Based upon process evaluations of two HIV/AID epidemiologic studies and one program evaluation, t... more Based upon process evaluations of two HIV/AID epidemiologic studies and one program evaluation, the authors focus on the subtle and culturally latent ways that respondents differentially make themselves available as research subjects. Our primary thesis is that injection drug users respond to opportunities to be interviewed and paid as a group as well as individuals. In which case, they influence as a group who is recruited for interviews. In this retrospective review, we show the ways that some IDUs respond differentially to research methods based on ways that they are organized in the larger community.
This study used qualitative methods to explore the social and psychological context of sexual beh... more This study used qualitative methods to explore the social and psychological context of sexual behavior and HIV risk among African American non-gay-identified men who have sex with men. Analysis of men's narratives on their sexual behaviors revealed four social and psychological factors contributing to risk for HIV infection: (a) a tendency to compartmentalize and personally disengage from same-sex behavior, (b) traditional gender roles that reinforce men's adherence to masculine images and ambivalent attitudes toward women, (c) cultural norms that favor secrecy and privacy about any personal matters, and (d) spontaneous and unplanned sexual episodes with other men. Findings indicate that innovative HIV prevention and risk reduction strategies are necessary to reach this group and question the legitimacy of conventional sexual orientation categories for these men. Interventions must address social contextual determinants of risk, reinforce men's public identifications as straight/heterosexual, and maintain men's need for privacy about same-sex behaviors.
Http Dx Doi Org 10 1521 Aeap 2005 17 4 300, Aug 26, 2005
ABSTRACT Through forming a collaborative relationship to develop, pilot and evaluate an innovativ... more ABSTRACT Through forming a collaborative relationship to develop, pilot and evaluate an innovative bio-psycho-behavioral (BPB) HIV prevention intervention, capacity was built in developing an effective intervention and conducting community based research at both the California Prostitutes Prevention and Education Project (CAL-PEP) and the University of California's Family Health Outcomes Project. The research objective was to investigate whether the BPB intervention that included sexually transmitted diseases (STD) testing and behavioral counseling, is superior to standard HIV counseling and testing. This necessitated building capacity at CAL-PEP to deliver clinical services, implement the counseling model, conduct outreach and follow-up, and manage data. University of California, San Francisco, staff needed to build capacity to listen to and incorporate feedback from staff with widely diverse educational and cultural backgrounds. The outcome was to develop the study questionnaire and effective follow-up systems as well as to be able to teach research methods to these staff. Frequent staff meetings to promote trust and mutual respect, incorporating staff and client input into the intervention design, and ongoing training and quality assurance processes were critical to the project's success. Preliminary analyses indicate the BPB intervention is effective at improving condom related attitudes, self-efficacy to use condoms, and intentions to practice other HIV/STD risk reduction.
Progress in Community Health Partnerships: Research, Education, and Action, 2013
Late diagnosis of HIV is an important problem in the United States, particularly in ethnically an... more Late diagnosis of HIV is an important problem in the United States, particularly in ethnically and socially diverse communities. We created and used a partnership covenant to ensure our adherence to community-based participatory research (CBPR) principles as we began studying and addressing individual and structural barriers to timely HIV testing. Sample CBPR principles were used to help develop a partnership covenant that in turn was used in steering committee (SC) meetings to gauge our adherence to CBPR in our work together and in the field. Continuing dialogue around our fidelity to the covenant resulted in concrete changes including a "crash course" on sampling for community partners and development of a community advisory board (CAB). Our ability to meet the project's specific aims was enhanced by using the covenant. Although time consuming, development and use of a CBPR covenant can improve high-level engagement and help to accomplish a study's specific aims.
California Prevention Education Program (Cal-Pep) provides street outreach services to injection ... more California Prevention Education Program (Cal-Pep) provides street outreach services to injection drugs users and sex traders in Oakland and San Francisco, CA, to reduce their chances of contracting HIV/AIDS. Drug treatment is an effective barrier to HIV infections, but only clients who are ready for total abstinence from drug use can be referred to traditional treatment. Drug treatment readiness is currently defined by funding policies in the U.S. as a client's willingness to totally abstain from alcohol and illegal drug use. This policy and practice eliminates a major harm reduction opportunity to reach drug users who are just contemplating recovery with treatment. With a CSAT grant to demonstrate an effective innovation in treatment, Cal-Pep started a harm reduction outpatient program for women who were active drug users. Over the course of 1 year, actively drug-using clients came to the program house during the day for meals, for risk-reduction education sessions, group discu...
