
Caregivers of nondisclosed combined antiretroviral therapy patients aged 10.0–17.8 years were invited to participate. Data were collected by separate one-on-one face-to-face interviews of caregivers and youth by study staff and medical record review by pediatricians at enrollment and 3 months after disclosure or after intervention discontinuation.
Results:
To date, 65 Dominican Republic and 27 Haiti caregiver–youth pairs have enrolled. At enrollment, only 46.4% of youth had viral suppression and 43.4% of caregivers had clinically significant depressive symptomatology. To date, two serious study-related adverse events have occurred. Seven of the 92 (7.6%, 6 in the Dominican Republic) enrolled pairs discontinued participation before disclosure and 39 had completed postdisclosure participation. Median plasma HIV-RNA concentration was lower in youth who completed aBDM than in youth who discontinued participation before aBDM disclosure (<40 versus 8673 copies/ml; P = 0.027). Completers expressed considerable satisfaction with aBDM.
Conclusion:
Preliminary results suggest safety, acceptability, and possible effectiveness of the aBDM.

 

Disclosure of their status to youth with human immunodeficiency virus infection in the Dominican Republic: a mixed-methods study. AIDS and Behavior, 2015. 19(2): p. 302-310. Beck-Sagué C, Pinzón-Iregui MC, Abreu-Pérez R, Lerebours-Nadal L, Navarro CM, Ibanez G, Soto S, Halpern M, Nicholas SW, Malow R, Dévieux JG, et al. (2015). Disclosure of their status to youth with human immunodeficiency virus infection in the Dominican Republic: a mixed-methods study. AIDS and Behavior. doi:10.1007/s10461-014-0888-7.
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A mixed-methods study was conducted to determine the proportion of HIV-infected children who knew their status, identify characteristics associated with children’s knowledge of their status, and describe caregivers’ and adolescents’ experiences relevant to disclosure in the Dominican Republic (DR). Of 327 patients aged 6–18 years treated in the principal DR pediatric HIV facilities, 74 (22.6 %) knew their status. Patients aged 13 years or older and/or who had participated in non-clinical activities for HIV-infected children were more likely to know their status. Caregivers who had disclosed cited healthcare providers’ advice, children’s desire to know and concerns that children might initiate sexual activity before knowing or discover their status by accidental or malicious disclosure. Non-disclosing caregivers worried that children would be traumatized by disclosure and/or stigmatized if they revealed it to others. Adolescents supported disclosure by 10–12 years of age, considered withholding of children’s HIV diagnosis ill-advised, and recommended a disclosure process focused initially on promoting non-stigmatizing attitudes about HIV.

 

G6PD deficiency in an HIV clinic setting in the Dominican Republic. The American journal of tropical medicine and hygiene, 2015. 93(4): p. 722-729. Xu JZ, Francis RO, Lerebours Nadal LE, Shirazi M, Jobanputra V, Hod EA, Jhang JS, Stotler BA, Spitalnik SL, Nicholas SW, et al. (2015). G6PD deficiency in an HIV clinic setting in the Dominican Republic. The American Journal of Tropical Medicine and Hygiene, 93(4), 722-729. doi:https://doi.org/10.4269/ajtmh.14-0295.
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Because human immunodeficiency virus (HIV)-infected patients receive prophylaxis with oxidative drugs, those with glucose-6-phosphate dehydrogenase (G6PD) deficiency may experience hemolysis. However, G6PD deficiency has not been studied in the Dominican Republic, where many individuals have African ancestry. Our objective was to determine the prevalence of G6PD deficiency in Dominican HIV-infected patients and to attempt to develop a cost-effective algorithm for identifying such individuals. To this end, histories, chart reviews, and G6PD testing were performed for 238 consecutive HIV-infected adult clinic patients. The overall prevalence of G6PD deficiency (8.8%) was similar in males (9.3%) and females (8.5%), and higher in Haitians (18%) than Dominicans (6.4%; P = 0.01). By logistic regression, three clinical variables predicted G6PD status: maternal country of birth (P = 0.01) and a history of hemolysis (P = 0.01) or severe anemia (P = 0.03). Using these criteria, an algorithm was developed, in which a patient subset was identified that would benefit most from G6PD screening, yielding a sensitivity of 94.7% and a specificity of 97.2%, increasing the pretest probability (8.8–15.1%), and halving the number of patients needing testing. This algorithm may provide a cost-effective strategy for improving care in resource-limited settings.

