Testing the Efficacy of an HIV Prevention Intervention Among Latina Immigrants Living in Farmworker Communities in South Florida

Abstract

Background:

Latina immigrants living in farmworker communities are a population in need of HIV risk reduction interventions due to their high risk for HIV and their limited access to health care and prevention services.

Methods:

The present study is the first to evaluate the efficacy of SEPA intervention on a cohort of 234 pre-established Latina immigrants living in farmworker communities in South Florida. SEPA is a CDC evidenced-based and Latinx culturally tailored HIV risk reduction intervention. Data were collected through structured interviews at baseline and 6-months post intervention and were analyzed using generalized linear mixed modeling.

Results:

Results showed that SEPA was effective on increasing condom use during vaginal and anal sex with male partners, self-efficacy for condom use, intentions to negotiate safe sex and HIV-related knowledge from baseline to 6-month post intervention.

Discussion:

These findings contribute to the evidence supporting the efficacy of SEPA by confirming previous results and demonstrating the efficacy of this intervention for Latinas of diverse backgrounds.

Background

Latinas are disproportionately affected by the human immunodeficiency virus (HIV) in the United States (U.S.). In 2016, the HIV diagnosis rate among Latinas was more than three times that of Whites [1]. An estimate of 88% of HIV diagnoses among Latinas are acquired through heterosexual contact [2]. This is concerning because Latinas tend to have sexual partners from the same race/ethnicity and Latino men have one of the highest rates of HIV [2, 3]. Thus, preventing unprotected sex with a male partner is critical to prevent HIV transmission in this population.

A subgroup of Latinas that may be at a particularly higher risk for HIV infection are Latina immigrants in farmworker communities. As Latina immigrants become more exposed to U.S. norms surrounding sexuality, they are more likely to engage in risky sexual behaviors which increase their likelihood of acquiring HIV [4,5] In fact, Latina immigrants living with HIV in the U.S. become infected after arriving to the U.S. [6,7]. Moreover, HIV rates in farmworker communities are high, ranging from 3.5 to 13% [8]. Two studies conducted in 1987 and 1992 by the CDC found that rates of HIV infection in migrant farmworker communities in Florida and North Carolina were 10 times the national average [9, 10].

Overall, Latina immigrants are at an increased risk for HIV due to low HIV/AIDS knowledge, low HIV risk perception, higher HIV-related stigma, and limited access to health care and HIV prevention services [6, 11-13]. In addition, traditional gender roles such as machismo and marianismo further contribute to the high risk for HIV in this population [14-15]. These gender roles encourage women to be sexually submissive and obedient towards male partners which make negotiating safer sex (i.e. condom use) difficult and increase their risk for HIV [14-16]. Latinas living in farmworker communities may be even more vulnerable to HIV due to the social circumstances they experienced, including immigration stress, language barriers, high rates of poverty and unemployment, social marginalization and isolation, drug and alcohol abuse, and mental health issues (i.e. depression) [16-18]. Also, they may be reluctant to accessing HIV prevention services such as HIV testing, due to fear of deportation and/or risking the possibility of receiving permanent residence or citizenship [19, 20].

Therefore, providing culturally specific HIV prevention services to Latina immigrants in farmworker communities is critical to address the unique context of HIV prevention in this population and reduce their risk for HIV during early immigration years. This is particularly important for Latinas living in areas with high concentration of Latino immigrants and high rates of HIV such as Miami-Dade County, Florida. Miami-Dade County has one of the highest rates of new HIV diagnoses in the U.S. and 68.6% of the population are Latinos (of these 52.9% are foreign born) [21, 22].

Latina immigrants in farmworker communities are an understudied and vulnerable population. Studies examining HIV risk factors in this population are scarce, and even less is known about how to effectively prevent HIV among Latina immigrant farmworkers. Therefore, the aim of the present study is to examine the efficacy of a culturally tailored HIV risk reduction intervention for increasing cognitive (HIV knowledge, self-efficacy, intentions for safe sex negotiation) and behavioral (condom use) HIV prevention strategies among Latina immigrants in farmworker communities in Miami-Dade County, Florida. We hypothesized that 6 months after receiving the HIV risk reduction intervention, women will have increased HIV knowledge, self-efficacy, intentions for safe sex negotiation and condom use with male partners.