Identification of peptide substrates for proteases can be a major undertaking. To overcome issues... more Identification of peptide substrates for proteases can be a major undertaking. To overcome issues such as feasibility and deconvolution, associated with large peptide libraries, a 'small but smart' generic fluorescence resonance energy transfer rapid endopeptidase profiling library (REPLi) was synthesised as a tool for rapidly identifying protease substrates. Within a tripeptide core, flanked by Gly residues, similar amino acids were paired giving rise to a relatively small library of 3375 peptides divided into 512 distinct pools each containing only 8 peptides. The REPLi was validated with trypsin, pepsin, the matrix metalloprotease (MMP)-12 and MMP-13 and calpains-1 and -2. In the case of calpain-2, a single iteration step involving LC-MS, provided the definitive residue specificity from which a highly sensitive fluorogenic substrate, (FAM)-Gly-Gly-Gly-Gln-Leu-Tyr-Gly-Gly-DPA-Arg-Arg-Lys-(TAMRA), was then designed. The thorough validation of this 'small but smart' peptide library with representatives from each of the four mechanistic protease classes indicates that the REPLi will be useful for the rapid identification of substrates for multiple proteases.
MORE was a mobile outreach drug abuse prevention and HIV harm reduction program primarily for ex-... more MORE was a mobile outreach drug abuse prevention and HIV harm reduction program primarily for ex-offenders who are active drug users. Through case management, clients were provided substance abuse education, counseling and referral. A long-term goal of these services was to reduce their drug use and re-incarceration for drug related crimes. From
JAIDS Journal of Acquired Immune Deficiency Syndromes, 2013
The authors piloted an HIV testing and counseling (HTC) approach using respondent-driven sampling... more The authors piloted an HIV testing and counseling (HTC) approach using respondent-driven sampling (RDS), financial incentives, and persons living with HIV infection (PLHIV). Eligible participants were aged 30-60 years, African American or black, and residents of Oakland, CA. Participants were tested for HIV infection and asked to refer up to 3 others. The authors compared the efficiency of RDS to conventional outreach-based HTC with the number needed to screen (NNS). They evaluated the effect of 2 randomly allocated recruitment incentives on the enrollment of high-risk or HIV-positive network associates: a flat incentive ($20) for eligible recruits or a conditional incentive ($10-35) for eligible recruits in priority groups, such as first-time testers. Forty-eight participants (10 PLHIV and 38 HIV negative) initiated recruitment chains resulting in 243 network associates. Nine (3.7%) participants tested HIV positive, of whom 7 (78%) were previously recognized. RDS was more efficient than conventional HTC at identifying any PLHIV (new or previously recognized; RDS: NNS = 27, 95% CI: 14 to 59; conventional: NNS = 154, 95% CI: 95 to 270). There was no difference between the 2 incentive groups in the likelihood of recruiting at least 1 high-risk HIV-negative or HIV-positive network associate (adjusted odds ratio = 0.89, 95% CI: 0.06 to 13.06) or in total number of high-risk HIV-negative or HIV-positive associates (adjusted odds ratio = 0.79, 95% CI: 0.23 to 2.71). Social network HTC strategies may increase demand for HTC and efficiently identify PLHIV. The flat incentive was as successful as the conditional incentive for recruiting high-risk individuals. Unexpectedly, this method also reidentified PLHIV aware of their status.
