The findings in this report are subject to at least two limitations. First, the findings are based on self-reported risk and protective behaviors, which are subject to recall or social desirability response bias. Second, both intervention and comparison participants reported relatively low rates of alcohol use and drug use and high rates of condom use and abstinence at baseline.11 Therefore, these findings might not be generalizable to black women who are at higher risk for acquiring or transmitting HIV, such as substance users, STD clinic patients, and women with HIV/AIDS. Several efficacious interventions are available for these higher-risk women.15-20
Although HIV infection during heterosexual sex accounts for an estimated 85% of HIV infections among all black women,1 prevention resources for these women remain limited.25 The Healthy Love intervention was designed to address this gap in prevention coverage for black women whose greatest risk for HIV infection is sex with an infected male partner. The intervention reduced participants' self-described actions with male partners that can increase black women's risks for HIV infection and increased participants' likelihood of using condoms, being tested for HIV, and receiving their test results. Healthy Love is the only efficacious behavioral HIV prevention intervention developed for black heterosexual women of widely varying ages. As such, Healthy Love provides a needed resource for efforts to reduce HIV-related disparities that affect black women in the United States.7,26-30
The study demonstrated the efficacy of a single-session intervention for increasing condom use and HIV testing among black women. On the basis of the findings and rigor of the study methods used, CDC identified Healthy Love as a Good Evidence behavioral intervention and included it in the August 2011 update of the Compendium of Evidence-Based HIV Prevention Interventions.31 In 2012, CDC's Replicating Effective Programs Project24 packaged the intervention materials and, in 2013, made the materials available (http://www.effectiveinterventions.org) for use by service-provider organizations.
Several features of Healthy Love might enhance its potential as a resource for HIV/STD prevention. The intervention's short duration and relatively low cost (an estimated $92 per participant ) might make it attractive to service provider organizations. Intervention delivery to women who know each other at locations they select might facilitate open discussion and learning about HIV/STD risk- and prevention-related topics and promote their capacity to translate the knowledge and changed attitudes from the intervention into protective actions. The relatively short single-session format also might make the intervention more attractive to potential participants, thereby overcoming some attrition-related difficulties that can affect multiple-session interventions. Finally, the intervention was developed by and for heterosexual black women to provide them with a culturally appropriate tool for addressing their unique HIV/STD prevention needs.
Since completing the evaluation study, SisterLove has delivered Healthy Love to increasing numbers of women, totaling 3,780 in 2010 and 4,198 in 2011; most were aged 16-63 years and resided in six of metropolitan Atlanta's 28 counties (SisterLove, Inc., unpublished data, January 2012). Approximately 90% of the women served by SisterLove during these years resided in DeKalb and Fulton counties, which contain 17 of the 20 metropolitan Atlanta ZIP codes that have the largest number of AIDS cases in the region (Georgia HIV/AIDS Internal Reporting System, unpublished data, January 18, 2008). Of all women who received Healthy Love in 2010 and 2011, 92%-100% stated that they intended to discuss safer sex with their sex partners; use condoms or other barrier methods during vaginal, oral, or anal sex; and be tested for HIV (SisterLove, Inc., unpublished data, January 2012). SisterLove routinely delivers the intervention to black women aged 13-65 years (Lisa Diane White, personal communication, February 26, 2013).
After the evaluation, SisterLove began several initiatives to increase the potential effectiveness and reach of Healthy Love. To complement the intervention's promotion of HIV testing and facilitate follow-up actions by participants, SisterLove provides screening for HIV, chlamydia, gonorrhea, and hepatitis C and linkage to care for Healthy Love participants and other women who seek these services. To address the promising but nonstatistically significant intervention effects observed during the evaluation, such as women's condom use at the 6-month follow-up, SisterLove invites Healthy Love participants to attend the single-session intervention whenever the CBO delivers it to reinforce its effectiveness over time. To gauge the potential longer-term effects of Healthy Love, from mid-2012 through mid-2013, SisterLove followed up with selected women who receive the intervention as it is routinely delivered and provided the intervention to members of their social and sexual networks. This follow-up will enable SisterLove to ascertain the degree to which network members and their sex partners are tested for HIV/STDs and linked to care.
To address intimate-partner violence that can increase women's vulnerability to HIV/STD infection, SisterLove is collaborating with local domestic violence shelters. SisterLove delivers Healthy Love, which promotes HIV counseling, and shelter staff members assist participants with developing plans to reduce their HIV risks with abusive partners. SisterLove is also co-developing and implementing a nationwide training curriculum to increase the capacity of HIV and domestic violence educators to screen and provide referrals for women who are vulnerable to both HIV and sex-based violence. To increase the accessibility of Healthy Love to other high-risk populations, SisterLove is delivering adapted versions of the intervention to heterosexual and homosexual adolescent men and HIV-positive women. SisterLove intends to evaluate the effectiveness of these adaptations and will continue to adapt Healthy Love for use with transgender females and adult heterosexual and HIV-positive men.
The study demonstrated that a CBO can successfully develop and deliver a culturally appropriate, efficacious HIV prevention intervention for heterosexual black women. The single-session Healthy Love intervention provides a relatively low-cost tool for use by CBOs and other service provider organizations. CDC's support for evaluating and packaging SisterLove's intervention materials is an important contribution toward addressing HIV-related disparities that affect black women.
Funding for the evaluation study described in this supplement was provided by CDC to SisterLove, Inc., under cooperative agreement U65/CCU424514. The study is registered with www.clinicaltrials.gov (NCT00362375). The authors acknowledge the contribution of Angela Clements, Kozetta Harris, Kelly M. Jackson, L. Nyrobi N. Moss, Paulyne M. Ngalame, Kerriann Peart, and Aisha Tucker-Brown at SisterLove, Inc.; and James W. Carey, Cynthia M. Lyles, Duane Moody, Trent Wade Moore, David Purcell, Sima Rama, and Sekhar R. Thadiparthi at CDC.
Thomas M. Painter, Ph.D., and Jeffrey H. Herbst, Ph.D., are with the National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention, CDC. Dázon Dixon Diallo, M.P.H., and Lisa Diane White, M.P.H., are with SisterLove, Inc., Atlanta, Georgia.