California State University, Monterey Bay, College of Health Sciences and Human Services, Seaside, CA

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1 Pulic Helth Evlution Evlution of Community Helth Worker Intervention to Reduce HIV/AIDS Stigm nd Increse HIV Testing Among Underserved Ltinos in the Southwestern U.S. Britt Rios-Ellis, PhD, MS, Dvid Becker, PhD c Lili Espinoz, PhD d Selen Nguyen-Rodriguez, PhD e Gy Diz, MD An Crricchi, MPP Gino Glvez, PhD Melwhy Grci, MPH ABSTRACT Ojectives. Ltinos re t n elevted risk for HIV infection. Continued HIV/ AIDS stigm presents rriers to HIV testing nd ffects the qulity of life of HIV-positive individuls, yet few interventions ddressing HIV/AIDS stigm hve een developed for Ltinos. Methods. An intervention led y community helth workers (promotores de slud, or promotores) trgeting underserved Ltinos in three southwestern U.S. communities ws developed to decrese HIV/AIDS stigm nd increse HIV knowledge nd perception of risk. The intervention ws led y HIV-positive nd HIV-ffected (i.e., those who hve, or hve hd, close fmily memer or friend with HIV/AIDS) promotores, who delivered interctive group-sed eductionl sessions to groups of Ltinos in Spnish nd English. To decrese stigm nd motivte ehviorl nd ttitudinl chnge, the eductionl sessions emphsized positive Ltino culturl vlues nd community ssets. The prticipnt pool comprised 579 Ltino dults recruited in El Pso, Texs (n5204); Sn Ysidro, Cliforni (n5175); nd Los Angeles, Cliforni (n5200). Results. From pretest to posttest, HIV/AIDS stigm scores decresed significntly (p). Significnt increses were oserved in HIV/AIDS knowledge (p), willingness to discuss HIV/AIDS with one s sexul prtner (p), nd HIV risk perception (p50.006). Willingness to test for HIV in the three months following the intervention did not increse. Women demonstrted greter reduction in HIV/AIDS stigm scores when compred with their mle counterprts, which my hve een relted to greter increse in HIV/AIDS knowledge scores (p nd p50.007, respectively). Conclusion. Promotores interventions to reduce HIV/AIDS stigm nd increse HIV-relted knowledge, perception of risk, nd willingness to discuss sexul risk with prtners show promise in reching underserved Ltino communities. Cliforni Stte University, Monterey By, College of Helth Sciences nd Humn Services, Seside, CA Ntionl Council of L Rz/Cliforni Stte University, Long Bech Center for Ltino Community Helth, Evlution nd Ledership Trining, Long Bech, CA c Kiser Permnente, Psden, CA d Cliforni Stte University, Fullerton Deprtment of Helth Science, Fullerton, CA e Cliforni Stte University, Long Bech, Deprtment of Helth Science, Long Bech, CA Address correspondence to: Britt Rios-Ellis, PhD, MS, Cliforni Stte University, Monterey By, College of Helth Sciences nd Humn Services, 100 Cmpus Center, Seside, CA 93955; tel ; fx ; e-mil <rios-ellis@csum.edu> Assocition of Schools nd Progrms of Pulic Helth 458

2 A Community Helth Worker HIV/AIDS Intervention 459 Humn immunodeficiency virus (HIV)/cquired immunodeficiency syndrome (AIDS) hs disproportiontely ffected U.S. Ltinos during the lst 25 yers. Although Ltinos constitute 16% of the U.S. popultion, they ccount for 19% of those living with HIV nd 21% of new HIV infections. 1 Since 2006, the Centers for Disese Control nd Prevention (CDC) hs recommended HIV testing for ll people ged yers. 2 However, nerly hlf (46%) of Ltino dults ged yers hve never een tested, compred with 23% of lck nd 50% of white dults. 3 Additionlly, HIV testing often occurs t lte stge mong HIVpositive Ltinos. More thn one-third (36%) of HIVpositive Ltinos were dignosed with AIDS within one yer of lerning their HIV sttus, compred with 32% of white people nd 31% of lck people. 3 Lte HIV testing hinders tretment options nd my contriute to unknowing HIV trnsmission. Fctors contriuting to low HIV testing rtes mong Ltinos include poverty, lck of helth-cre ccess, nd limited vilility of culturlly nd linguisticlly responsive services. 