1. Rachel Jones, PhD, RN, FAAN - School of Nursing & Institute on Urban Health Research- Northeastern University Donald R Hoover, PhD, MPH, Rutgers University Lorraine Lacroix, MPH, Northeastern University

2. National Institute of Nursing Research R01NR10860 National Library of Medicine G08 LM008349 Healthcare Foundation of New Jersey

6. Women had unprotected sex with partners they believed engaged in HIV risk behaviors Jones, 2006; Jones & Gulick, 2009 Patterns of Unprotected Sex Among Women Importance of unprotected sex to win and hold onto a man and to show trust Jones & Oliver, 2007

8.  Sex scripts: socially shared meanings about sex behavior (Simon & Gagnon, 1989)  Power as Knowing Participation in Change® (Barrett, 2010) ▪ being aware of what one is chooses to do ▪ feeling the freedom to act intentionally ▪ being involved in creating the changes that one intends  People participate in change, but not always in a knowing manner Jones, 2006; Jones & Oliver, 2007

9.  Lower power sex scripts: risks of HIV are buried under an awareness of oneself as having to satisfy a man and accept cheating.  What He’s Doing for Me; As Long as He Comes Home to Me ;Gotta Do What You Gotta Do  Higher power sex scripts. Expanding awareness of one’s own value as a woman, recognition that there are choices, engaging the will to pursue these choices.  Intentional use of condoms, abstaining, and HIV testing. ▪ Use a Condom or You Wont Go With Me; Girl Power; Expecting Sex is Not All Right;You Don’t Own Me Jones, R. (2006) Sex Scripts and power: A framework to explain urban women’s HIV sexual risk with male partners. Nursing Clinics of North America, 41, 425-436. Jones, R. & Oliver, M. J. (2007). Young urban women’s patterns of unprotected sex with men engaging in HIV risk behaviors. AIDS & Behavior, 11 (6), 812-821.

10. If women are more powerful, meaning, they are more aware of themselves as worthy of respect, make choices intentionally, feel free to pursue their intentions, and involve themselves in creating change,  they are less likely to follow a lower power sex script of unprotected sex with a high risk partner.

11.  By popularizing higher power sex scripts and associating these with familiar scripts, new health promoting behaviors are more likely to be adopted  The health promotion messages are designed to satisfy these needs while promoting health. Stacy, Newcomb, & Ames, (2000).

13. Entertainment-Education Stories grounded in urban women’s own experiences Women identify with the heroines’ process of change Messages to reduce HIV risk fulfill familiar relationship needs Soap Operas Singhal, Cody, Rogers, Santelli,, 2004 2

14. A Story about Toni, Mike, and Valerie  43 minute pilot video available at: www.womenspoweragainsthiv.com www.womenspoweragainsthiv.com Jones, 2008; Jones & Oliver 2007

15. Twelve, 15-20 minute episodes; Written & scripted by study team, professional filmmaker(Alan Roth), and actors

16.  1:1 randomized controlled trial (RCT)  Comparing LS&C to 12-week HIV prevention intervention of text messages  Both groups used study-provided smartphones Jones & Lacroix, 2012  Expected Outcome  Video intervention participants have less unprotected vaginal and anal sex with high risk partners at 3 months (T2) and at 6 months (T3) than the comparison text message group

17.  Unprotected anal and vaginal sex using the vaginal episode equivalent (VEE)* with high risk partners ∑ (#UV) i + 2 (#UA) i )= sex risk  the sum of the # of unprotected vaginal sex acts + 2 x the number of unprotected anal sex acts, where i is the # of high risk partners in the past 3 months * Susser, Desvarieux, & Wittkowski (1998), Reporting sexual risk behavior for HIV: A practical risk index and a method for improving indices. American Journal of Public Health, 88, 671-674.

18.  18 to 29 year old women ▪ Inclusion criteria: ▪ Had unprotected vaginal / anal sex with men they believed had sex with other women/men, and/or injected drugs -past 3 months  Recruited in Newark, Jersey City, East Orange, & Irvington, NJ from:  Public housing, STD Clinics, Community Center, Storefront, Food Pantry  Screening, Baseline, and Post-Intervention Interviews conducted with Audio Computer Assisted Self-Interview (ACASI)

19. Video (n=117) Written (n=121) Sent weekly for 12 wks√√ Study provided smartphones√√ Weekly email to phone with link to open intervention√√ F/u contact if missed weekly emails √√ Can watch/read current & previous episodes /messages 24/7√√ Track Frequency√√ Track viewing time√ Responds on the phone with reason for re-watching√ Responds on the phone with answers about content√√

20.  Outcome = VEE with high risk partners at T2 (3 mo), and T3 (6 mo)  Due to skewness (VEE +0.5) was log transformed  Repeated measures mixed linear models that adjusted for baseline behavior were fit

