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Purpose: The community-based participatory research approach has been identified as a great asset in reducing health disparities through the integration of community members in all phases of the research process. It is essential to provide skills to community members to achieve successful research partnerships. The purpose of this study is to evaluate the feasibility, acceptability, and preliminary efficacy of the community-based participatory research training curriculum for community members. Methods: Using mixed-methods, noncomparative design, eight workshops were developed and tested. Workshops covered topics such as community-based participatory research principles, health disparities, ethics in community-based participatory research, and fundamentals of research methodology. A total of 25 community leaders were trained. Pre-/post-test knowledge (unpaired t-test), retention rate, workshop satisfaction, and cognitive debriefing sessions were used to assess knowledge gained and acceptability and feasibility of the curriculum. Results: A retention rate of 100% and an average satisfaction of 92.68% were obtained. Preliminary effectiveness results indicate that there was an overall significant change in participant's knowledge before and after the curriculum (p<0.001). In the cognitive debriefing, participants were satisfied with the organization and structure and found the curriculum feasible. Furthermore, participants identified the skills acquired to aid in being more effective in their communities and work with academic researchers. The following changes were recommended: workshops' order, time, practical activities, and level of language. Discussion: Findings from this study suggest that the curriculum was acceptable and feasible to community leaders and that it might provide skills to actively incorporate community members in research activities. A large randomized clinical trial (RCT) study to evaluate curriculum effectiveness is recommended.

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INTRODUCTION: Effective communication skills that foster responsible sexual decisions are known to have the potential to reduce the risky adolescent sexual behavior. It is well understood that maternal communication is a key element in modifying the adolescent sexual behavior. The objective of this qualitative study was to explore if Puerto Rican mothers of adolescent girls have conversations about sexuality with their daughters and the content of such conversations. METHODS: A total of 22 HIV-seropositive mothers and 22 HIV-seronegative mothers were enrolled. Six focus groups were conducted, sessions were transcribed ad-verbum and coded for specific topics. All qualitative analysis was incorporated into Atlas.ti. RESULTS: Participants in both groups had a similar average age (mean=41 years old); but, the HIV-seropositive mothers were more likely single, less educated and unemployed. Regarding having engaged in conversations about sexuality and the topics covered, however, there were no differences revealed among HIV-seropositive mothers and seronegative mothers. In both groups, mothers understood the importance of these conversations, but most said they were difficult and uncomfortable. CONCLUSION: These findings reinforce the importance of communication between mothers and daughters for the prevention of STIs, HIV/AIDS, and teenage pregnancy in minority populations.Interventions are needed for mother and daughter to improve communication skills, communication about sexuality, and addressing prevention.

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PURPOSE: To identify perceived barriers and facilitators for HAART adherence among people living with HIV/AIDS in Southern Puerto Rico using a Social Ecological framework. PATIENTS AND METHODS: Individual in-depths interviews were conducted with 12 HIV patients with a history of HAART non-adherence. Interviews were audio-taped and transcribed. Content analysis was performed for each transcribed interview by three independent coders using a codebook. Using Atlas TI, super-codes and families were generated to facilitate the categorization tree as well as grounded analyses and density estimates. RESULTS: Most participants reported a monthly income of $500 or less (n = 7), a high school education level (n = 7), being unemployed (n = 9) and being recipients of government health insurance (n = 11). Three out of six women reported living alone with their children and most men informed living with their parents or other relatives (n = 4). For the grounded analyses, the top four sub-categories linked to high number of quotations were mental health barriers (G = 32) followed by treatment regimen (G = 28), health system (G = 24) and interpersonal relations (G = 16). The top four sub-categories linked to high number of codes are treatment regimen (D = 4), health status perception (D = 3), interpersonal relations (D = 3) and health system (D = 3). CONCLUSION: The results of this study suggest the interconnection of HIV treatment adherence barriers at various system levels. Future studies on HIV treatment barriers should explore these interactions and investigate the possible synergistic effect on non-adherent behavior.