1,4 6 HIV/AIDS stigm is nother fctor. 7,8 UNAIDS (Joint United Ntions Progrmme on AIDS) defines HIV stigm s the devlution of people either living with or ssocited with HIV/ AIDS. 9 Stigm often results from fers out HIV s well s the ssocitions of HIV with stigmtized groups such s homosexuls, sex workers, nd injection drug users. 9,10 HIV/AIDS stigm hs negtive consequences oth t popultion level nd for individuls who re its trgets, including people living with HIV/AIDS. Stigmtizing ttitudes towrd people living with HIV/AIDS re ssocited with decresed HIV testing, limited utiliztion of HIV prevention services, nd high-risk sexul ehviors. 7,10,11 Additionlly, for people living with HIV/ AIDS, the stigm ssocited with HIV/AIDS contriutes to unwillingness to disclose HIV sttus, unsfe sexul ehviors, delys in cre seeking, reduced tretment dherence, mentl helth issues, nd difficulties otining socil support. 9,11 14 Despite significnt implictions, few interventions hve een developed to reduce HIV/AIDS stigm. 10,11,15 Existing interventions hve often focused on specific popultions (e.g., university students nd helth-cre providers), with few interventions focused on Ltinos, 11,15,16 who hve high levels of stigmtizing ttitudes towrd people living with HIV/AIDS 1,17,18 tht contriute to negtive outcomes. 7,19 Among Ltinos, reserch indictes tht community helth workers (promotores de slud, hereinfter promotores ) re n effective nd culturlly cceptle mens of reching the popultion with helth informtion nd motivting helth ehviors. 20,21 Promotores re well positioned to promote chnges in their communities ecuse they shre lnguge nd culturl vlues, re held in high esteem, nd re perceived s role models. 21 Promotores hve een used to ddress helth conditions rnging from chronic diseses to preventive screenings Severl interventions hve incorported promotores into HIV prevention, finding significnt chnges in HIV risk ehviors, HIV counseling nd testing, nd other psychosocil constructs importnt to prevention. 16,23 29 To dte, few studies hve used promotores in interventions to reduce HIV stigm mong Ltinos. 16 We descrie nd report findings of n intervention using promotores to reduce HIV/AIDS stigm nd increse willingness to seek HIV testing mong Ltinos in three communities in the southwestern United Sttes: Los Angeles, Cliforni; Sn Ysidro, Cliforni; nd El Pso, Texs. PROGRAM DESCRIPTION Our intervention ws informed y Airhihenuw nd Wester s PEN-3 model 30 nd Elder et l. s frmework for promoting Ltino helth through communiction. 21 The PEN-3 model ws creted to guide the development of culturlly competent HIV prevention progrms. The model includes three primry domins: culturl identity, reltionships, nd culturl empowerment. 30 For the project, the model ws used to guide the inclusion of culturl components in the formtive nd development phses, including culturl vlues, eliefs, nd importnt icons, s well s n emphsis on culturl strengths. Elder s frmework outlines the importnce of using cler nd effective communiction messges for individuls, fmily, peers, orgniztions, nd communities. 21 This frmework ws used to ensure tht the project ddressed the different socio-environmentl influences tht hve role in the helth of Ltinos. We chose s our study s nme Slud es Cultur: Protégete! (Helth Is Culture: Protect Yourself!) to emphsize positive culturl ttriutes nd motivte HIV prevention y emphsizing Ltino culturl vlues, such s the importnce of fmily (fmilismo), community (communidd), respect (respeto), nd trust (confinz). HIV/AIDS prevention ws frmed using positive, community, nd ction-oriented perspective to increse culturl pride, self-cre through incresed knowledge, nd ehvior chnge to reduce the risk for HIV. Promotores prticiption We prtnered with three community-sed orgniztions to develop nd implement the intervention.