Methods

The present study is the full-scale analysis (n=234) of the preliminary findings published during the course of the study [16] to evaluate the efficacy of the Salud/Health, Educación/Education, Prevención/Prevention, y Autocuidado/Selfcare (SEPA) intervention on the same cohort of pre-established Latina immigrants in a farmworker community in Miami-Dade County. Data for this study was collected between 2014 and 2016 through an ongoing community based participatory research (CBPR) project. The CBPR project aimed to spur community actions for preventing HIV/AIDS among Latinas living in farmworkers communities in South Florida, improve knowledge and access to HIV/AIDS prevention services, and increase community capacity (through education and communication skills) to address HIV issues at the local level [16].

Data Collection

Study participants were recruited through flyers distributed at neighborhood settings (i.e. health fairs, migrant camps), street outreach activities and word of mouth. Interviews were conducted by trained bilingual female interviewers in a private office in a community agency using computer assisted personal interviewing (CAPI) software. All interviews lasted approximately 1.5 hours. Participants received $50 for each session of the intervention completed, and a total of $110 for completing both the baseline and post-intervention assessments. Several strategies were implemented for retention in the study including home visits, telephone calls and letters. All participants completed an informed consent. The study protocol was reviewed and approved by the Institutional Review Board of a large public university in South Florida.

Further information on the design and procedures are included in a previous publication [16].

Participants

The eligibility criteria for the study included 1) being sexually active, 2) self-identifying as Latina, 3) being between the ages of 18 to 50, 4) residing in the farmworker community in Miami-Dade County 5) having lived in the U.S. between 2 to 10 years, and 6) not ever having participated or being participating in a HIV risk reduction intervention or SEPA.

Intervention and Theoretical Framework

The SEPA intervention is a CDC (Centers for Disease Control and Prevention) evidenced-based, culturally tailored HIV risk reduction intervention, designed for heterosexual sexually active Latinas in the U.S. and is based on social cognitive theory [15, 16]. This theory posits that self-efficacy (confidence in one’s capability) is a key factor in enabling behavioral action and change. Individuals go through a cognitive process to evaluate their outcome and efficacy expectations, which in turn determines whether or not a person will engage in safer sex practices [16, 23]. SEPA focuses on building knowledge, self-efficacy, and communication skills through capacity building exercises (e.g. role playing, skills demonstration, group discussions) to improve condom use, safe sex negotiation, and partner communication among Latinas. The intervention was revised for use in this population and included three sessions of 2.5-hours (in Spanish) led by a trained facilitator over a period of three weeks to 22 small groups of 8 to 10 Latinas.

Measures

Sociodemographic.

The variables age, time in the U.S., and total income for the past 6 months were continuous. Marital status was coded as 0=married, 1=free union or committed boyfriend and 2=single. Employment status as 1=employed and 0=not employed. Documentation status as 1= authorized and 0=unauthorized and country of origin as 0= Mexico, 1=Central America and 2=Caribbean or South America. Education level was measured as 1 =less than high school to 6=graduate/ professional studies, and then recoded as 1=less than high school, 2=high school diploma and 3=some university training or higher due to few participants reporting college or post graduate education.

Condom Use.

Four items examining frequency of vaginal and anal sex with primary sex partners or someone other than a primary sex partner in the past six months (e.g. “How often did you have vaginal sex with your primary sex partner?”), and four additional items examining frequency of condom use for the vaginal and anal sex with primary sex partner or someone other than the primary sex partner (e.g. “How often was a condom used with your primary sex partner?”) were used to measure condom use in the past six months. Differences in frequencies of vaginal/anal sex and condom use were calculated. A dichotomous variable for condom use was then created that 1=always used a condom in past six months, and 0=did not always use a condom in past six months. Condom use for oral sex was not included due to rarely being reported.

Condom Use Self-Efficacy.

Self-efficacy for condom use, defined as a woman’s confidence in her ability to use condoms and practice HIV prevention behaviors, was measured using a seven-item Likert-type scale [15, 24-25]. A sample item included “If I decide to use condoms, I can have (all) my partner(s) use them”. Responses to each item were rated from 1 (strongly disagree) to 4 (strongly agree). Summed total scores ranged from 7 to 28. Higher scores indicated higher condom use self-efficacy. The Cronbach’s alpha for this sample was 0.66. Previous studies have reported alphas for the scale of 0.68 [26].

Intentions to Negotiate Safe Sex.

A four-item Likert-type scale was used to assess intentions to negotiate safe sex (adapted from [27]), with responses 1=not very sure, 2=somewhat sure, and 3=very sure. A sample item for this scale included “Say no when your partner wants to have sex and you don’t”. Summed scores ranged from 0 to 12 and higher scores indicated stronger intentions to negotiate safer sex. The Cronbach’s alpha for the sample was 0.75.