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OBJECTIVE: HIV felt stigma is a major problem needing to be addressed because of its association with poor treatment adherence, decreases in help-seeking behaviors, high-risk sexual conduct, emotional discomfort, and the reduction of well-being in people with HIV/AIDS (PWHA). The aim of this study was to identify the frequency of felt stigma among PWHA in Puerto Rico. METHODS: A cross-sectional study was conducted with 249 subjects (59% men, 41% women). Participants completed the Puerto Rico Comprehensive Center for HIV Disparities (PR-CCHD) Sociodemographic Questionnaire and the HIV Felt Sigma Scale. RESULTS: 80% of the subjects showed some level of felt stigma. Women showed significantly higher levels of HIV-related felt stigma than did men. Disclosure, negative self-image, and public attitude scores were also higher in women than in men. Sociodemographic variables such as age, marital status, employment status, income, and educational level showed significant associations with felt stigma and its dimensions. CONCLUSION: Results of this study evidence the need to develop culturally sensitive intervention models to reduce the felt-stigma burden in PWHA.

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Though many studies have conclusively linked felt stigma and HIV, few have focused on the experiences of rejection felt by members of such socially marginalized groups as intravenous drug users (IDU) and sex workers (SW). Using focus groups, our study explored these experiences in 34 individuals (17 male UDUs and 17 female SWs) at risk of becoming infected with HIV, the objective being to discover why they engaged in maladaptive behaviors as a way of coping with felt stigma. We used deductive and inductive analysis to codify the resulting data. Concepts associated with the word stigma, emotional reactions to felt stigma, and the impact of felt stigma on self-schema helped elucidate how the internalization of felt stigma can lead to negative affective states and self-destructive behaviors (e.g., drug use and syringe exchange). Results underline the importance of developing intervention models that reduce stigma as a means of HIV prevention in vulnerable populations.

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The objective of this study was to culturally adapt and validate a scale to measure HIV-related felt stigma in a group of People living with HIV/AIDS (PLWHA) in Puerto Rico. The researchers conducted a two-phase cross-sectional study with 216 participants (60, first phase; 156, second phase). The first phase consisted of the cultural adaptation of the scale; the second evaluated its psychometric properties. After conducting a factor analysis, a 17-item scale, the HIV Felt-Stigma Scale (HFSS), resulted. Participants completed the Puerto Rico Comprehensive Center for the Study of Health Disparities Socio-demographic Questionnaire, the HFSS, the Beck Depression Inventory-II, and the Sexual Abuse dimension of the History of Abuse Questionnaire; the case managers completed the Case Manager Stigma Guide with subjects. The HFSS measures four dimensions: personalized stigma, disclosure concerns, negative self-image, and concern with public attitudes. The alpha and Pearson correlation coefficients (0.91 and 0.68, respectively) indicated satisfactory validity and reliability; the scale suggested adequate convergent validity. The HFSS is a culturally sensitive instrument that fills the existing gap in the measurement of felt stigma in Spanish-speaking PLWHA.

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In an era of significant biomedical advances in the treatment of HIV, health disparities still persist. The participation of minority researchers brings new perspectives to health-disparities research. Mentoring is key to this process. We present the multifaceted mentoring model that evolved in the Puerto Rico Comprehensive Center for the Study of HIV Disparities and the Mentoring Institute for HIV and Mental Health. The model includes (1) multi-institutional collaborations, (2) competency development, and (3) cross-disciplinary teams. These aspects of the model provide guidelines for institutions seeking to formalize mentoring programs while addressing the complexities of health disparities. The competency development component is a powerful tool in assessing and supporting the researchers. Further explorations on the applicability of the model are encouraged.