3 460 Pulic Helth Evlution Prtners included two Federlly Qulified Helth Centers serving predominntly Spnish-speking Ltino immigrnts (Sn Ysidro nd El Pso) nd nonprofit gency dedicted to HIV prevention serving ll Ltinos, ut focused on the Ltino lesin, gy, isexul, nd trnsgender popultion (Los Angeles). HIV-positive nd HIV-ffected promotores delivered the intervention. Those personlly ffected y HIV hd fmily or friends who were HIV positive. Stff from the prtner gencies identified the promotores. In totl, 20 promotores were recruited (five from El Pso, 10 from Sn Ysidro, nd five from Los Angeles). Most of the promotores were ilingul in English nd Spnish, nd ll hd demonstrted ledership experience in reching their respective communities. Eleven promotores were HIV positive, 12 were orn in Mexico, nd eight were orn in the United Sttes. Using community-sed prticiptory reserch (CBPR) techniques, promotores nd stff t collorting orgniztions provided input on content development, intervention delivery, nd the evlution protocol through focus groups nd group discussions throughout the project. Bsed on their extensive experience nd high percentge of HIV seropositivity, promotores from Sn Ysidro prticipted in two focus groups to collect formtive dt regrding how to pproch stigm. Content nlysis reveled stigm s eing complex nd intertwined with religion nd stigmt, potentiting the elief tht HIV sttus could e perceived s divine punishment for sinful ehvior. Promotores recommended tht the concept of stigm e introduced t the end of the interctive group eduction sessions, or chrls, only fter HIV trnsmission ws clerly defined, s it is often misinterpreted in Spnish s estigmt, or mrks of God. Introducing the concept of stigm lter ensured tht prticipnts would not confuse someone with AIDS s hving een punished or mrked y God, thus excerting the overll effects of stigm. Although Sn Ysidro promotores prticipted in focus groups, promotores from ll sites prticipted in informl group discussions during preliminry project meetings to review mterils, recommend chnges, nd ssist in finlizing the intervention nd evlution. Modifictions to the project title nd content of the interctive group eduction sessions were mde sed on the promotores recommendtions nd their insight regrding the respective trget communities. The promotores suggested title without the word stigm nd one tht promoted culturl positivity. Bsed on the promotores feedck, the interctive group eduction sessions were dpted to incorporte culturl icons, including fmous individuls from diverse Ltin Americn countries, thus reinforcing Ltino identity, contriutions to society, nd culturl pride. Promotores dvised voidnce of fer-sed messging due to the dily vulnerilities fced y underserved Ltino communities. Recommendtions from ll sites stressed tht y promoting culturl pride during the interctive group eduction sessions, common discrimintory myths nd stereotypes contriuting to HIV risk ehvior could e ted to fcilitte prticipnts intke of importnt HIV-relted informtion. Promotores lso recommended using ppeling pckging colors nd lyout to ensure community ppel. Following finl development, ll promotores prticipted in one-dy skills-sed trining on the study protocol, ethicl issues, nd intervention delivery techniques. All promotores received study mnul outlining procedures nd expecttions of promotores, including guidelines for recruitment nd interctive group eduction sessions content delivery. To id in the delivery of the interctive group eduction sessions, promotores were trined to use rotfolio, full-color, ilingul HIV prevention flip chrt developed to incorporte promotores insights nd recommendtions. Contents of the flip chrt mirrored the topics outlined previously nd included detiled script followed t ech interctive group eduction session. The script llowed promotores to deliver the sme content t ech interctive group eduction session nd ctively engge prticipnts in sequenced dilogue throughout the session. Roleply, ctive demonstrtion, oservtion, nd feedck throughout the trining y the reserch tem nd sitespecific coordintors ensured tht ll promotores were skilled in interctive group eduction session delivery nd reserch protocol prior to prticipnt recruitment. Prticipnt recruitment nd eligiility criteri The promotores used stndrdized scripts, including n introduction to the promotores nd project, nd the interctive group eduction session components to recruit prticipnts from community loctions. Prticipnts were recruited in Ltino-dominnt neighorhoods from pulic trnsporttion stops, outdoor mrketplces, community centers nd events, nd lundromts. Individuls were eligile to prticipte if they were t lest 18 yers of ge, self-identified s Ltino/Hispnic, nd resided in the service res of the prtnering community-sed orgniztions. After introducing the study, the promotores sked potentil prticipnts out their vilility nd interest in prticipting in n interctive group eduction session, which ws held from one dy to one week following recruitment. On the dy of the interctive group eduction session, ll prticipnts provided consent prior to prticipting nd received hrd copy of the