In the United States, there is an urgent need to provide HIV prevention services to African Ameri... more In the United States, there is an urgent need to provide HIV prevention services to African American men who have sex with men and women (MSMW) but who do not identify as gay or homosexual. Engaging these men in HIV prevention has historically been challenging. This study used qualitative methodology to explore the beliefs and experiences from community-based service providers (n = 21) and from African American MSMW (n = 21) regarding the provision of HIV prevention education and counseling to these men. Data analysis revealed that (a) African American MSMW who do not identify as gay can challenge service providers' assumptions about sexual behavior and sexual identity; (b) service providers' attitudes toward these men can be affected by ambivalent or negative beliefs that pervade the general community; (c) African American MSMW need safe and nonjudgmental spaces that offer HIV risk reduction, but they also might experience anxiety about disclosing same-sex behaviors to counselors. Findings highlighted the complexities related to culture, masculinity, and sexuality as determinants of HIV risk in African American MSMW, and findings also revealed tensions between these factors that may affect the quality of HIV prevention services. Service providers may need additional training to provide appropriate and non-judgmental HIV prevention counseling and education.
This study used qualitative methods to explore the social and psychological context of sexual beh... more This study used qualitative methods to explore the social and psychological context of sexual behavior and HIV risk among African American non-gay-identified men who have sex with men. Analysis of men's narratives on their sexual behaviors revealed four social and psychological factors contributing to risk for HIV infection: (a) a tendency to compartmentalize and personally disengage from same-sex behavior, (b) traditional gender roles that reinforce men's adherence to masculine images and ambivalent attitudes toward women, (c) cultural norms that favor secrecy and privacy about any personal matters, and (d) spontaneous and unplanned sexual episodes with other men. Findings indicate that innovative HIV prevention and risk reduction strategies are necessary to reach this group and question the legitimacy of conventional sexual orientation categories for these men. Interventions must address social contextual determinants of risk, reinforce men's public identifications as straight/heterosexual, and maintain men's need for privacy about same-sex behaviors.
... This necessitated building ca-pacity at CAL–PEP to deliver clinical services, implement the c... more ... This necessitated building ca-pacity at CAL–PEP to deliver clinical services, implement the counseling model, conduct outreach and follow ... COLLABORATIVE FRAMEWORK CAL–PEP is a nonprofit organization, founded in 1985 by ex–prostitute Gloria Lockett, whose mission is ...
African American men who have sex with men and women (MSMW), but who do not form a sexual identit... more African American men who have sex with men and women (MSMW), but who do not form a sexual identity around same-sex behavior, may experience risk for HIV infection and transmission. This paper reports cross-sectional survey findings on sexual behaviors and substance use of urban non-gay- or non-bisexual-identified African American MSMW (n = 68), who completed behavior assessment surveys using audio-computer assisted self-interviewing technology. Overall, 17.6% reported being HIV-positive. In the past 3 months, 70.6% had unprotected insertive sex with a female, 51.5% had unprotected insertive anal sex (UIAS) with a male, 33.8% had unprotected receptive anal sex (URAS) with a male, 25% had UIAS with a transgender female, and 10.3% had URAS with a transgender female. Findings indicated a bridging potential for HIV and sexually transmitted infections across groups, such that 38.2% reported concurrent unprotected sex with female and male partners and 17.6% reported concurrent unprotected sex with female and transgender female partners. In the past 3 months, 70.6% used alcohol before sex and 85% used drugs before sex. Men who used drugs before sex had a tenfold increased likelihood for unprotected sex with male partners, and men who injected drugs had a nearly fivefold increased likelihood for unprotected sex with a transgender female. Interventions to address sexual risk behaviors, especially partner concurrency, and substance use behavior for these men are warranted.
African American men who have sex with both men and women (AAMSMW) are at high risk for acquiring... more African American men who have sex with both men and women (AAMSMW) are at high risk for acquiring and transmitting HIV, yet few interventions exist to address their unique prevention needs. We conducted 3 focus groups, 21 in-depth interviews, and a pilot test of our intervention with = 61 AAMSMW, which showed significant reductions in sexual risk behavior after 6 months. The intervention is currently being tested in a randomized controlled trial (RCT). We discuss the development of a culturally tailored, theoretically grounded counseling intervention for AAMSMW, presenting findings from our formative research, intervention development process, pilot study, and the implementation of our RCT. We describe the content of each session, our protocol for merging Bruthas with HIV testing, and best practices for recruiting AAMSMW. If Bruthas is found to be efficacious, the intervention will reach a vulnerable population to encourage uptake of regular HIV testing and reduced sexual risk taking.
