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Heterosexual non-Hispanic black women in the United States are far more affected than women of other races or ethnicities by human immunodeficiency virus (HIV).  SisterLove, Inc., a community-based organization in Atlanta, Georgia, responded to this disparity early in the epidemic by creating the Healthy Love HIV and sexually transmitted disease (STD) prevention intervention in 1989.  Since then, SisterLove has been delivering the intervention to black women in metropolitan Atlanta. 

This report describes successful efforts by SisterLove, Inc., to develop, rigorously evaluate, and demonstrate the efficacy of Healthy Love, a 3-4–hour interactive, educational workshop, to reduce HIV- and sexually transmitted disease-related risk behaviors among heterosexual black women.  On the basis of the evaluation findings, CDC packaged the intervention materials for use by service provider organizations in their efforts to reduce HIV disparities that affect black women in metropolitan Atlanta, the South, and the United States.  This report also describes initiatives by SisterLove after the efficacy study to increase the potential effectiveness and reach of the Healthy Love intervention and further address HIV-related disparities that affect black women.  CDC's Office of Minority Health and Health Equity selected the intervention analysis and discussion that follows to provide an example of a program that might be effective in reducing HIV-related disparities in the United States. 

The results of the randomized controlled efficacy trial highlight the potential of culturally tailored, interactive group intervention efforts to reduce health disparities.  CDC's support for evaluating and packaging SisterLove's intervention materials, and making the materials available (www.effectiveinterventions.org) for use by service provider organizations, are important contributions toward efforts to address HIV-related disparities that affect black women. 

Introduction

Heterosexual non-Hispanic black women in the United States are far more affected than women of other races or ethnicities by human immunodeficiency virus (HIV) (1).  The greatest source of risk for HIV infection for U.S. black women is unprotected sex with a male partner (1).  In 2010, non-Hispanic blacks constituted 12.6% of the U.S. population but accounted for 45% of all new HIV infections (2,3).  Of women aged ≥13 years, black women accounted for 63.5% of new infections and had a reported HIV infection rate 15 and three times as high as those for white women and Latina women, respectively (2).  An estimated 85% of black women who are infected with HIV are infected during heterosexual sex; the remaining 15% are infected through injection drug use (1). 

The South accounts for approximately one third of the U.S. population and for half of newly reported HIV infections (4).  During 2005–2008 in the South, black women accounted for 71% of new HIV diagnoses among all women (4).  In Georgia, blacks accounted for 30% of the state's population and for 74% of all HIV cases in 2009 (5).  Black women in Georgia have been particularly affected; in 2012, they accounted for 75% of all women in the state who were living with HIV (6). 

Among the social determinants and situational factors that can contribute to HIV/AIDS among black women are poverty, limited partner availability because of high incarceration rates and death among black men, and sex-based power differentials within couple relationships that can limit women's ability to negotiate HIV protective actions with their regular male sex partners (7).  Effective, culturally appropriate interventions are needed to reduce HIV-related risks among black women (8). 

Community-based organizations (CBOs) are uniquely placed to understand the circumstances of the communities of color and other high-risk populations they serve.  In addition, these organizations can potentially translate their knowledge, credibility, and cultural competence into effective HIV prevention initiatives, thereby addressing HIV disparities that affect these populations (9,10). 

Background

Actions by the Atlanta-based CBO, SisterLove, Inc. (http://sisterlove.org), exemplify such a community-based effort.  Responding early to the disproportionate effects of the epidemic of HIV/AIDS on heterosexual black women and the lack of prevention resources for this population, SisterLove created the Healthy Love intervention to prevent HIV and sexually transmitted disease (STD) infection in 1989.  Since then, SisterLove has been delivering Healthy Love to preexisting social groups (e.g., sororities, churches, and friendship circles) of black women in metropolitan Atlanta.  CBO staff members describe Healthy Love as an intervention that "makes house calls" because it is delivered to groups of women at locations they select. 