4 A Community Helth Worker HIV/AIDS Intervention 461 consent form. Prticipnts were given t-shirts for their involvement. Intervention The intervention consisted of one 60- to 90-minute interctive group eduction session held t vriety of ccessile loctions, including community helth clinics, community centers, housing complexes, schools, nd churches from April to June Tems of promotores delivered totl of 53 interctive group eduction sessions, which were given to groups comprising 3 25 prticipnts, with n verge of 13 prticipnts per group. To fcilitte interctive group eduction session effectiveness, ensure dequte time nd personnel to respond to ech prticipnt s questions, nd crete n opportunity for dilogue, collorting gencies ssiged 2 4 promotores per session, depending on the numer of recruits. The mjority of interctive group eduction sessions held in Sn Ysidro nd El Pso were conducted in Spnish. In Los Angeles, hlf were in English. Primry interctive group eduction session components included (1) project introduction; (2) n interctive ctivity emphsizing helthy Ltino culturl vlues such s fmilismo, personlismo, nd respeto; (3) HIV/AIDS trnsmission, prevention, nd testing informtion including discussion questions; (4) overview of generl Ltino culturl ttitudes out sexulity, including homosexulity, nd n ctivity to discuss culturl myths nd stereotypes; (5) informtion out how to discuss sex with children; (6) informtion out the concept of HIV/AIDS stigm; (7) novelit (story) out n HIV-positive neighor tht ws used to stimulte discussion of HIV/AIDS nd how HIV stigm cn ffect prevention; (8) wys to eliminte HIV/AIDS stigm; nd (9) strtegies to mintin personl nd fmily helth. The mjority of prticipnts ctively engged in discussions, shred their experiences, nd sked followup questions. Ech site exceeded its trget enrollment, demonstrting high community interest. Additionlly, promotores disseminted eight different trget groupspecific rochures in Spnish nd English to ech interctive group eduction session with stories on HIV prevention focused on fmilies, men, women, nd young people, s well s outrech crds contining fcts out the impct of HIV/AIDS on Ltino communities nd contct informtion for locl HIV testing sites, including ddresses, phone numers, nd HIV testing nd counseling services. METHODS The evlution consisted of pretest nd posttest surveys immeditely efore nd fter the intervention. Surveys were self- or verlly dministered (for low litercy) nd could e completed in English or Spnish. Detils on survey mesures, which were dpted from previous study, 16 re shown (Tle 1). Items were mesured on five-point Likert scle rnging from 1 (very uncomfortle/completely disgree) to 5 (very comfortle/ completely gree). To mesure sexul risk ehviors, we sked prticipnts to report the numer nd sex of their sexul prtners in the previous 12 months (i.e., mle, femle, or oth mle nd femle). We lso sked prticipnts to report if they hd engged in vginl nd nl sex in the previous six months, how frequently they hd used condoms during vginl nd nl sex in the previous six months, nd whether or not they hd hd ny HIV-positive sexul prtners in the previous six months. We used six-month rther thn 12-month time frme ecuse we nticipted etter recll of these ehviors. Dt were entered into dtse nd descriptive sttistics (i.e., mens nd percentges) were estimted to present seline chrcteristics of the smple. We compred demogrphic chrcteristics nd sexul risk ehviors cross sites t seline using the chi-squre test. Next, we estimted pired t-tests to compre pretest vs. posttest scores on HIV knowledge, HIV/AIDS stigm, willingness to e tested for HIV, willingness to communicte out HIV with sexul prtners, nd HIV risk perception. We tested for differences in intervention outcomes cross sites, y ge group, nd y sex y performing nlysis of vrince or t-tests on gin scores. We clculted gin scores y sutrcting pretest from posttest scores. 31 Finlly, we estimted descriptive sttistics for items mesured on the posttest only tht mesured prticipnts perceptions of the intervention. All nlyses were performed using Stt version RESULTS Smple profile A totl of 579 prticipnts ttended the interctive group eduction sessions: 204 in El Pso, 200 in Los Angeles, nd 175 in Sn Ysidro. More thn hlf (57%) were women, most (62%) prticipnts were ged yers, nd 55% were orn outside of the United Sttes, of which 97% were from Mexico. On verge, foreignorn prticipnts hd lived in the United Sttes for 14.8 yers (stndrd devition [SD] ). More thn one-third (35%) were single, 34% were mrried, nd 14% were cohiting. Most (67%) hd children.