Based upon process evaluations of two HIV/AID epidemiologic studies and one program evaluation, t... more Based upon process evaluations of two HIV/AID epidemiologic studies and one program evaluation, the authors focus on the subtle and culturally latent ways that respondents differentially make themselves available as research subjects. Our primary thesis is that injection drug users respond to opportunities to be interviewed and paid as a group as well as individuals. In which case, they influence as a group who is recruited for interviews. In this retrospective review, we show the ways that some IDUs respond differentially to research methods based on ways that they are organized in the larger community.
This study used qualitative methods to explore the social and psychological context of sexual beh... more This study used qualitative methods to explore the social and psychological context of sexual behavior and HIV risk among African American non-gay-identified men who have sex with men. Analysis of men's narratives on their sexual behaviors revealed four social and psychological factors contributing to risk for HIV infection: (a) a tendency to compartmentalize and personally disengage from same-sex behavior, (b) traditional gender roles that reinforce men's adherence to masculine images and ambivalent attitudes toward women, (c) cultural norms that favor secrecy and privacy about any personal matters, and (d) spontaneous and unplanned sexual episodes with other men. Findings indicate that innovative HIV prevention and risk reduction strategies are necessary to reach this group and question the legitimacy of conventional sexual orientation categories for these men. Interventions must address social contextual determinants of risk, reinforce men's public identifications as straight/heterosexual, and maintain men's need for privacy about same-sex behaviors.
Http Dx Doi Org 10 1521 Aeap 2005 17 4 300, Aug 26, 2005
ABSTRACT Through forming a collaborative relationship to develop, pilot and evaluate an innovativ... more ABSTRACT Through forming a collaborative relationship to develop, pilot and evaluate an innovative bio-psycho-behavioral (BPB) HIV prevention intervention, capacity was built in developing an effective intervention and conducting community based research at both the California Prostitutes Prevention and Education Project (CAL-PEP) and the University of California's Family Health Outcomes Project. The research objective was to investigate whether the BPB intervention that included sexually transmitted diseases (STD) testing and behavioral counseling, is superior to standard HIV counseling and testing. This necessitated building capacity at CAL-PEP to deliver clinical services, implement the counseling model, conduct outreach and follow-up, and manage data. University of California, San Francisco, staff needed to build capacity to listen to and incorporate feedback from staff with widely diverse educational and cultural backgrounds. The outcome was to develop the study questionnaire and effective follow-up systems as well as to be able to teach research methods to these staff. Frequent staff meetings to promote trust and mutual respect, incorporating staff and client input into the intervention design, and ongoing training and quality assurance processes were critical to the project's success. Preliminary analyses indicate the BPB intervention is effective at improving condom related attitudes, self-efficacy to use condoms, and intentions to practice other HIV/STD risk reduction.
Progress in Community Health Partnerships: Research, Education, and Action, 2013
Late diagnosis of HIV is an important problem in the United States, particularly in ethnically an... more Late diagnosis of HIV is an important problem in the United States, particularly in ethnically and socially diverse communities. We created and used a partnership covenant to ensure our adherence to community-based participatory research (CBPR) principles as we began studying and addressing individual and structural barriers to timely HIV testing. Sample CBPR principles were used to help develop a partnership covenant that in turn was used in steering committee (SC) meetings to gauge our adherence to CBPR in our work together and in the field. Continuing dialogue around our fidelity to the covenant resulted in concrete changes including a "crash course" on sampling for community partners and development of a community advisory board (CAB). Our ability to meet the project's specific aims was enhanced by using the covenant. Although time consuming, development and use of a CBPR covenant can improve high-level engagement and help to accomplish a study's specific aims.
California Prevention Education Program (Cal-Pep) provides street outreach services to injection ... more California Prevention Education Program (Cal-Pep) provides street outreach services to injection drugs users and sex traders in Oakland and San Francisco, CA, to reduce their chances of contracting HIV/AIDS. Drug treatment is an effective barrier to HIV infections, but only clients who are ready for total abstinence from drug use can be referred to traditional treatment. Drug treatment readiness is currently defined by funding policies in the U.S. as a client's willingness to totally abstain from alcohol and illegal drug use. This policy and practice eliminates a major harm reduction opportunity to reach drug users who are just contemplating recovery with treatment. With a CSAT grant to demonstrate an effective innovation in treatment, Cal-Pep started a harm reduction outpatient program for women who were active drug users. Over the course of 1 year, actively drug-using clients came to the program house during the day for meals, for risk-reduction education sessions, group discu...