 

Evaluation of an HIV Adherence Counseling Program in La Romana, Dominican Republic. J Int Assoc Provid AIDS Care, 2014. 
Winter MC, Halpern M, Brozovich A, Neu N, et al. (2014). Evaluation of an HIV Adherence Counseling Program in La Romana, Dominican Republic. Journal of the International Association of Providers of AIDS Care. doi:https://doi.org/10.1177%2F2325957413514630.
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Research has demonstrated that adherence to antiretroviral therapy (ART) results in lower rates of morbidity and mortality associated with HIV infection, yet adherence remains a challenge in resource-limited settings like the Dominican Republic. Clínica de Familia La Romana addressed this problem with an education-based adherence program for adult patients new to ART, and this retrospective cohort study aimed to evaluate the impact of this intervention. Appointment adherence and biological markers were assessed in cases and controls through 12 months. A total of 101 participants were included, with 61 controls and 40 cases. The baseline CD4 count was 162 and 157 cells/mm³ in controls and cases, respectively. Cases showed a 15-fold increase in CD4 count compared with a 2.5-fold increase in controls. Cases were more likely to adhere to appointments with adherence rates of 86% versus 76% in controls. There was no difference between the rates of treatment abandonment, transfer of care, or death.

 

Factors Influencing Use of Family Planning Services among HIV-positive Women in the PMTCT Program at Clínica de Familia La Romana in the Dominican Republic. Sexuality Research and Social Policy, 2013. 10(3): p. 200-207. McKinney JR, Halpern M, Levison J, Callender G, Lerebours L, Fernandez-Esquer ME, et al. (2013). Factors Influencing Use of Family Planning Services among HIV-positive Women in the PMTCT Program at Clínica de Familia La Romana in the Dominican Republic. Sexuality Research and Social Policy. doi:10.1007/s13178-013-0115-8.
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Reducing unmet family planning need to zero is an integral part of UNAIDS’ Global Plan to virtually eliminate infant HIV infection by 2015. This study aims to understand the beliefs and attitudes that influence family planning use among HIV-positive women in the prevention of mother-to-child transmission (PMTCT) program at Clínica de Familia La Romana, Dominican Republic, and to determine which barriers to use are most important in this population and prioritize them as targets for intervention. Data were collected from one focus group and 21 single investigator-administered semistructured interviews with women in the PMTCT program at Clínica de Familia La Romana, Dominican Republic. The majority of women stated that their last pregnancy was undesired, although they were not using family planning at the time of the pregnancy. Knowledge about the methods, social influences (family, friends), and logistics were not significant barriers within this population. The two barriers that were most frequently reported as reasons for not using, or stopping use of, a family planning method were the attitudes and beliefs of the partner and menstrual changes ranging from irregular bleeding to amenorrhea. This study suggests two main categories of interventions to reduce unmet family planning need in this PMTCT population. First, further research is needed to probe family planning attitudes and beliefs among the partners of HIV-positive women. Only by exploring both partners’ beliefs and expectations can culturally sensitive interventions be developed to increase family planning acceptability among the partners, and thus potentially increase use among women. Second, specific counseling is needed to ask for and address concerns of the women. Importantly, women need to understand that menstrual change is normal with certain methods and does not indicate a decline in their health status. Involving partners in family planning education and improving women’s understanding of how methods work and side effects to expect may improve uptake of contraception in this population.