5 462 Pulic Helth Evlution Tle 1. Description of HIV-relted knowledge, risk, communiction, nd stigm survey mesures included on pretest nd posttest surveys conducted with dult Ltinos who prticipted in community helth worker HIV/AIDS intervention in three southwestern U.S. cities, April June 2008 Construct Items Description HIV/AIDS stigm HIV/AIDS knowledge Willingness to communicte with sexul prtner out HIV/AIDS Willingness to seek HIV testing in next three months 9-item scle, α item scle, α item scle, α50.76 Comfort nd willingness to interct with people living with HIV/AIDS under hypotheticl scenrios, e.g., How comfortle would you e shring mel with person with HIV? True/flse questions ssessing HIV/AIDS knowledge, e.g., A person with HIV cn look nd feel helthy. c Willingness to suggest HIV testing/condom use to prtner(s), e.g., I m willing to suggest to my prtner tht he/she tke n HIV test. d 1 item Willingness to receive n HIV test, e.g., I m willing to hve n HIV test in the next three months. d HIV risk perception 1 item Personl risk for HIV, e.g., I m concerned out ecoming HIV infected. d Perception of the intervention 5 items Perception of the intervention, including whether or not their ttitudes, knowledge, nd ehvior hd or would chnge due to prticiption, e.g., After prticipting in the interctive group eduction session, I feel more compssionte towrd those with HIV/AIDS. e Cronch s lph is shown for ll vriles tht were mesured using multi-item scles, with the exception of perception of the intervention, in which items were not comined into scle ecuse they mesured distinct vriles. Items were mesured on five-point scle rnging from 1 (very uncomfortle/completely disgree) to 5 (very comfortle/completely gree). Items were reverse coded so tht higher scores indicte greter stigm. c Correct responses were coded s 1 nd incorrect responses were coded s 0. Scle scores were creted y verging the numer of correct responses for nonmissing items nd then multiplying tht numer y 8. Higher scores indicte greter knowledge. d Responses were scored on five-point scle from 1 (completely disgree) to 5 (completely gree). e Items mesuring perception of the intervention were included on the posttest only. HIV 5 humn immunodeficiency virus AIDS 5 cquired immunodeficiency syndrome Slightly less thn hlf of prticipnts reported Spnish s their preferred lnguge. Aout one-fifth of prticipnts reported #middle school s their highest eduction level, while 36% hd t lest some college. Forty-eight percent were uninsured (Tle 2). We found significnt differences in seline chrcteristics cross sites. A higher percentge of prticipnts in Los Angeles vs. Sn Ysidro nd El Pso were single nd hd no children. Foreign-orn prticipnts constituted the mjority (87%) of those in Sn Ysidro, more thn hlf (56%) in El Pso, nd out one-qurter (26%) in Los Angeles. Eduction levels lso vried, with prticipnts in Los Angeles reporting the highest eduction levels nd those in Sn Ysidro the lowest. The percentge of prticipnts ged $45 yers ws more thn twice s high in Sn Ysidro s in the other two sites (Tle 2). Most prticipnts reported either one (54%), no (11%), or two (10%) sexul prtners in the previous 12 months; however, 6% reported $6 prtners. We found significnt differences cross sites in the numer of sexul prtners reported in the lst 12 months, with those in Los Angeles reporting higher numer of prtners (p). More thn three-qurters of prticipnts (77%) reported only heterosexul prtners in the previous 12 months, while 20% reported ny sme-sex prtners. The type of sexul prtners lso vried y site, with higher percentge of Los Angeles prticipnts (41%) reporting ny sme-sex prtners compred with the other two sites (p). More thn two-thirds (66%) reported