HIV-related Knowledge.

The 12-item scale on HIV knowledge developed by Heckman et al. (1995) [28] was used to assess knowledge about HIV transmission, prevention and consequences. The scale consisted of 12 true or false items. A sample item included “Latex is the best material to protect against HIV”. Total summed scores ranged from 0 to 12 and a higher score indicated a higher level of HIV-related knowledge. The Cronbach’s alpha for the sample was 0.80.

Statistical Analysis

Descriptive statistics for participants’ characteristics were generated. Univariate normality of continuous variables was assessed using Kolmogorov-Smirnov test. Due to non-normal distribution, the sample median and interquartile range were used to describe the continuous variables. Counts and percentages were used to describe categorical variables. Participants’ characteristics pre- and post-intervention were compared using Sign test for continuous variables, McNemar’s test for condom use and employment status, and marginal homogeneity (Stuart-Maxwell) test for education and marital status.

Generalized linear mixed modeling was used to test the effect of the intervention on condom use, HIV-related knowledge, condom use self-efficacy, and intentions to negotiate safe sex, controlling for sociodemographic variables. Specifically, logistic regression with random intercept was applied to predict condom use, while mixed effects beta regression was used for HIV-related knowledge, condom use self-efficacy, and intentions to negotiate safe sex. To fit the mixed effects beta regression models, each outcome was converted from integer scores to percentages out of the maximum total score of the scale. For example, if a participant’s score of HIV-related knowledge was 11, then the percentage would be 11/12=92%, where 12 was the maximum total score of the scale. SAS Enterprise Guide 7.1 was used for all data analyses (SAS Institute, Cary, NC, USA). A statistical significance level of 0.05 was used.

Results

Sociodemographic Characteristics

The current analysis included 175 (74.8%) participants who were not missing any baseline or 6-month follow up assessment data. The sample median age was 33 years at baseline. Only 33.1% of the women were authorized immigrants by the six months follow up. The majority of women immigrated from Mexico (59.7%) and other countries of Central America (28.8%). The median time living in the U.S. was 8 years (96 months). Approximately half of the participants were employed (53.4%, 53.7%), had less than high school diploma (54.3%, 55.2%), and were married (46.2%, 48.6%) at both baseline and 6-months follow up. The median total income for the past 6 months was 10.8 (in thousands of U.S. dollars) at baseline and 11.3 at follow up respectively. No significant changes were found in socio-demographic characteristics at baseline or pre- or post-intervention, including total income during the last six months, employment status, educational level and marital status (Table 1, p>0.05).

Table 1.

Descriptive statistics of participant characteristics pre and post SEPA intervention

Variable	Pre		Post		pa
	N	Median (IQR)	N	Median (IQR)
Age in years	234	33.0 (11.0)
Time lived in the U.S. (in months)	234	96.0 (24.0)
Total income for the past 6 months (in thousands of U.S. dollars)	231	10.8 (5.3)	174	11.3 (6.1)	0.244
HIV knowledge scale (total score: 12 items)	234	7.0 (3.0)	175	10.0 (2.0)	<0.001
Condom use self-efficacy scale (total score: 7 items)	233	22.0 (6.0)	175	23.0 (2.0)	0.049
Intentions to negotiate safe sex (total score: 4 items)	233	12.0 (3.0)	175	12.0 (2.0)	<0.001
Variable	N	%	N	%	pa
Condom use					<0.001
Always	46	19.7	58	33.1
Not always	188	80.3	117	66.9
Documentation status
Authorized			58	33.1
Unauthorized			117	66.9
Country of origin
Mexico	139	59.7
Central America	67	28.8
Caribbean or South America	27	11.6
Employment status					0.274
Employed	125	53.4	94	53.7
Unemployed	109	46.6	81	46.3
Educational level					0.223
Less than high school	127	54.3	96	55.2
High school	66	28.2	41	23.6
Some university training or higher	41	17.5	37	21.3
Marital status					0.574
Married	108	46.2	85	48.6
Free union or committed boyfriend	77	32.9	60	34.3
Single	49	20.9	30	17.1

Note.

^aP-values are from Sign test for continuous variables; McNemar's test for condom use and employment status; marginal homogeneity test (Stuart-Maxwell) for education and marital status. P-values above are from individuals who participated at both time points. Participants lost to follow up were excluded from the tests.