Progress towards Elimination of HIV Mother-to-Child Transmission in the Dominican Republic from 1999 to 2011. Infectious Diseases in Obstetrics and Gynecology, 2012.Lorenzo O, Beck-Sagué CM, Bautista-Soriano C, Halpern M, Roman-Poueriet J, Henderson N, Perez-Then E, Abreu-Perez R, Soto S, Martínez L, Rives-Gray S, Veras B, et al. (2012). Progress towards Elimination of HIV Mother-to-Child Transmission in the Dominican Republic from 1999 to 2011. Infectious Diseases in Obstetrics and Gynecology. doi:10.1155/2012/543916.
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In 1999, prevention of mother-to-child transmission (pMTCT) using antiretrovirals was introduced in the Dominican Republic (DR). Highly active antiretroviral therapy (HAART) was introduced for immunosuppressed persons in 2004 and for pMTCT in 2008. To assess progress towards MTCT elimination, data from requisitions for HIV nucleic acid amplification tests for diagnosis of HIV infection in perinatally exposed infants born in the DR from 1999 to 2011 were analyzed. The MTCT rate was 142/1,274 (11.1%) in 1999–2008 and 12/302 (4.0%) in 2009–2011 (), with a rate of 154/1,576 (9.8%) for both periods combined. This decline was associated with significant increases in the proportions of women who received prenatal HAART (from 12.3% to 67.9%) and infants who received exclusive formula feeding (from 76.3% to 86.1%) and declines in proportions of women who received no prenatal antiretrovirals (from 31.9% to 12.2%) or received only single-dose nevirapine (from 39.5% to 19.5%). In 2007, over 95% of DR pregnant women received prenatal care, HIV testing, and professionally attended delivery. However, only 58% of women in underserved sugarcane plantation communities (2007) and 76% in HIV sentinel surveillance hospitals (2003–2005) received their HIV test results. HIV-MTCT elimination is feasible but persistent lack of access to critical pMTCT measures must be addressed.

 

Costs and benefits of multidrug, multidose antiretroviral therapy for prevention of mother‐to‐child transmission of HIV in the Dominican Republic. International Journal of Gynecology & Obstetrics, 2012. 116(3): p. 219-222.Schmidt NC, Roman-Pouriet J, Fernandez AD, Beck-Sagué CM, Leonardo-Guerrero J, Nicholas SW, et al. (2012). Costs and benefits of multidrug, multidose antiretroviral therapy for prevention of mother‐to‐child transmission of HIV in the Dominican Republic. International Journal of Gynecology & Obstetrics. doi:https://doi.org/10.1016/j.ijgo.2011.10.028.
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Objective
To investigate whether costs of multidose antiretroviral regimens (MD-ARVs), including highly active antiretroviral therapy (HAART), for prevention of mother-to-child transmission (PMTCT) of HIV might be offset by savings gained from treating fewer perinatally acquired infections.
Methods
Rates of MTCT reported in the Dominican Republic among mother-infant pairs treated with single-dose nevirapine (SD-NVP; n = 39) and MD-ARVs (n = 91) for PMTCT were compared. Annual births to women infected with HIV were estimated from seroprevalence studies. Antiretroviral costs for both PMTCT and for HAART during the first 2 years of life (in cases of perinatal infection) were based on 2008 low-income country price estimates.
Results
Rates of MTCT were 3.3% and 15.4% for the MD-ARV and SD-NVP groups, respectively (P = 0.02). Assuming that 5775 of 231 000 annual births (2.5%) were to HIV-positive women, it was estimated that 191 perinatally acquired infections would occur using MD-ARVs and 889 using SD-NVP. High costs of maternal MD-ARVs (HAART, US$914,760 versus SD-NVP, $1155) would be offset by lower 2-year HAART costs ($250,344 versus $1,168,272 for infants in the SD-NVP group) for the lower number of children with prenatally acquired infection (191 versus 889) associated with the use of MD-ARVs for PMTCT (net national saving $3168).
Conclusion
Despite the high costs, use of MD-ARVs, such as HAART, for PMTCT offer societal savings because fewer perinatally acquired infections are anticipated to require treatment.

  