hving hd vginl sex in the previous six months, nd 18% reporting hving hd nl sex during the sme time period. Significnt differences were found cross sites regrding these mesures. In Los Angeles, 31% of prticipnts reported nl sex in the previous six months compred with 12% of prticipnts in El Pso nd 11% of prticipnts in Sn Ysidro (p). Among prticipnts reporting vginl sex, 16% reported consistent use of condoms during sex, while 38% of those reporting nl sex reported consistent condom use. Overll, 62% of prticipnts reported ever hving een tested for HIV, ut this percentge vried significntly cross sites, with the highest percentge in Los Angeles (p50.004). Among those tested, 5% reported not knowing or not receiving their lst HIV test result. Two percent of prticipnts

6 A Community Helth Worker HIV/AIDS Intervention 463 Tle 2. Socil nd demogrphic chrcteristics of prticipnts in community helth worker HIV/AIDS intervention conducted in three southwestern U.S. cities showing differences cross sites in prticipnt chrcteristics, April June 2008 Chrcteristics Totl (n5579) El Pso, Texs (n5204) Sn Ysidro, Cliforni (n5175) Los Angeles, Cliforni (n5200) P-vlue Sex Mle Femle No dt Age (in yers) $ No dt Numer of children $ No dt Highest level of eduction #Middle school Some high school to high school grdute/ GED Preprtory, technicl, or voctionl Some college $College grdute No dt Mritl sttus Single Cohiting Mrried Seprted, divorced, or widowed No dt Ntivity U.S.-orn Foreign-orn Men time in the United Sttes: yers (SD) 14.8 (11.8) 11.9 (9.7) 14.1 (11.5) 22.8 (13.3) No dt Preferred lnguge Spnish English Both No dt Hs medicl insurnce No Yes No dt Dte of lst generl physicl exmintion Within the lst 5 yers $5 yers go Never No dt P-vlues otined from Person s chi-squred test nd one-wy nlysis of vrince to test for sttisticlly significnt differences in mens or proportions mong sites Among prticipnts who were foreign-orn HIV 5 humn immunodeficiency virus AIDS 5 cquired immunodeficiency syndrome GED 5 generl eductionl development SD 5 stndrd devition

7 464 Pulic Helth Evlution Tle 3. Recent sexul ehviors reported y prticipnts in community helth worker HIV/AIDS intervention conducted in three southwestern U.S. cities showing differences cross sites in sexul ehviors, April June 2008 Sexul ehvior Totl (n5579) El Pso, Texs (n5204) Sn Ysidro, Cliforni (n5175) Los Angeles, Cliforni (n5200) P-vlue Numer of sexul prtners, lst 12 months $ No dt Type of sexul prtnerships, lst 12 months Only opposite-sex prtners reported Any sme-sex prtners No dt Hd vginl sex, lst 6 months Yes No No dt Consistent condom use during vginl sex, lst 6 months c Yes No No dt Hd nl sex, lst 6 months Yes No No dt Consistent condom use during nl sex, lst 6 months d Yes No Hd sex with n HIV-positive person, lst 6 months Yes No Not sure No dt Ever een tested for HIV Yes No No dt Most recent HIV test e 0.001,1 yer go Within 1 2 yers Within 2 5 yers yers go No dt Result of most recent HIV test e HIV negtive HIV positive Don t know/did not get result No dt P-vlues otined from Person s chi-squred to test for sttisticlly significnt differences in proportions Among prticipnts who reported eing sexully ctive in the lst 12 months c Among prticipnts who reported hving vginl sex in the lst 6 months d Among prticipnts who reported hving nl sex in the lst 6 months e Among prticipnts who reported ever eing tested for HIV HIV 5 humn immunodeficiency virus AIDS 5 cquired immunodeficiency syndrome