Identification of peptide substrates for proteases can be a major undertaking. To overcome issues... more Identification of peptide substrates for proteases can be a major undertaking. To overcome issues such as feasibility and deconvolution, associated with large peptide libraries, a 'small but smart' generic fluorescence resonance energy transfer rapid endopeptidase profiling library (REPLi) was synthesised as a tool for rapidly identifying protease substrates. Within a tripeptide core, flanked by Gly residues, similar amino acids were paired giving rise to a relatively small library of 3375 peptides divided into 512 distinct pools each containing only 8 peptides. The REPLi was validated with trypsin, pepsin, the matrix metalloprotease (MMP)-12 and MMP-13 and calpains-1 and -2. In the case of calpain-2, a single iteration step involving LC-MS, provided the definitive residue specificity from which a highly sensitive fluorogenic substrate, (FAM)-Gly-Gly-Gly-Gln-Leu-Tyr-Gly-Gly-DPA-Arg-Arg-Lys-(TAMRA), was then designed. The thorough validation of this 'small but smart' peptide library with representatives from each of the four mechanistic protease classes indicates that the REPLi will be useful for the rapid identification of substrates for multiple proteases.
MORE was a mobile outreach drug abuse prevention and HIV harm reduction program primarily for ex-... more MORE was a mobile outreach drug abuse prevention and HIV harm reduction program primarily for ex-offenders who are active drug users. Through case management, clients were provided substance abuse education, counseling and referral. A long-term goal of these services was to reduce their drug use and re-incarceration for drug related crimes. From
JAIDS Journal of Acquired Immune Deficiency Syndromes, 2013
The authors piloted an HIV testing and counseling (HTC) approach using respondent-driven sampling... more The authors piloted an HIV testing and counseling (HTC) approach using respondent-driven sampling (RDS), financial incentives, and persons living with HIV infection (PLHIV). Eligible participants were aged 30-60 years, African American or black, and residents of Oakland, CA. Participants were tested for HIV infection and asked to refer up to 3 others. The authors compared the efficiency of RDS to conventional outreach-based HTC with the number needed to screen (NNS). They evaluated the effect of 2 randomly allocated recruitment incentives on the enrollment of high-risk or HIV-positive network associates: a flat incentive ($20) for eligible recruits or a conditional incentive ($10-35) for eligible recruits in priority groups, such as first-time testers. Forty-eight participants (10 PLHIV and 38 HIV negative) initiated recruitment chains resulting in 243 network associates. Nine (3.7%) participants tested HIV positive, of whom 7 (78%) were previously recognized. RDS was more efficient than conventional HTC at identifying any PLHIV (new or previously recognized; RDS: NNS = 27, 95% CI: 14 to 59; conventional: NNS = 154, 95% CI: 95 to 270). There was no difference between the 2 incentive groups in the likelihood of recruiting at least 1 high-risk HIV-negative or HIV-positive network associate (adjusted odds ratio = 0.89, 95% CI: 0.06 to 13.06) or in total number of high-risk HIV-negative or HIV-positive associates (adjusted odds ratio = 0.79, 95% CI: 0.23 to 2.71). Social network HTC strategies may increase demand for HTC and efficiently identify PLHIV. The flat incentive was as successful as the conditional incentive for recruiting high-risk individuals. Unexpectedly, this method also reidentified PLHIV aware of their status.