HIV infection and prevention of mother-to-child transmission in childbearing women: La Romana, Dominican Republic, 2002-2006. Revista Panamericana de Salud Pública, 2009. 26(4): p. 315-323. Román-Poueriet J, Fernandez AD, Beck-Sagué CM, Szabó RG, Mercedes F, Duke W, Martinez A, Nicholas S, et al. (2009). HIV infection and prevention of mother-to-child transmission in childbearing women: La Romana, Dominican Republic, 2002-2006. Revista Panamericana de Salud Pública, 26(4), 315-323. Enlace: https://iris.paho.org/handle/10665.2/9764
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OBJECTIVES: To strengthen prevention of mother-to-child HIV transmission (pMTCT) program implementation in La Romana (LR) province, by estimating HIV prevalence and identifying characteristics associated with HIV infection in parturients.
METHODS: Umbilical cord blood samples were collected at seven obstetrical sites where over 95 percent of LR’s deliveries occur during four phases (pilot, expanded pilot, full study, and pMTCT program monitoring) from 2 August 2002 to 30 September 2006. Results were linked to data abstracted from delivery records.
RESULTS: HIV seroprevalence was 2.6 percent (263/10 040 overall; 114/4 452, full-study phase (95 percent confidence interval = 2.1 percent-3.1 percent)). Most HIV-infected parturients were Dominican (68.9 percent) and urban (64.0 percent). However, prevalence was higher among Haitians (3.7 percent) than Dominicans (2.3 percent (p 0.001)), especially those aged 21-25 years (5.2 percent vs. 2.3 percent (p 0.001)), and among rural, batey, and peri-urban (vs. urban) parturients (3.4 percent vs. 2.3 percent, (p = 0.003)). HIV prevalence was associated with commercial sex work (reported by only 0.4 percent), and prior pregnancy. In logistic regression analysis, commercial sex work, Haitian nationality, and prior pregnancy were independently associated with HIV infection. Caesarean deliveries were more frequent, and rose in the last years of the study, among HIV seropositives; however, most deliveries among seropositives (57.5 percent) were vaginal.
CONCLUSIONS: HIV prevalence among LR parturients was higher than the estimated prevalence in the Dominican Republic (0.8 percent-1.0 percent) and, in contrast to past studies, predominantly affected urban Dominicans. HIV prevalence among LR Haitian parturients was higher than among Dominican counterparts and prenatal clinic attendees in Haiti (who had a rate of 3.1 percent). Consistently implemented, targeted pMTCT interventions are needed.(AU)

Depression, substance abuse and antiretroviral non-adherence among adults with HIV in care at the Clínica de Familia in La Romana, Dominican Republic. The Journal of Global Health, 2016.  Fay, C., En Sus Palabras. 2017, Raleigh, North Carolina: Lulu: Online Self Publishing.
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Background: People living with HIV/AIDS (PLWHA) are more likely to experience a psychiatric disorder in their lifetime when compared to the general population. is can greatly a ect adherence to the centerpiece of HIV treatment, antiretroviral therapy (ART), and the course that the illness can take. Depression and substance use are the two most common psychiatric disorders in PLWHA. is cross-sectional study examined rates of depression, substance use, adherence to ART and HIV biomarkers on a sample of HIV-positive patients serviced by a general medical clinic, Clinica de Familia La Romana (CFLR) in the Dominican Republic (DR).
Methods: A cross-sectional, questionnaire-based study was conducted in a clinic with a special program for PLWHA in La Romana, DR, over four weeks in Fall 2015. The questionnaire included demographic information and scales for assessing adherence, depression and substance use: the Morisky Medication Adherence Scale (MMAS- 4), Patient Health Questionnaire-2 and -9 (PHQ-2 and -9) and CAGE-AID, respectively. Open-ended, exploratory questions on the experience of living with HIV/AIDS were posed to every fourth or fifth participant. Additionally, two important biomarkers for measuring HIV progression and severity, CD4 cell counts and HIV-RNA viral loads (most recent value within the last six months), were extracted from the medical chart. Data analysis was carried out using the Statistical Package of Social Sciences (SPSS) software.
Results: 89 participants were involved in the study. The mean age was 40.0 years old (SD 10.9) with an almost equal distribution of women and men; two participants self-identified as transgender. 80 participants (89.9%) scored positively on the PHQ-2, which means they met at least one of the two major criteria for depression: loss of interest in activities and depressed mood. The mean PHQ-9 for those who scored positive on the PHQ-2 was 10.6 (SD 4.7; threshold of 10 for major depression). Those with good ART adherence had a mean PHQ-9 of 9.4 (SD 5.0) while the mean for those with poor ART adherence was 11.2 (SD: 4.4). 27 participants (30.3%) fit criterion for severe alcohol or drug use (> 2). Participants endorsing drug use in their lifetime used marijuana (n=8) and cocaine (n=5). Based on the MMAS-4, 41.3% of those on ART had good adherence (score=0), whereas 58.7% had poor adherence (score > 1). Dominican origin and the completion of at least primary school were associated with good adherence (p-value = 0.04 and p-value = 0.03, respectively). Being female was associated with increased PHQ-9 scores (p-value = 0.01) as well as undetectable viral loads (p-value = 0.03); being male was associated with increased alcohol or drug use (p-value < 0.01). In the exploratory questions, most individuals reported acquiring HIV from a spouse or known romantic partner and reported being diagnosed after personally falling ill or witnessing their partner do so. Major concerns were inability to nd work, loneliness and fear of discrimination.
Conclusions: Depressive symptoms and substance use were common factors that impacted ART adherence in a sample of PLWHA treated at Clinica de Familia La Romana in the Dominican Republic. Using validated measures to implement screening for depression and substance use could help identify those requiring diagnosis and appropriate care within the constraints of this low-resource clinic.