8 A Community Helth Worker HIV/AIDS Intervention 465 Tle 4. Chnges from pretest to posttest scores in HIV/AIDS-relted knowledge, ttitudes, nd intentions mong prticipnts in community helth worker HIV/AIDS intervention in three southwestern U.S. cities, April June 2008 Outcome mesure N Pretest scores Posttest scores Difference in men scores (pretest to posttest) P-vlue HIV/AIDS knowledge (rnge: 0 8) (5.9, 6.2) 7.1 (7.0, 7.2) 1.1 HIV risk perception (rnge: 1 5) (3.6, 3.8) 3.9 (3.7, 4.0) HIV/AIDS stigm (rnge: 1 5) (2.4, 2.6) 2.2 (2.1, 2.2) 20.3 Willingness to communicte with sexul (3.9, 4.1) 4.2 (4.1, 4.3) 0.2 prtner out HIV/AIDS (rnge: 1 5) Willingness to seek HIV testing in next three months (rnge: 1 5) (4.2, 4.4) 4.3 (4.3, 4.4) On scle from 0 to 8, where 0 5 low nd 8 5 high On scle from 1 to 5, where 1 5 low nd 5 5 high HIV 5 humn immunodeficiency virus AIDS 5 cquired immunodeficiency syndrome CI 5 confidence intervl reported n HIV-positive sexul prtner in the lst six months (Tle 3). Chnge in outcomes from pretest to posttest HIV/AIDS stigm scores decresed from pretest to posttest (2.5 vs. 2.2; t511.2, p). HIV/AIDS knowledge scores incresed significntly from pretest to posttest (6.0 vs. 7.1; t5215.8, p), s did perceptions of HIV risk (3.7 vs. 3.9; t522.8, p50.006) nd willingness to communicte with one s sexul prtner out HIV/AIDS (4.0 vs. 4.2; t523.8, p). No significnt differences were found in willingness to seek HIV testing in the next three months for the smple overll (Tle 4). Differences in gin scores cross sites nd prticipnt chrcteristics We found differences in gin scores y sex for two outcomes (Tle 5). There ws greter decrese in men HIV/AIDS stigm scores from pretest to posttest mong women thn mong men (20.4 vs. 20.2, t522.4, p50.016). Additionlly, the increse in men HIV/AIDS knowledge score from pretest to posttest ws greter mong women thn mong men (1.3 vs. 0.9, t52.7, p50.007). There were no differences in gin scores y site or ge group. Prticipnt evlution of the intervention On the posttest survey, 28% greed nd 64% completely greed tht they understood lot more out HIV/AIDS fter the intervention. Additionlly, 26% Tle 5. Differences etween mles nd femles in HIV/AIDS knowledge score chnges nd HIV/AIDS stigm score chnges following prticiption in community helth worker HIV/AIDS intervention conducted in three southwestern U.S. cities, April June 2008 HIV/AIDS knowledge HIV stigm Sex Pretest scores Posttest scores Gin score (95% CI) Pretest scores Posttest scores Gin score (95% CI) Femle 5.8 (5.6, 6.0) 7.1 (7.0, 7.2) 1.3 (1.1, 1.5) 2.6 (2.5, 2.7) 2.2 (2.1, 2.3) 20.4 (20.5, 20.3) Mle 6.3 (6.0, 6.5) 7.2 (7.0, 7.3) 0.9 (0.7, 1.1) 2.4 (2.3, 2.5) 2.1 (2.0, 2.3) 20.2 (20.3, 20.2) Difference in gin score, t52.7, p Difference in gin score, t522.4, p HIV 5 humn immunodeficiency virus AIDS 5 cquired immunodeficiency syndrome CI 5 confidence intervl

9 466 Pulic Helth Evlution greed nd 63% completely greed tht they felt more compssion towrd those with HIV/AIDS, nd 27% greed nd 62% completely greed tht they felt more comfortle tlking out sex nd sexulity fter the intervention. When sked whether or not they thought tht their helth ehvior would chnge s result of their prticiption, 82% indicted tht they would e more likely to prctice sfe sex nd 79% indicted tht they would e more likely to help or e ssocited with n HIV-positive person (dt not shown). LESSONS LEARNED Results suggest tht promotores-led intervention is promising strtegy to reduce HIV/AIDS stigm nd improve HIV/AIDS knowledge, increse comfort communicting out HIV/AIDS with sexul prtners, nd increse HIV risk perception, ll of which re relevnt for HIV prevention. However, we did not find chnges in prticipnts willingness to test for HIV within the next three months. The lck of mesurle chnge in willingness to e tested for HIV my reflect prticipnts perceptions of low personl risk for HIV. High percentges of prticipnts reported hving hd only one or no sexul prtners in the previous 