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INTRODUCTION: Two hundred and thirty nine (239) drinking water systems in Puerto Rico are not connected to the Puerto Rico Aqueducts and Sewers Authority (PRASA), and are thus known as Non-PRASA drinking water systems. Population served estimates by Non-PRASA systems are in the 100,000 to 300,000 range. OBJECTIVES: To identify the determinants of compliance with drinking water standards by rural drinking water systems in Puerto Rico. To identify the best analytical methods for studying the problem of non-compliance with drinking water standards in Puerto Rico and its generalization to similar communities elsewhere. METHODS: We reviewed capacity development and drinking water system evaluations performed by governmental and academic institutions between 1993 and 2004. Community and system variables were used to fit a multilevel model to predict compliance with drinking water standards. Data was obtained from the Environmental Protection Agency' Safe Drinking Water Information System and the Puerto Rico Health Department drinking water database for 231 systems, serving 90,000 persons. RESULTS: There was an 11% increase in compliance (1996 = 4%; 2000=15%), a decrease of 13,634 people served by non-compliant systems (1996 = 86,169; 2000 = 72,535) and a 6% decrease in the number of non-compliant systems which had installed treatment equipment (1996 = 93%; 2000=87%). The prevalence of compliance among those systems that had installed treatment equipment was higher than among those systems that did not have treatment equipment, after adjusting by the time period (est. POR = 2.2, 95% CI, 1.40 - 3.44). CONCLUSIONS: Our findings suggest alternative public health strategies are needed to ensure sustained safe water capacity in rural communities.

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In this study, the RESPECT-2, an HIV risk reduction intervention developed by the Centers for Disease Control and Prevention, was translated into Spanish and culturally adapted to the Puerto Rican population. A new intervention emerged called the RReduC-PR (Risk Reduction Counseling-Puerto Rico). This instrument allows the assessment of sexual behaviors and development of risk reduction plans. Women from three distinct risk behavior groups participated: women recruited from a community-based organization (CBO), which includes street sex workers, crack users, and sexual partners of intravenous drug users; participants from a sexually transmitted infection (STI) clinic; and participants from a family planning clinic (FPC) in Puerto Rico. As part of the RReduC-PR, participants were provided counseling before and after a rapid HIV test to explore their attitudes about sexual behaviors. At baseline, all participants from the FPC reported having monogamous relationships (100%), as compared with the participants from the STI clinic (70%) and those from the CBO (20%). STI risk-reduction behaviors varied by site. Most of the participants acknowledged risk behaviors that may have exposed them to HIV. They did not use condoms, or used them inconsistently, even though acquiring HIV was a great concern for them. Most regarded a positive HIV diagnosis as a negative event. Their attitudes toward an HIV diagnosis varied by site. The groups varied in the perception of risk behaviors, knowledge, and concerns. These findings provide useful information for future risk-reduction interventions with these women.

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The AIDS pandemic had a significant impact in Puerto Rico, especially among the heterosexual populations, in particular women. Women are one of the fastest growing risk groups with HIV/AIDS in the USA and constitute about half of the AIDS cases in the world. During the past 10 years Puerto Rico has ranked among the top 5 jurisdictions in the United States in AIDS cases rates, among men, women and children. In 1987 a universal prenatal HIV screening program was implemented in the University Hospital catchment area consisting of approximately 5,000 deliveries per year. Because of the early identification of pregnant women living with HIV, access to lifesaving clinical research and the implementation of multiple strategies and comprehensive care, the perinatal HIV transmission has been reduced to zero since 1997, with a blip of one case in 2002, and none since then. The availability and access to clinical and behavioral research has been one of the key elements for this success story. The programs involved and responsible for this spectacular outcome, namely the Maternal Infant Studies Center (CEMI-Spanish Acronym) and Gamma Projects at the University of Puerto Rico School of Medicine are described. The cost savings impact of stopping mother-infant perinatal HIV-1 transmission has been calculated to be approximately $34 to $58 million dollars in 10 years. The impact of the effectiveness of these programs in having healthy uninfected infants, prolonging and improving the quality of life of those living with HIV, and providing hope to families affected by this epidemic is incalculable.