22. 505 screened -295 eligible, consented, randomized -57 lost to f/u, most due to lost cell phones 238 completed T2 and T3 post-intervention interviews -117 in Video Group -121 in Text Group

23. Table 1. Baseline Equality of Video and Text Arms * Note- The intervention groups did not differ on any of these variables at p < 0.05 by exact test or Wicoxon test VariableText (n=121)Video (n=117) Mean ± std-dev or % Age (years)22.0 ± 3.422.1 ± 3.6 Age at first sexual intercourse (years)14.4 ± 1.814.5 ± 2.2 Highest grade completed12.2 ± 1.712.22 ± 1.7 African American/Black90.1%86.32% Employment outside home36.4%40.2% Study Site Community center Public Housing Food Pantry Storefront STD Clinics 14.1% 30.6% 14.1% 19.0% 22.3% 18.8% 30.8% 10.3% 17.1% 23.1% Used Alcohol before /during sex81.8%75.2% Injected drugs2.53.4 Any unprotected vaginal sex with a high risk partner99.2% Any unprotected anal sex with a high risk partner 40.5%47.9% Sexual Pressure Score25.5 ± 15.329.7 ± 16.3 Sensation Seeking Score13.6 ± 6.915.1 ± 7.5 High Risk Sex Scripts Score 5.1± 5.96.6 ± 7.4 Any Male partner had sex with other women99.2%100% Any Male partner had sex with men29.8%41.9% Any Male partner injected drugs25.6%31.6%

24.  Almost half had unprotected anal sex in the prior 3 months with high risk partners.  Half (n=121, 51%) had 3 or more partners  A surprising number knew/ suspected their partners had sex with men –42 % Video vs 30% of Text arm, P =0.06.  Over half the sample (56.7%) had first coitus at ≤ 14 years old.

25. 1.P > 0.20 from Wilcoxon test for difference in VEE between Video Arm and Text Arm at each of the three time points NOTE THE DRAMATIC DECLINE IN VEE FOR BOTH GROUPS FROM BASELINE TO T2 and T3. ALL DECLINES AT P < 0.001 Geometric Mean Of VEE Acts Point Estimate ± Standard Error Text ArmVideo Arm At baseline 1 21.32 ± 2.8322.20 ± 3.01 Follow Up At T2 (3 months) 1 6.55 ± 1.025.70 ± 0.84 At T3 (6 months) 1 5.93 ± 0.914.85 ± 0.73

26. 1. From Mixed Model Linear Regression on log transformed VEE at T2 and T3 with log baseline VEE as a covariate. Video Vs. Text and time points T2 Vs. T3 are forced into the model, otherwise only variables with P < 0.20 in Adjusted Models are included. Pre-intervention baseline VEE is included in all models. 2. NOTE – Age, Age at First Sex, Ethnicity, Work Outside of Home, Education, Sexual Pressure Score, Sensation Seeking Score, and Any Male Partner had sex with Men did not meet the P < 0.20 Selection criteria 3. From exponentiation of parameter estimates from mixed linear regression models with Log transformed VEE at post intervention Visits 2 and 3 as outcomes. 4. Overall P-value for study site association with post intervention behavior was 0.03 in the multivariate model Characteristic 2 Association With Ratio of the Post to Pre intervention VEE Behavior 3 Point Estimate( ±SE)P Video (Vs Text).0.81±0.130.21 Visit 3 (Vs Visit 2)0.88±0.080.17 High Risk Sex Script/ Log Unit0.87 ±0.08 0.10 Study Site 4 Community center Public Housing Food Pantry Storefront STD clinics 1.48 2.10 1.73 1.74 Baseline ±0.39 ±0.48 ±0.50 ±0.45 NA.03 -OVERALL 4 0.12 0.002 0.06 0.03 NA

27.  Sex risk behavior declined by 19% more in the soap opera video group than the HIV prevention text group. Difference was not statistically significant (p=0.21).  VEE risk behavior was ~12% lower at T3 (6 Mo) than T2 (3 Mo) in both groups, this difference between time points was not statistically significant (p = 0.17)  Greater post-baseline risk reduction of VEE at STD clinic sites than in storefront or public housing.

28. Evaluation of ‘Love, Sex, and Choices’(N=117) No N (%) Don’t Think So N (%) Maybe N (%) Probably N (%) Yes N (%) Do the videos address important problems? 1 (0.9) 2 (1.7)112 (95.6) Were the stories realistic? 2 (1.7) 6 (5.1)10 (8.6)97 (82.9) Do you know anyone who went through experiences similar to any of the lead characters? 7 (6.0)3 (2.6)12(10.2)23(19.7)72 (61.5) Could the videos change a woman's attitude sex when she does not want to? 2 (1.7) 7 (6.0)19(16.2)87 (74.4) Do you think the videos could make it more likely that a woman will use condoms with her partner? 2 (1.7) 4 (3.4)30(25.7)79 (67.5) Could the videos help a woman handle herself if a male partner wants to have unprotected sex? 0 (0.0)3 (2.6)15(12.8)19(16.2)80 (68.4) Would you want the video series to continue? 0 (0.0)1 (0.9)7 (6.0)10 (8.5)99 (84.6) Do you think your friends might like to see the videos? 0 (0.0)12 (10.3)13(11.1)40(34.2)52 (44.4)