12 months, nd hlf were mrried or cohiting, perhps contriuting to low perception (rel or perceived) of HIV risk. Importntly, consistent condom use ws low, so even prticipnts with one sexul prtner my hve een t risk for HIV, depending on prtners sexul ehvior. Another explntion for the lck of chnge in this mesure my e tht other structurl or socil fctors ply role in prticipnts willingness to e tested for HIV, fctors tht were not ddressed y the intervention. A recent study tht exmined the correltes of pst voluntry HIV testing nd counseling mong 135 middle-ged nd older Ltins in South Florid found tht the strongest predictors of receiving previous HIV test were helth-cre provider s endorsement nd hving clinic s regulr source of helth cre. 5 It my e tht for Ltinos in the generl popultion who perceive themselves to e t low risk for HIV, helthcre providers would e more compelling messengers thn promotores to motivte HIV testing ehvior. It my lso e tht Ltinos lck ccess to regulr source of helth cre, which is mjor rrier to HIV testing. We found greter reduction in HIV/AIDS stigm scores from pretest to posttest mong women thn mong men, nd greter pretest to posttest increse in HIV/AIDS knowledge scores mong women. This finding my reflect higher levels of HIV/AIDS stigm nd lower HIV/AIDS knowledge mong women t seline, nd, therefore, greter impct on these outcomes s result of the intervention. At posttest, the knowledge nd stigm scores were comprle for men nd women. Limittions This study ws suject to severl limittions. We were unle to include control group in our study due to resource constrints. Furthermore, ecuse the posttest survey ws conducted immeditely fter the intervention, we do not know if the chnges oserved persisted over time, nd we were unle to mesure ctul HIV testing ehvior fter the intervention. It is lso possile tht socil desirility is my hve influenced prticipnts responses. Finlly, the generlizility of our results ws limited. Our smple included prticipnts who were ville to tke prt in group session, so those who were too usy to prticipte or not willing to prticipte in group session were not represented. Furthermore, the smple ws predominntly of Mexicn descent, reflecting the chrcteristics of the Ltino popultions in the southwestern United Sttes. As such, the results my hve een different if the study were conducted with other sugroups of Ltinos in other geogrphic regions. CONCLUSION This study contriutes to the growing literture documenting promotores s effective messengers of HIV prevention to Ltinos. Future studies should evlute this model using experimentl or qusi-experimentl study designs. It is importnt tht future studies try to lern more out the components of this type of intervention tht re criticl to its success. One element tht my hve contriuted to the chnges oserved in this intervention ws the use of HIV-positive nd -ffected promotores to deliver the intervention. Contct with HIV-ffected groups hs een identified s n importnt strtegy in efforts to reduce HIV/AIDS stigm. 10 Further reserch should test whether HIV-unffected promotores re s effective s HIV-ffected promotores t delivering this type of intervention. Another fctor of potentil importnce is n emphsis on positive culturl trits. While the mjority of reserch regrding Ltino culture hs emphsized mchismo nd mrinismo, two negtively perceived culturl trits, positive Ltino vlues nd culture my help to uild feelings of self-worth nd dignity nd contriute to prticipnt receptivity nd motivtion to tke ction. Other scholrs hve lso commented on the importnce of uilding on positive spects of culture in HIV interventions. 30 Given the high risks of HIV infection, low rtes of

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