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Because of improved therapeutic strategies, both human immunodeficiency virus (HIV) infection and breast cancer can be considered life-threatening illnesses that eventually become a chronic condition. Both diagnoses carry a psychological impact, stigma, body alterations, intense medical evaluations, and therapies. Both conditions are prevalent among minorities, especially women of Hispanic heritage. This article describes an empowerment intervention originally designed for women living with HIV and adapted for women with a diagnosis of breast cancer. We will describe the conceptual framework for the intervention and the rationale for the chosen groups. The Women's Empowerment Intervention Model consists of a series of six full-day workshops in which multiple biopsychosocial dimensions are explored within the group, and diverse experiential activities are carried out related to the day's topics. The workshops were modified to deal with the specific issues that women confront when diagnosed with breast cancer. This model was chosen precisely because it deals with specific aspects of healing and living with a chronic illness. We propose that HIV should be viewed as a chronic condition and compared to other conditions that affect women's lives in similar ways.

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This paper examines the narrative testimony of women survivors of two atrocious events that took place in the XX century: the Holocaust in the 40's and the HIV/AIDS pandemic in the 80's. The author recognizes similarities in thoughts, feelings, experiences and meaning regarding several issues of human suffering that emerge from these testimonies. It expounds the perceptions on death, motherhood, family separation, intimacy and sexuality. For the author approach of these issues from a female perspective can provide new meanings arrived at the development of a new discourse and new social practices. Promotes to think about reactions of indifference before human suffering. Concludes by questioning why technological, scientific advances and advances in social development have not been able to provide human responses to human problems.

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Theater of Life is an educational model that integrate theater theories and techniques as a strategy for health education. Theater as an educational technique has become a useful tool for the health context. In this work the author discuss the role of social change as an important element in health education and suggests the use of theatrical techniques for it's promotion. Also offers information about the different approaches of popular theatre and popular education incorporated in this model, Theatre of the Oppressed by A. Boal, Popular Education by P. Freire, Poor Theater by J. Grotowoski and Education for Peace by C. Beristain and P. Cascón and explain the basic principles of each one of them. In the methodology section the author explains the different steps for implementing the strategy: solidarity and connection games, story telling technique and script development, presentation and forum. In the practice section the author shares the process of model development and the significance events that had contribute to their elaboration.

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Women have been placed at a vulnerable situation regarding the HIV epidemic. Recent advances in antiretroviral therapies have placed in evidence the gender disparities and the new challenges to overcome them. The mortality of AIDS has decreased dramatically in the United States and Puerto Rico as a consequence of new combination therapies. Still, women constitute the fastest growing group of AIDS cases. There are gender differences in access to treatment and care, economic income and social and personal power. Among women's barriers to care are the lack of knowledge about AIDS in women by health providers, the family responsibilities and the burden and fear of disclosure. The authors suggest the need for empowerment as strategy for attaining better health and improving the quality of life in women living with HIV.

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Women's needs are different from men's; the research and services related to HIV/AIDS have been focused in men's needs. The implication of this approach is that it has had very serious consequences for women who live with HIV/AIDS. It has resulted in health professionals failing to understand the emergence of the symptoms, the complications, the necessary treatments, and the complex patterns of progression of the disease. Oral testimonies are an alternative methodology for the development of theoretical and intervention models that incorporate issues pertaining to the life-styles and world-view of women with HIV and other socially alienated people. Through the testimonies of three women living with HIV the author discusses concepts such as social stigma, family, spirituality, and human solidarity and denounces the oppression, exclusion and dehumanization experiences that these brave women have experienced as a result of living with this condition.

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The HIV/AIDS epidemic has presented many challenges to both: researchers and care providers. In addition, the concepts and models of human behavior needed a re-examination in response to this pandemic. We are redefining both empowerment and sexual negotiation for women living with HIV. Empowerment is defined as a process of awareness throughout which women recognize their capacity to achieve individual and social changes. This process involves a mental and spiritual awareness that will enable them to focus on their physical, psychological and social aspects. For women living with HIV, this is also a strategy for survival. For women living with HIV, sexual negotiation is a straightforward issue: it is either safer sex or nothing. Safer sexual practices then are a consequence or by-product of the process of empowerment. To facilitate this process our approach is directed to the individual, in an attempt to reach the inner power source that all human beings share.

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