Condom Use

The percentage of condom use increased from 19.7% to 33.1% after the intervention (p<0.001). The odds of condom use after the intervention were three times of that at baseline (aOR=3.21, p=0.001), adjusting for sociodemographic variables (Table 2). In addition, higher total income for the past six months was significantly associated with lower odds of condom use, that an increase of one thousand dollars in total income reduced the odds of condom use by 10% (aOR=0.90, p=0.024). Compared to those women that were married, women who were single were more likely to always use a condom for sex in the past three months (aOR=3.62, p=0.029). Women who had some university level or higher had greater adjusted odds of condom use than those that had educational level of less than high school (aOR=5.06, p=0.024).

Table 2.

Results from Generalized Linear Mixed Models using SEPA pre and post data

Predictor	Condom Use	HIV Related Knowledge	Condom Use Self-Efficacy	Intentions to Negotiate Safe Sex
	aOR (95% CI)	aOR (95% CI)	aOR (95% CI)	aOR (95% CI)
Post vs. Pre	3.21 [1.58, 6.53]**	3.86 [3.25, 4.59]***	1.19 [1.03, 1.38]*	1.91 [1.48, 2.46]***
Age in years at baseline	1.01 [0.95, 1.08]	0.99 [0.97, 1.01]	1.00 [0.98, 1.01]	0.99 [0.96, 1.02]
Employment status:
Employed vs. Unemployed	1.45 [0.61, 3.43]	0.77 [0.61, 0.98]*	0.95 [0.77, 1.15]	0.89 [0.61, 1.28]
Time lived in the U.S. (in months)	1.01 [0.99, 1.03]	1.00 [0.99, 1.01]	1.00 [0.99, 1.00]	0.99 [0.98, 1.00]
Total income for the past 6 months (in thousands of U.S. dollars)	0.90 [0.82, 0.99]*	1.01 [0.98, 1.03]	1.00 [0.98, 1.02]	1.00 [0.97, 1.04]
Documentation status:
Authorized vs. Unauthorized	1.03 [0.39, 2.75]	1.10 [0.81, 1.48]	1.34 [1.04, 1.72]*	1.56 [0.92, 2.65]
Country of origin:
Central America vs. Mexico	0.76 [0.26, 2.20]	0.63 [0.46, 0.85]**	1.01 [0.78, 1.30]	0.94 [0.55, 1.59]
Caribbean or South America vs. Mexico	0.29 [0.04, 1.99]	1.26 [0.7, 2.27]	1.24 [0.76, 2.04]	1.12 [0.4, 3.15]
Marital status:
In a relationship vs. Married	0.99 [0.36, 2.73]	1.04 [0.77, 1.39]	1.00 [0.78, 1.28]	0.84 [0.52, 1.37]
Single vs. Married	3.62 [1.14, 11.42]*	1.03 [0.73, 1.44]	0.95 [0.71, 1.26]	0.71 [0.42, 1.23]
Educational level:
High school vs. Less than high school	1.17 [0.40, 3.42]	1.46 [1.07, 1.99]*	1.04 [0.8, 1.34]	1.08 [0.64, 1.81]
Some university training or higher vs. Less than high school	5.06 [1.24, 20.65]*	1.87 [1.23, 2.83]**	1.11 [0.79, 1.55]	1.02 [0.51, 2.02]

Notes:

Logistic regression with random effects was used for condom use. Generalized linear mixed model with beta distribution and logit link was applied to the rest three outcomes.

^*p<0.05

^**p<0.01

^***p<0.001

HIV-related knowledge

There was a significant increase in HIV-related knowledge after the intervention (aOR=3.86, p<0.001), adjusting for sociodemographic variables (Table 2). Compared to unemployed women, those who were employed reported significantly lower HIV-related knowledge (aOR=0.77, p=0.033). Compared to women originally from Mexico, those originally from other countries of Central America had lower levels of HIV-related knowledge (aOR=0.63, p=0.003). Higher educational level was significantly associated with higher level of HIV-related knowledge (aORs=1.46 and 1.87, p<0.05). No significant associations were found between HIV-related knowledge and age, time in the U.S., income or marital status (p>0.05).

Condom use self-efficacy

Significant increases in condom use self-efficacy were found after the intervention (aOR=1.19, p=0.018), adjusting for sociodemographic variables (Table 2). In addition, women who were authorized immigrants reported higher condom use self-efficacy than those who were unauthorized immigrants (aOR=1.34, p=0.023). No significant associations were found between condom use self-efficacy and other sociodemographic variables (p>0.05).

