Healthy Love is a highly interactive intervention designed to provide a safe environment in which women can learn about modes of HIV transmission and effective strategies for reducing risks for contracting or transmitting HIV and other STDs. It provides opportunities for participants to develop or enhance skills for assessing the risks of different sexual acts and for using safer sex techniques and to develop awareness of personal, community, and social attitudes, beliefs, and norms that can influence women's relationships, sexual behaviors, and risk-related decision making.
Healthy Love seeks to increase women's use of condoms during vaginal sex with male partners; encourage sexual abstinence, HIV testing, and receipt of test results; and reduce the number of women's sex partners and unprotected vaginal and anal sex with male partners. Healthy Love also aims to improve HIV/STD knowledge, self-efficacy for using condoms, intentions to use condoms, and condom-related attitudes.
The intervention is based on principles of self-help developed by the National Black Women's Health Project21 and incorporates elements of the Health Belief and Trans-Theoretical Models and Social Cognitive Theory.22-24 Healthy Love is delivered as a single session containing three modules: Setting the Tone, The Facts, and Safer Sex. Overall, the intervention includes an opening, 11 content-focused components, and a closing. Three of the content-focused components provide basic information about HIV/AIDS and STDs (HIV/AIDS Facts, STD Facts, and The Look of HIV). The remaining eight components are activities in which participants interact with the facilitator and each other on such topics as rating their personal risks for contracting HIV and other STDs, practicing correct use of male and female condoms, role-playing negotiations of condom use with male partners, and demonstrating their increased knowledge about HIV infection risks and protective actions (Table). The intervention lasts 3-4 hours and is typically delivered to groups of four to 15 women.
The following components of Healthy Love illustrate how the intervention addresses the shared cultural aspects of black women's experiences that can affect their vulnerability to HIV infection. The synonym activity demonstrates how words, when used to describe sexual acts and sexual organs, can be demeaning of sex and reinforce women's feelings of having limited power and worth because they are women or can contribute to their empowerment and appreciation of their rights relative to male partners. The risk-identification exercise makes the potentially abstract notion of HIV risk more concrete by teaching black women how to assess their own risks on the basis of their past or current sexual behaviors and through group discussions of high-, low-, or no-risk behaviors. The intervention also provides information about the impact of HIV on black women in a way that helps participants situate known risk factors in their lives and communities while maintaining an affirming, black woman-centered, sex-positive focus on ways to avoid or eliminate some of those risks.
Women trained as facilitators to deliver Healthy Love are required to have previous experience as a facilitator and to know about HIV/STD transmission and prevention, the disproportionate impact of HIV on black women, safer sex practices, and HIV testing methods. Healthy Love facilitators are trained during two consecutive day-long training sessions that are designed to increase their knowledge of Healthy Love, show them how to prepare for and implement the intervention, and give them opportunities to review and practice group facilitation skills. Program managers from service-provider organizations implementing Healthy Love supervise the facilitators to ensure fidelity of their intervention delivery to the intervention manual.
SisterLove evaluated the efficacy of Healthy Love in Atlanta during March 2006 - June 2007 using a group-randomized controlled trial design.11 Women who were eligible to participate in the evaluation were those who self-identified as black (i.e., African American, African, or Caribbean), were aged ≥18 years, were not pregnant or planning to become pregnant during the next 6 months, and were English speakers. Ineligible women were those who had participated in a group-level HIV prevention intervention during the preceding 6 months or whose religious beliefs prohibited the use of male or female condoms.
Information about the evaluation was disseminated through diverse print and electronic media, mailings to local AIDS-service organizations, county health departments, medical clinics, and community centers. Outreach was used to recruit groups of women affiliated with faith-based organizations and CBOs serving African immigrants and at college health fairs, community events, and SisterLove-sponsored activities. Persons from such groups as friendship circles, church groups, college classes, and dormitories who were interested in participating in the evaluation of the Healthy Love intervention contacted SisterLove. Evaluation staff broadly determined whether groups met the eligibility criteria, matched them by type of group (i.e., friendship circles were matched with friendship circles and church groups were matched with church groups), randomly assigned groups by coin toss to receive Healthy Love or the comparison workshop, and arranged a date and preferred workshop location. Immediately before each workshop, women were individually screened to ensure they met the study inclusion criteria.
Thirty groups totaling 313 women were enrolled and randomized to receive the Healthy Love workshop (15 groups totaling 161 women) or the comparison HIV 101 workshop (15 groups totaling 152 women). The comparison workshop used a didactic presentation format to provide the same HIV/STD-related information.11 The groups of women in the evaluation were friendship circles (16 groups), college classes or dormitories (six groups), residential housing units (two groups), churches (two groups), social support groups (two groups), and groups of African immigrants (two groups). Each Healthy Love and comparison workshop was delivered by a trained black female facilitator. Details on the methods used to recruit and enroll groups of women into the trial, measure behavioral and psychosocial outcomes, and sociodemographic characteristics of study participants are reported elsewhere.11
Analysis of the intervention outcomes used an intent-to-treat approach based on the initial random assignment of participants' groups to Healthy Love or the comparison workshop and regardless of whether participants completed their respective workshops. All but one of the 161 women assigned to receive Healthy Love completed the intervention workshops; all of the 152 assigned to the comparison condition completed their workshops. Generalized estimating equation models were used to assess intervention efficacy, and all statistical analyses controlled for clustering that could result from the group-level randomization process. The study was approved by the institutional review boards of the AIDS Research Consortium of Atlanta and CDC and was registered on www.clinicaltrials.gov.
Healthy Love participants reported significantly higher rates of condom use during vaginal sex with any male partner (adjusted odds ratio [AOR] = 2.40, 95% confidence interval [CI] = 1.28-4.50) and with a primary male partner (AOR = 2.87, CI = 1.18-6.95) during the past 3 months than did comparison participants at the 3-month follow-up assessment. However, intervention effects on these condom-use outcomes were not sustained at the 6-month follow-up. Healthy Love participants reported significantly higher rates of condom use than did comparison participants at last vaginal, anal, or oral sex with any male partner at both the 3-month (cluster-adjusted χ2 = 6.66; p = 0.01) and 6-month follow-up assessments (cluster-adjusted χ2 = 4.62; p = 0.03). At the 6-month follow-up, Healthy Love participants reported significantly higher rates of HIV testing and receipt of test results (AOR = 2.30, CI = 1.10-4.81). There was no significant intervention effect on sexual abstinence. Healthy Love participants reported greater improvements than comparison participants in HIV knowledge (p = 0.04) and self-efficacy for using condoms (p = 0.04) immediately after the intervention, greater intentions to use condoms with their primary male partners at the 3-month follow-up (p = 0.04), and greater improvements in attitudes toward using condoms (p = 0.054) and HIV knowledge (p = 0.01) at the 6-month follow-up assessment.