In the United States, there is an urgent need to provide HIV prevention services to African Ameri... more In the United States, there is an urgent need to provide HIV prevention services to African American men who have sex with men and women (MSMW) but who do not identify as gay or homosexual. Engaging these men in HIV prevention has historically been challenging. This study used qualitative methodology to explore the beliefs and experiences from community-based service providers (n = 21) and from African American MSMW (n = 21) regarding the provision of HIV prevention education and counseling to these men. Data analysis revealed that (a) African American MSMW who do not identify as gay can challenge service providers' assumptions about sexual behavior and sexual identity; (b) service providers' attitudes toward these men can be affected by ambivalent or negative beliefs that pervade the general community; (c) African American MSMW need safe and nonjudgmental spaces that offer HIV risk reduction, but they also might experience anxiety about disclosing same-sex behaviors to counselors. Findings highlighted the complexities related to culture, masculinity, and sexuality as determinants of HIV risk in African American MSMW, and findings also revealed tensions between these factors that may affect the quality of HIV prevention services. Service providers may need additional training to provide appropriate and non-judgmental HIV prevention counseling and education.
This study used qualitative methods to explore the social and psychological context of sexual beh... more This study used qualitative methods to explore the social and psychological context of sexual behavior and HIV risk among African American non-gay-identified men who have sex with men. Analysis of men's narratives on their sexual behaviors revealed four social and psychological factors contributing to risk for HIV infection: (a) a tendency to compartmentalize and personally disengage from same-sex behavior, (b) traditional gender roles that reinforce men's adherence to masculine images and ambivalent attitudes toward women, (c) cultural norms that favor secrecy and privacy about any personal matters, and (d) spontaneous and unplanned sexual episodes with other men. Findings indicate that innovative HIV prevention and risk reduction strategies are necessary to reach this group and question the legitimacy of conventional sexual orientation categories for these men. Interventions must address social contextual determinants of risk, reinforce men's public identifications as straight/heterosexual, and maintain men's need for privacy about same-sex behaviors.
... This necessitated building ca-pacity at CAL–PEP to deliver clinical services, implement the c... more ... This necessitated building ca-pacity at CAL–PEP to deliver clinical services, implement the counseling model, conduct outreach and follow ... COLLABORATIVE FRAMEWORK CAL–PEP is a nonprofit organization, founded in 1985 by ex–prostitute Gloria Lockett, whose mission is ...
African American men who have sex with men and women (MSMW), but who do not form a sexual identit... more African American men who have sex with men and women (MSMW), but who do not form a sexual identity around same-sex behavior, may experience risk for HIV infection and transmission. This paper reports cross-sectional survey findings on sexual behaviors and substance use of urban non-gay- or non-bisexual-identified African American MSMW (n = 68), who completed behavior assessment surveys using audio-computer assisted self-interviewing technology. Overall, 17.6% reported being HIV-positive. In the past 3 months, 70.6% had unprotected insertive sex with a female, 51.5% had unprotected insertive anal sex (UIAS) with a male, 33.8% had unprotected receptive anal sex (URAS) with a male, 25% had UIAS with a transgender female, and 10.3% had URAS with a transgender female. Findings indicated a bridging potential for HIV and sexually transmitted infections across groups, such that 38.2% reported concurrent unprotected sex with female and male partners and 17.6% reported concurrent unprotected sex with female and transgender female partners. In the past 3 months, 70.6% used alcohol before sex and 85% used drugs before sex. Men who used drugs before sex had a tenfold increased likelihood for unprotected sex with male partners, and men who injected drugs had a nearly fivefold increased likelihood for unprotected sex with a transgender female. Interventions to address sexual risk behaviors, especially partner concurrency, and substance use behavior for these men are warranted.
African American men who have sex with both men and women (AAMSMW) are at high risk for acquiring... more African American men who have sex with both men and women (AAMSMW) are at high risk for acquiring and transmitting HIV, yet few interventions exist to address their unique prevention needs. We conducted 3 focus groups, 21 in-depth interviews, and a pilot test of our intervention with = 61 AAMSMW, which showed significant reductions in sexual risk behavior after 6 months. The intervention is currently being tested in a randomized controlled trial (RCT). We discuss the development of a culturally tailored, theoretically grounded counseling intervention for AAMSMW, presenting findings from our formative research, intervention development process, pilot study, and the implementation of our RCT. We describe the content of each session, our protocol for merging Bruthas with HIV testing, and best practices for recruiting AAMSMW. If Bruthas is found to be efficacious, the intervention will reach a vulnerable population to encourage uptake of regular HIV testing and reduced sexual risk taking.
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Papers by Carla Smith