 

Substance Use and Condom Use Among the HIV population at Clínica de Familia La Romana, Dominican Republic. The Journal of Global Health, 2016.
Isabel del Canto, Mina Halpern, Silvia Cunto-Amesty, Leo Lerebours Nadal, Mireya Cruz, Alexander Bowman.
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The primary purpose of this cross-sectional investigation was to quantify illicit substance use among the HIV positive population at Clínica de Familia La Romana in the Dominican Republic. The secondary goal was to identify whether there exists a relationship between alcohol consumption and condom use. Of the 97 participants who were interviewed in the study, 49% self-reported alcohol or tobacco use in the last three months. Based on the calculated ASSIST risk score, 20% of participants were classified as “moderate” or “high risk,” requiring an intervention. Additionally, 51% of the sample reported having sexual intercourse in the last 30 days. Out of the 49 participants who were sexually active, 67% reported using a condom during their last sexual experience, 31% reported not using a condom and the remaining 2% declined to respond. Contrary to prior research, no association was found between alcohol consumption and unprotected sex at Clínica de Familia La Romana, possibly due to the low percentage of patients that report consuming alcohol frequently

 

HIV infection and prevention of mother-to-child transmission in childbearing women: La Romana, Dominican Republic, 2002-2006. Revista Panamericana de Salud Pública, 2009. 26(4): p. 315-323.
José Román-Poueriet, Aracelis Fernandez, Consuelo Beck-Sagué, René García Szabó, Fermin Mercedes, William Duke, Anny Martinez, Stephen Nicholas.
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OBJECTIVES: To strengthen prevention of mother-to-child HIV transmission (pMTCT) program implementation in La Romana (LR) province, by estimating HIV prevalence and identifying characteristics associated with HIV infection in parturients.
METHODS: Umbilical cord blood samples were collected at seven obstetrical sites where over 95 percent of LR’s deliveries occur during four phases (pilot, expanded pilot, full study, and pMTCT program monitoring) from 2 August 2002 to 30 September 2006. Results were linked to data abstracted from delivery records.
RESULTS: HIV seroprevalence was 2.6 percent (263/10 040 overall; 114/4 452, full-study phase (95 percent confidence interval = 2.1 percent-3.1 percent)). Most HIV-infected parturients were Dominican (68.9 percent) and urban (64.0 percent). However, prevalence was higher among Haitians (3.7 percent) than Dominicans (2.3 percent (p 0.001)), especially those aged 21-25 years (5.2 percent vs. 2.3 percent (p 0.001)), and among rural, batey, and peri-urban (vs. urban) parturients (3.4 percent vs. 2.3 percent, (p = 0.003)). HIV prevalence was associated with commercial sex work (reported by only 0.4 percent), and prior pregnancy. In logistic regression analysis, commercial sex work, Haitian nationality, and prior pregnancy were independently associated with HIV infection. Caesarean deliveries were more frequent, and rose in the last years of the study, among HIV seropositives; however, most deliveries among seropositives (57.5 percent) were vaginal.
CONCLUSIONS: HIV prevalence among LR parturients was higher than the estimated prevalence in the Dominican Republic (0.8 percent-1.0 percent) and, in contrast to past studies, predominantly affected urban Dominicans. HIV prevalence among LR Haitian parturients was higher than among Dominican counterparts and prenatal clinic attendees in Haiti (who had a rate of 3.1 percent). Consistently implemented, targeted pMTCT interventions are needed.(AU)