29.  Women were enthusiastic about the videos.  All but 4 of 117 thought the stories were realistic  All but 8 could relate to the characters  90 % thought their friends might like to watch  All but one wanted the stories to continue

30.  Using the cell phone for the project was easy (n = 113, 96.6%)  Using the cell phone maintained privacy (n =113, 96.6%)  Wanted to continue watching with the phone (n =107, 91.4%)  Jones & Lacroix (2012)

32.  Prevalent high risk behavior at baseline  Post-intervention sex risk VEE behavior was reduced (p < 0.001) in both groups.  While reduction was 19% more in the video group, this difference was not statistically significant.  Both groups received emails, calls, smartphones, and a high level of involvement from the study team  Greater VEE reduction at STD clinic sites than public housing or storefront: further study needed  The stories held participants’ attention; they identified with characters & stories and wanted to continue watching

33.  We believe that Love, Sex, and Choices was highly effective in reducing HIV risk behavior and the comparison group also received a viable HIV prevention intervention.  This is the first study to evaluate streaming weekly videos to smartphones to promote health.  A streamed video intervention  can be widely distributed and accessed 24/7  Allows usage to be tracked, providing measures of treatment fidelity

34.  The National Institute of Nursing Research (NINR) supported this work (RO1-NRO10864).  Technical support at Rutgers Newark Computing Services  Alan Roth, filmmaker, Martinique L. Moore, Assistant Director  The cast of Love, Sex and Choices; Starring: Toni:Yasmine Weaver, Diamond:Tationna Bosier, Valerie: Leeann Hellijas, Keyanna: Darnell Rhea Williams, Mike: Laurence Covington, Dante: Omar Golden, James: Jaylen Sansom  Rutgers University College of Nursing and the Educational Opportunity Fund (EOF) research assistants whose dedication made this work possible: Yvesnallie Antoine, Magnolita Bonheur, Essence Burrows, Fernandine Charles, Lin Chen, Geraldine Dufort, Catherine Lora, Judeline Marcellus, Sandra Rios, Tatiana Saavedra, Griselda Sanchez, and Mireille Zuniga;  Thank you to the site recruiters, and to: Carol Tyler, the late Kevin Burnett, Brenda Davis, MS, LCSW, and Grace Malley, at Jersey City Public Housing; Honorable Mayor Wayne Smith of Irvington Township; Dorothy Wojcik, Program Manager, Jersey City Preventive Medicine Clinic; Ms. Verna Sims, Director at Mary McLeod Bethune Life Center; Rochelle D. Williams-Evans, RN, MS, Director/Health Officer, East Orange Department of Health & Human Services;  And with gratitude to the women who participated in this study.

35.  Jones, R. & Lacroix, L.J. (2012). Using Smartphones to View Weekly Soap Opera Videos in a Randomized Controlled Trial to Reduce HIV Risk in Young Adult, Urban African American/Black Women. DOI 10.1007/s10461-012-0170-9 AIDS & Behavior, 16, 1341–1358.  Jones, R. (2012). Handheld computers to run ACASI to assess HIV risk and deliver tailored soap opera video feedback: Acceptability among young adult urban women. DOI: 10.1016/j.jana.2011.04.001 Journal of the Association of Nurses in AIDS Care, 23 (3).  Jones, R. & Gulick, E. (2009).The Sexual Pressure Scale for Women-Revised. Research in Nursing and Health. 32, 71–85  Jones, R. (2008). Soap opera video on handheld computers to reduce urban women’s HIV risk. AIDS and Behavior, 12, 876–884  Jones, R. & Oliver, M. J. (2007). Young urban women’s patterns of unprotected sex with men engaging in HIV risk behaviors. AIDS and Behavior, 11 (6), 812-821.  Jones, R. (2006). Reliability and validity of the Sexual Pressure Scale. Research in Nursing and Health, 29, 281-293.  Jones, R. (2006) Sex Scripts and power: A framework to explain urban women’s HIV sexual risk with male partners. Nursing Clinics of North America, 41, 425-436.  Jones, R. (2004). Relationships of sexual imposition, dyadic trust, and sensation seeking with sexual risk behaviors in young urban women. Research in Nursing and Health, 27, 185- 197.  Jones, R. (2003). Survey data collection using Audio Computer Assisted Self-Interview. Western Journal of Nursing Research, 25, 349-358. Study Related Publications

36. ra.jones@neu.edu www.womenspoweragainsthiv.com