This report describes 1) efforts by SisterLove, to develop the Healthy Love Intervention; 2) previously published findings (11) demonstrating the efficacy of the Healthy Love intervention for reducing HIV/STD-related risk behaviors among heterosexual black women; 3) CDC support for packaging the intervention and making it freely available to the public; and 4) subsequent initiatives by SisterLove to increase the potential effectiveness and reach of Healthy Love, further address HIV-related disparities that affect black women, and make the intervention accessible to other high-risk populations. 

CDC's Office of Minority Health and Health Equity selected the intervention analysis and discussion that follows to provide an example of a program that might be effective in reducing HIV-related disparities in the United States.  Criteria for selecting this program are described in the Background and Rationale for this supplement(12). 

History

To learn from community-based HIV prevention practices and make effective practices available more broadly, CDC initiated the Innovative Interventions Project in 2004 (13).  The project aimed to identify and rigorously evaluate culturally appropriate HIV prevention interventions that CBOs had developed with substantial community input and were delivering to minority populations at high risk for HIV infection in their communities and that had shown some promise of being effective but had not been evaluated because of funding constraints.  Before the project began in 2004, CDC had identified only one efficacious HIV prevention intervention designed specifically for black heterosexual women (14).  The other interventions for black women targeted women at higher risk for acquiring or transmitting HIV, including crack cocaine users (15,16), patients at inner-city family-planning or primary-care clinics (17–19), and women with HIV/AIDS (20).  In 2004, the Innovative Interventions Project supported SisterLove to evaluate the efficacy of its Healthy Love intervention in a randomized controlled trial. 

Intervention

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 Project (21) 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. 

Methods

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. 

Limitations

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). 

Discussion

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 Project (24) 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 [32]) 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. 

Conclusion

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. 

Helps participants recall and acknowledge positive and negative feelings, attitudes, and beliefs about words associated with sex and sexuality

Helps participants appreciate the societal influences that can trivialize or denigrate women's sexuality

Promotes agreement by participants to use only positive words for remainder of the intervention

The Facts (60 minutes)

HIV/AIDS Facts*

Defines the acronyms HIV and AIDS, provides basic information on behaviors and circumstances that can increase a woman's risk for contracting or transmitting HIV, and discusses the relation between HIV and AIDS

STD Facts*

Provides basic information about common STDs: their names, how they are spread, symptoms, and protective actions

Elicits discussion; gives participants an opportunity to share what they know

The Look of HIV*

Dispels myth that one can visually tell if someone is living with HIV or AIDS

Describes HIV testing options and encourages testing for HIV and knowledge of serostatus

Provides information about prevalence of HIV/AIDS in the United States and among women of color

Safer Sex (120 minutes)

Risk Assessment

Participants rate their personal risk for HIV and other STDs on the basis of past and current sexual behaviors

Condom Demonstration

Demonstrates correct application of male condom to penis model and disposal of male condoms after ejaculation

Promotes discussion of how to negotiate condom use with a male partner

Condom Race

Competitive game gives participants opportunity to practice placing a condom on a penis model "under pressure" (under conditions resembling a romantic situation, with lights out and music playing)

Female Condom Demonstration

Provides basic information on the female condom as a means of preventing HIV and STDs

Demonstrates correct use of female condom with vagina model

Participants practice inserting female condom in vagina model

Oral Sex

Demonstrates use of dental dams, plastic wrap, and the oral application of a male condom to a penis model as methods for reducing HIV and STD risks

High-Low-No Risk

Participants discuss high, low, and no risk activities and demonstrate their increased knowledge of HIV transmission risk by assessing and ranking various behaviors on the basis of their associated risk levels

Gives participants opportunities to ask lingering questions and to provide feedback on the relevance and usefulness of the workshop

* Denotes components included in the HIV 101 comparison workshop during the randomized controlled trial. 

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