Depression, substance abuse and antiretroviral non-adherence among adults with HIV in care at the Clínica de Familia in La Romana, Dominican Republic. The Journal of Global Health, 2016.
Maya Koenig-Dzialowski, Milton Wainberg, Mina Halpern, Andrea Norcini-Pala, Rosanna Matic, Wendy Galvez-Castro.
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Background: People living with HIV/AIDS (PLWHA) are more likely to experience a psychiatric disorder in their lifetime when compared to the general population. is can greatly a ect adherence to the centerpiece of HIV treatment, antiretroviral therapy (ART), and the course that the illness can take. Depression and substance use are the two most common psychiatric disorders in PLWHA. is cross-sectional study examined rates of depression, substance use, adherence to ART and HIV biomarkers on a sample of HIV-positive patients serviced by a general medical clinic, Clinica de Familia La Romana (CFLR) in the Dominican Republic (DR).
Methods: A cross-sectional, questionnaire-based study was conducted in a clinic with a special program for PLWHA in La Romana, DR, over four weeks in Fall 2015. The questionnaire included demographic information and scales for assessing adherence, depression and substance use: the Morisky Medication Adherence Scale (MMAS- 4), Patient Health Questionnaire-2 and -9 (PHQ-2 and -9) and CAGE-AID, respectively. Open-ended, exploratory questions on the experience of living with HIV/AIDS were posed to every fourth or fifth participant. Additionally, two important biomarkers for measuring HIV progression and severity, CD4 cell counts and HIV-RNA viral loads (most recent value within the last six months), were extracted from the medical chart. Data analysis was carried out using the Statistical Package of Social Sciences (SPSS) software.
Results: 89 participants were involved in the study. The mean age was 40.0 years old (SD 10.9) with an almost equal distribution of women and men; two participants self-identified as transgender. 80 participants (89.9%) scored positively on the PHQ-2, which means they met at least one of the two major criteria for depression: loss of interest in activities and depressed mood. The mean PHQ-9 for those who scored positive on the PHQ-2 was 10.6 (SD 4.7; threshold of 10 for major depression). Those with good ART adherence had a mean PHQ-9 of 9.4 (SD 5.0) while the mean for those with poor ART adherence was 11.2 (SD: 4.4). 27 participants (30.3%) fit criterion for severe alcohol or drug use (> 2). Participants endorsing drug use in their lifetime used marijuana (n=8) and cocaine (n=5). Based on the MMAS-4, 41.3% of those on ART had good adherence (score=0), whereas 58.7% had poor adherence (score > 1). Dominican origin and the completion of at least primary school were associated with good adherence (p-value = 0.04 and p-value = 0.03, respectively). Being female was associated with increased PHQ-9 scores (p-value = 0.01) as well as undetectable viral loads (p-value = 0.03); being male was associated with increased alcohol or drug use (p-value < 0.01). In the exploratory questions, most individuals reported acquiring HIV from a spouse or known romantic partner and reported being diagnosed after personally falling ill or witnessing their partner do so. Major concerns were inability to nd work, loneliness and fear of discrimination.
Conclusions: Depressive symptoms and substance use were common factors that impacted ART adherence in a sample of PLWHA treated at Clinica de Familia La Romana in the Dominican Republic. Using validated measures to implement screening for depression and substance use could help identify those requiring diagnosis and appropriate care within the constraints of this low-resource clinic.

 

Substance Use and Condom Use Among the HIV population at Clínica de Familia La Romana, Dominican Republic. The Journal of Global Health, 2016. Isabel del Canto I, Halpern M, Cunto-Amesty S, Lerebours Nadal L, Cruz M, Bowman A, et al. (2016). Substance Use and Condom Use Among the HIV population at Clínica de Familia La Romana, Dominican Republic. The Journal of Global Health. doi:https://doi.org/10.7916/thejgh.v5i1.5295.
Ver en línea Abstracto

The primary purpose of this cross-sectional investigation was to quantify illicit substance use among the HIV positive population at Clínica de Familia La Romana in the Dominican Republic. The secondary goal was to identify whether there exists a relationship between alcohol consumption and condom use. Of the 97 participants who were interviewed in the study, 49% self-reported alcohol or tobacco use in the last three months. Based on the calculated ASSIST risk score, 20% of participants were classified as “moderate” or “high risk,” requiring an intervention. Additionally, 51% of the sample reported having sexual intercourse in the last 30 days. Out of the 49 participants who were sexually active, 67% reported using a condom during their last sexual experience, 31% reported not using a condom and the remaining 2% declined to respond. Contrary to prior research, no association was found between alcohol consumption and unprotected sex at Clínica de Familia La Romana, possibly due to the low percentage of patients that report consuming alcohol frequently