Intentions to negotiate safe sex

Results suggest a significant increase in intentions to negotiate safe sex after the intervention (aOR=1.91, p<0.001), adjusting for sociodemographic variables (Table 2). However, no significant association were found between intentions to negotiate safe sex and other sociodemographic variables (p>0.05).

Discussion

Results indicate an increase in condom use during vaginal and anal sex with primary and other than primary sexual partners, condom use self-efficacy, intentions to negotiate safe sex and HIV-related knowledge from baseline to 6-month post intervention. These results support our hypotheses that SEPA intervention would increase cognitive and behavioral HIV strategies among Latina immigrant farmworkers and confirm previous study findings on the effect of SEPA intervention among other Latina groups [15]. While the effects of the intervention were relatively modest on condom use self-efficacy and intentions to negotiate safe sex, larger effects were observed on condom use and HIV-related knowledge. These findings are promising to improve HIV prevention among Latinas in farmworker communities and other Latinas in the U.S.

SEPA addresses HIV and substance use disparities experienced by Latinas taking into consideration cultural factors contributing to their risk. Most of the women in this study were married or in a committed relationship, indicating a relatively low risk for HIV from having multiple partners, however, many of them engaged in unprotected vaginal and anal sex with their male partners (who may be having sex with multiple partners). Since the majority of HIV infections among Latinas are caused by heterosexual intercourse, providing these women with knowledge, confidence and skills in sexual risk reduction is critical to protect themselves and prevent HIV transmission in this population [2].

Moreover, Latinas in this study were pre-established immigrants that have lived in the U.S. between 2 to 10 years, and as these women acculturate to the U.S. they may begin to engage in riskier behaviors and become infected with HIV. Therefore, culturally tailored HIV risk reduction interventions, such as SEPA, provide critical prevention strategies and resources to these women as they adapt to their new host country. This underscores the public heath significance of SEPA intervention to improve HIV prevention and reduce HIV transmission in a health disparity population (i.e. Latinos) in the U.S. supporting the National HIV/AIDS Strategy.

The present study has several limitations. First, participants in this study appeared to be at a relatively low risk for HIV as most of the participants were married or on a committed relationship. However, most participants reported having unprotected vaginal and/or anal sex with their primary and other than primary sexual partners, which is the primary mode of HIV transmission among Latinas in the U.S. Second, the lack of a comparison group may limit the direct attribution of changes in cognitive and behavioral HIV prevention strategies to the SEPA intervention alone. Third, since this intervention included multiple approaches to target beliefs and skills related to reducing sexual risk, it is not possible to determine the effects of each approach on increasing HIV prevention strategies. Future studies with this population, should determine which approach is more cost-effective to inform the modification/development of interventions. Fourth, data on women’ behaviors were self-reported, and thus susceptible to recall and social desirability biases. However, to reduce the potential of recall bias, interviewers asked participants for the past 3 months and then for the past 6 months of the behavioral events. Fifth, only short-term effects of the intervention were examined. At 6-months follow up, the effects are most likely to be at their peak. In fact, a previous study on the SEPA intervention reported an increase in HIV-related knowledge in the first 6-months post intervention, but no difference was found between the intervention and control groups after 1-year of follow up [15]. Sixth, most of the participants immigrated from Central America (88.8%) and had lived in the U.S. for less than 10 years, limiting the generalizability of these findings to other Latina groups. Seventh, the non-probability sampling may have introduced selection bias and lastly, some scales had low reliability, however, they were used in this study to compare findings with previous samples and SEPA efficacy studies.

Conclusion

The present findings provide strong evidence of the efficacy of the SEPA intervention to increase cognitive and behavioral HIV prevention strategies among Latina farmworkers, a group experiencing vulnerable circumstances that put them at a high risk for HIV. Future research is warranted to measure specific stressors in farmworker communities (e.g. social isolation, seasonal migration patterns, immediate survival problems (e.g. substandard housing and limited employment, limited health care access and availability, etc.) to tailor HIV prevention and health care services to the needs of this population. Also, more research on the effectiveness and dissemination of SEPA should be conducted to successfully adapt and scale up this intervention to Latina farmworkers. Results from the present study suggest the effectiveness and importance of community-based prevention programs that reach farmworker communities across the United States. Continued efforts that target barriers to HIV/AIDS prevention services, empower these communities to address HIV issues, and respond to local HIV epidemics are warranted.